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ATI Fundamentals Exams Compilation (18 versions) 100% CORRECT UPDATED 2022 WITH BONUS TESTBANKS!
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ATI Fundamentals practice Test A,B&C 2022-100% CORRECT(DOWNLOAD TO SCORE A+)
1. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which... [Show More] of the following actions should the nurse take? - Ask another nurse to observe the medication wastage 2. A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) - 107... 750mL/7hr = 107.14 3. A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? - we would give you oxygen through a tube in your nose 4. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? - determine the reasons why the client is refusing to use the incentive spirometer 5. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? - pad the clients wrists before applying the restraints 6. A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? - let's talk about how the change in your job status will affect you 7. a nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? - droplet8. a nurse is caring for a group of clients. which of the following actions should the nurse take to prevent the spread of infection? - place a client who has tuberculosis in a room with negativepressure airflow 9. a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) - pupil clarity, visual fields, visual acuity 10. A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. - 1) obtain the pronouncement of death from the provider 2)remove the tubes and indwelling lines 3) wash the client's body 4) ask the client's family if they would like to view the body 5) place a name tag on the body 11. a client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? - it might help me to listen to music while i'm lying in bed 12. a nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following instructions should the nurse include in the teaching? - use tracheostomy covers when outdoors 13. a nurse is admitting a client who is having an exacerbation of heart failure. in planning this client's care, when should the nurse initiate discharge planning? - during the admission process 14. a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the client's pain? - is your pain sharp or dull? 15. a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? - examine personal values about the issue16. a nurse is reviewing a client's fluid and electrolyte status. which of the following findings should the nurse report to the provider? - potassium 5.4 mEq/L 17. a nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? - apply intermittent suction when withdrawing the catheter 18. a nurse is caring for a client who has a sodium level of 125 mEq/L. which of the following findings should the nurse expect? - abdominal cramping 19. a nurse is assessing a client's readiness to learn about insulin self-administration. which of the following statements should the nurse identify as an indication that the client is ready to learn? - i can concentrate best in the morning 20. a nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care? - situation, background, assessment, and recommendation (SBAR) 21. a nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and leaves the client's room. when the nurse asks if the client would like to discuss any concerns, the client declines. which of the following statements should the nurse make? - i am available to talk if you should change your mind 22. a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? - notify the nursing manager 23. a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? - advocacy ensures client's safety, health and rights 24. a nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements indicates an understanding of the teaching? - i will hire someone to trim the tree that hangs low over the stairs of my front porch25. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take when inserting the NG tube? - have the client take sips of water to promote insertion of the NG tube into the esophagus [Show Less]
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Nursing Fundamentals: The Nursing process (ATI) Study Guide 2022-Download to score A+
what is the nursing process? - a cyclical, critical thinking process. it is dynamic, continuous, client-centered, problem-solving, and decision making fra... [Show More] mework that is foundational to the nursing practice. five steps of the nursing process - 1. assessment/data collection 2. analysis 3. planning 4. implementation 5. evaluation methods of data collection - 1. observation 2. interviews 3. medical history 4. comprehensive or focused physical exam 5. diagnostic and laboratory reports 6. collaboration what is involved in collecting data effectively? - 1. ask appropriate questions 2. listen carefully to responses 3. develop good head to toe assessment skills 4. employ critical thinking and clinical judgment 5. recognize the need to collect data prior to interventions when do you collect subjective data (symptoms)? - during the nursing history what does subjective data include? - 1. symptoms 2. patients feelings 3. patients perceptions 4. description of health status when is objective data (signs) obtained? - during the physical assessment how do nurses obtain objective data? - "nurses feel, see, hear, and smell objective data through observation or physical assessment of the client" primary sources of data - this is what the patients tells the nurse (subjective) or what the nurse observes. secondary sources of data - what others tell the nurse based on what the client has told them (subjective; "she told me that her shoulder is sore every morning") and the objective data is obtained from another source such as, family, friends, health care professional, or records. what three things does the nurse do during assessment? - 1. validate 2. interpret 3. cluster data analysis - use of critical thinking to identify health status or problems, interpret, or monitor the collected data base, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care. what does analysis requires the nurse to do ..? - 1. recognize patterns or trends 2. compare the data with expected standards or reference pages 3. arrive at conclusions to guid nursing care documentation - documentation is essential. it should focus on facts and should be very descriptive. what does planning involve? - 1. establish priorities and outcomes that can be measured and evaluated 2. these priorities and outcomes are what directs selection of interventions 3. three types of planning 4. develop plan of care based on assessment 5. planning is continuous; obtain new info and evaluate responses to care; modify plan of care if necessary 6. discharge planning 7. nurses select priorities, determine outcomes, and select interventions implementation - Nurses base the care they provide on the assessment data, analysis, and the plan of care they developed in the previous steps. what does implementation involve? - 1. problem solving 2. clinical judgment 3. critical thinking to select and implement appropriate interventions 4. use nursing knowledge, priorities of care, and planned outcomes to promote, maintain and restore health. 5. use interpersonal skills and technical skills therapeutic interventions - 1. includes measures nurses take to minimize risk and to respond to unplanned events, such as observation of unsafe practice, a change in a status, or the emergence of a life threatening situation. roles of nurse during implementation - 1. perform nursing actions 2. delegate tasks 3. supervise other health staff 4. document the care and the patients responses. evaluation - 1. nurses evaluate the patients response to the interventions and form a clinical judgment about the extent to which the patient has met the goals/outcomes that were set what does the evaluation determine? - whether or not to modify the plan of care questions to consider-evaluation - 1. " did the client meet the planned outcomes?" 2. "were the nursing interventions appropriate and effective?" 3. "should i modify the outcomes or interventions?" factors that can lead to a lack of goal achievement - 1. incomplete database 2. unrealistic client outcomes 3. nonspecific nursing interventions 4. inadequate time for the client to achieve the outcomes. (q&a #1) By the second post op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? - pg. 55 ati the nurse should reassess the client to determine why he has no achieved satisfactory pain relief. Various factors may be influencing the lack of pain relief. (q&a#2) A nursing instructor is reviewing the steps of the nursing process with a group of students. The students should identify which of the following data as objective? - pg.55 ati A. RR of 22/min w/ even, unlabored respirations D. skin pink, warm, and dry E. urine output of 300 ml/8hr F. dressing clean, dry, and intact (q&a#3) A nursing instructor is reviewing which actions nurses can initiate w/out a provider's prescription w/ a group og nursing students. The student should identify which of the following interventions as nurse-initiated? - Pg.55 ati C. show a client how to use pregressive muscle relaxation D. perform daily bath after evening meal E. reposition the patient every 2 hours to reduce pressure ulcer risk (q&a#4) During evaluation, the nurse must gather information about the client to...? - pg. 55 ati A. determine whether the clients outcomes have been met the nursing process is... - the nursing process is nursing practice in action the group that legitimized the steps of the nursing process in 1973 by developing standards of practice to guid nursing practice - american nurses association for nursing practice the nursing process is considered dynamic - there is a great deal of overlapping interaction between the five steps, each step flows into the next step critical thinking process - nurses who use the critical thinking process must identify alternative decisions and reach a conclusion cases in which the nursing process is applicable - 1. when nurses work with patients who are able to participate in their care 2. when families are supportive and wish to participate in care 3. when patients are totally dependent on the nurse for care. traits that help nurses develop the attitudes and dispositions to think critically - 1. thinking independently 2. being intellectually humble 3. being curious and persevering critical thinking - can be intuitive, logical, or both role of documenting in the nursing process - 1. pt record is the chief means of communication between the members of the interdisciplinary team 2. nursing action not documented is an action not performed 3. content of the pt report and documentation helps establish nursing priorities [Show Less]
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ATI FUNDAMENTALS EXAM – 85 QUESTIONS & ANSWERS (UPDATED 2022) DOWNLOAD TO SCORE A+
A nurse is discussing restorative health care with newly licensed nurse. which of the following examples should the nurse include in the teaching? (select ... [Show More] all that apply) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology Centers - A, B, D a nurse is explaining the various types of health care coverage clients might have to a group of nurses. which of the following health care financing mechanisms should the nurse included as federally funded? (select all that apply) A. preferred provider organization (PPO) B. medicare C. long-term care insurance D. exclusive provider organization (EPO) E. medicaid - B, E a nurse manager is developing strategies to care for the increasing number of clients who have obesity. which of the following actions should the nurse included as a primary health care strategy? A. collaborating with providers to perform obesity screenings during routine office visits. B. ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. C. providing specialized intraoperative training in surgical treatments for obesity. D. educating acute care nurses about postoperative complications related to obesity. - A a nurse is discussing the purpose of regulatory agencies during a staff meeting. which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. monitoring evidence-based practice for clients who have a specific diagnosis. B. ensuring the health care providers comply with regulations. setting quality standards for accreditation of health care facilities. D. determining whether medications are safe for administration to clients. - B a nurse is explaining various levels of health care services to a group of newly licensed nurses. which of the following examples of care or care settings should the nurse classify as tertiary care? (select all that apply) A. intensive care unit B. oncology treatment center C. burn center D. cardiac rehabilitation E. home health care - A, B, C a nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. the nurse understands that the client's choice is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. nonmaleficence - B a nurse offers pain medication to a client who is postoperative prior to ambulation. the nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. beneficence - D a nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. when the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. nonmaleficence - C a nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. the nurse understands that this action is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. nonmaleficence - D a nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. a nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he does not stay in bed, she will have to apply restraints. C. a family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. a client who is terminally ill hesitates to name their partner on their durable power of attorney form. - C a nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. the AP tells the client that diapers will be used next time the urinal is used improperly. which of the following torts is the AP committing? A. assault B. battery C. false imprisonment D. invasion of privacy - A a nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." the nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. which of the following types of tort is the nurse about to commit? A. assault B. false imprisonment C. negligence D. breach of confidentiality - B a nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. the client tells the nurse that "I plan to prepare my advance directives before i come to the hospital." which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but i know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." - C a nurse is caring for a client who is about to undergo an elective surgical procedure. the nurse should take which of the following actions regarding informed consent? (select all that apply) A. make sure the surgeon obtained the client's consent B. witness the client's signature on the consent form C. explain the risks and benefits of the procedure D. describe the consequences of choosing not to have the surgery E. tell the client about alternatives to having the surgery - A, B a nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. today, the nurse was found asleep in a chair in the break room not during break time. which of the following actions should the nurse take? A. alert the American Nurse Association B. fill out an incident report C. report the observations to the nurse manager on the unit D. leave the nurse alone to sleep - C a nurse is performing an admission assessment for an older adult client. after gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. orient the client to their room B. conduct a client care conference C. review medical prescriptions D. develop a plan of care - A a nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. which of the following actions are essential steps of the admission procedure? (select all that apply) A. explain the roles of other care delivery staff B. begin discharge planning C. inform the client that advance directives are required for hospital admission D. document the client's wishes about organ donation E. introduce the client to their roommate - A, B, D, E a nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. which of the following tasks are the responsibility of the nurse at the transferring facility? (select all that apply) A. ensure that the client has possession of their valuables B. confirm that the rehabilitation center has a room available at the time of the transfer C. assess how the client tolerates the transfer D. give a verbal transfer report via telephone E. complete a transfer for the receiving facility - A, B, D, E a nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. which of the following information about the client should the nurse include in the discharge summary? (select all that apply) [Show Less]
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FUNDAMENTALS EXAM #1 ATI 68 Questions & Answers 2022 (100% CORRECT) Download to score A+
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nursing include in the teaching? (Sel... [Show More] ect all that apply) A. Home healthcare B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - a. home health care b. rehabilitation facilities c. skilled nursing facilities A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply) A. Preferred provider organization B. Medicare C. Long term care insurance D. Exclusive provider organization E. Medicaid - b. medicare c. medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?collaborating with providers to perform obesity screenings during routine office visits - collaborating with providers to perform obesity screenings during routine office visits A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health strategy? A. Collaborating with providers to perform obesity screenings during routine office visit B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized Intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on post operative complications related to obesity - A. Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a special diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administraion to clients - B. Ensuring that healthcare providers comply with regulations A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? SATA A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - A. Intensive care unit B. Oncology treatment center C. Burn center When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which id the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 feet away from client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organism into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change. - C. Place a mask on the client to limit the spread of micro-organism into the surgical wound. A nurse has removed a sterile pack form its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closet to the body B. The right side flap C. The left side flap D. The flap farthest from the body - D. The flap farthest from the body A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique. (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile fieldE. One gloved hand with the other gloved hand - C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand A nurse is reviewing hand hygiene technique with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing. - B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets. A nurse has prepared a sterile field for assisting a provider with a chest tube injection. Which of the following events should the nurse recognize as contaminating the sterile field. (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field. - B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. WHich of the following illistrate the rationale for reporting? (select all that apply.) A. Planning and evaluating control and prevention strategies. B. Determining public health priorities C.Ensuring proper medical treatment D. Identifying endemic diseasesE. Monitoring for common-source outbreaks - A. Planning and evaluating control and prevention strategies. B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks A nurse is caring for a client who reprtds of severe sore throat, pain when swallowing, and swollen lymph nodes. The cleint is experiencing which of the following stages of infection. A. Prodromal B. Incubation C. Convalescence D. Illness - D. Illness A nurse educator is revieing with a newly hired nurse the diferencies in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systmeic infection? (Slect all that apply.) A. fever B. malaise C. edema D. pain or tenderness E. increase in pulse and repiratory rate - A. fever B. malaise E. increase in pulse and respiratory rate A nurse is contributingto the plan of care for a client who is being admitted to the facility wit a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client C. PLace a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. - B, C, E A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (select all that apply) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E.Perform the general survey before the examination. - B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. E.Perform the general survey before the examination. A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (select all that apply) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status - A, B, C A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion - B. Auscultation A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply) A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering bathroom before beginning the examination. - B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering bathroom before beginning the examination. A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar Surface B. Fingertips C. Dorsal Surface D. Base of the fingers - C. Dorsal Surface A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F ), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently. - A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity. E. Assist the client with oral hygiene frequently. A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priory for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5 minutes before you measure their blood pressure." - A. "Do not measure the client's temperature rectally." (can cause bleeding) A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is irregular. E. Count and report an sighs the client demonstrates. - A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an anti hypertensive medication B. Ask client if they are having pain. C. Request a prescription for an anti anxiety medication. D. Return in 30 min to recheck the client's blood pressure. - B. Ask client if they are having pain. A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? - 16 A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply). A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch." - C and E A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the mid-line. - A. Palpating the thyroid in the lower half of the neck D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the mid-line. A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following action should the nurse take? (Select all that apply) A. Pull the auricle down and back B.insert speculum slightly down and forward C. Insert the speculum slightly down 2 to 2.5cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape - B, D, E A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? ( Select all the apply.) [Show Less]
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ATI Fundamentals Practice Test A with 58 Questions & Answers-updated 2022(Download to score A+)
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that... [Show More] the client has developed thrombophlebitis? Bladder distention Decreased blood pressure Calf swelling Diminished bowel sounds - Calf swelling A nurse is administering an optic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? Press gently on the tracks of the clients ear Pack a small piece of cotton deep into the clients ear canal Move the client's auricle down and back toward her head Tilt the client's head backward for 5 min - Press gently on the tragus of the clients ear A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? Pad the client's wrist before applying the restraints Evaluate the client's circulation every 8 hr after application Remove the restraints every 4 hr to evaluate the client's status Secure the restraints to the bed's side rails - Pad the client's wrists before applying the restraints A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? Verify the client's name on their identification bracelet with the medication administration record Call the pharmacy to determine whether the client's medications are available Compare the clients home medications with the provider's prescriptions Place the client's home medication bottles in a secure location - Compare the client's home medications with the provider's prescriptions The nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 107 mL/hr A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) Assist the client with a partial bed bath Measure the client's BP after the nurse administers antihypertensive medication. Test the client's swallowing ability by providing thickened liquids Use a communications board to ask what the client wants for lunch Irrigate the client's indwelling catheter - Assist the client with a partial bed bath Measure the client's BP after the nurse administers antihypertensive medication. Use a communications board to ask what the client wants for lunch A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position Instill 15 mL of irrigation fluid into the catheter with each flush Subtract the amount of irritant used from the clients urine output Perform the irrigation using a 20 mL syringe - Subtract the amount of irritant used from the client's urine output A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings & medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? The client is receiving normal formula at room temperature The feedings infuse at a slow, continuous drip over 8 hr each night. The client's caregiver washes of the feeding bag with warm water once every 24 hr The client's caregiver flush's the tubing before and after administering medications. - The client's caregiver washes of the feeding bag with warm water once every 24 hr A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client's room has at least six air exchanges per hour. Make sure the client wears a mask when outside her room if there's construction in the area. Place the client in a private room with negatives-pressure airflow. Wear an N95 respirator when giving client direct care. - Make sure the client wears a mask when outside her room if there's construction in the area. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Which of the following actions should the nurse take next? Document the providers statement in the medical record Complete an incident report Consult the facility's risk manager Notify the nursing manager - Notify the nursing manager A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? Insert the catheter at a 45 degree angle Place the client's arm in a dependent position Shave excess hair from the insertion site Initiate IV therapy in the veins of the hand - Place the client's arm in a dependent position A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to the client? Use a bed exit alarm system Raise four side rails while the client is in bed Apply soft wrist restraint Dim the lights in the client's room - Use a bed exit alarm system A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict - Role overload A nurse is caring for a client who has a terminal illness & is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? "I am not worries because I still have hope that he will be okay." "I am relying on support from our family during this time." "We can plan our family reunion once he recovers & comes home." "We don't see any reason to start discussing funeral arrangements right now." - "I am relying on support from our family during this time." A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Increase hematocrit Increase respiratory rate Decrease heart rate Decrease in capillary refill time - Decrease heart rate A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? Combine client care tasks when caring for multiple clients Wait until the end of the shift to document client care Use the planning step of the nursing process to prioritize client care delivery Allow for interruptions in tasks to discuss client care issues with colleagues - Use the planning step of the nursing process to prioritize client care delivery A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? "I can place an extension cord across my living room to plug in my television." "I will hire someone to trim the tree that hangs low over the stairs of my front porch." "I will place my alarm clock on my bedroom dresser across the room." "I will replace the old throw rug in my kitchen with a new one." - "I will hire someone to trim the tree that hangs low over the stairs of my front porch." A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, & Consolability (FLACC) pain rating scale for a client who is experiencing pain. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Obtain an apical heart rate by auscultating the third intercostal space left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. - Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family - During the admission process A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? 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ATI - Fundamentals Practice Quiz 1 with 40 Questions & Answers – updated 2022
A nurse is teaching a group of older adults about suspected changes of aging. Which statement by a group member indicates effective teaching? I should e... [Show More] xpect my HR to take longer to return to normal after exercise. Urinary incontinence is something I have to live with as I get older. I can expect to have less ear wax as I get older. My stomach will empty more quickly after meals as I grow older. - I should expect my HR to take longer to return to normal after exercise. A nurse is caring for a patient who is post-op with paralytic ileus. Which abdominal assessment is expected? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis - Absent bowel sounds with distention A nurse is planning care for a client with abdominal pain. An assessment reveals temperature of 102.6 F, HR 105, soft-non-tender abdomen, menses overdue by 2 days. Which of the following findings should be the priority? Heart rate Soft, non-tender abdomen Temperature Overdue menses - Temperature Which instruction should be followed for a child who is post-op following a tonsillectomy? Encourage frequent coughing to clear congestion from anesthesia. Place a heating pat at child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day. Provide the child with ice cream when oral intake is initiated. - Administer analgesics to the child on a routine schedule throughout the day. The nurse auscultates a high-pitched scratching sound during diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub - Pericardial friction rub A nurse is teaching an assistive personnel about proper hand hygiene. Which statement from AP indicates understanding? "There are times I should use soap and water instead of alcohol-based sanitizer" "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down." - "There are times I should use soap and water instead of alcohol-based sanitizer" A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take? Turn on the machine every 15 minutes to measure the BP. Record only BP readings needed for the 15-min intervals. Obtain manual and automatic readings & compare them. Disconnect the machine, measure the BP manually every 15 minutes. - Disconnect the machine, measure the BP manually every 15 minutes. A nurse is providing teaching to a client who has heart failure about how to reduce his sodium intake. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? Involvement of client in planning the change Emphasis provider places on the dietary changes Learning theory the nurse uses to teach the dietary changes The extent of the dietary changes planned for the client. - The involvement of the client in planning the change Nurse is obtaining vitals for a 2-year old child who is experiencing diarrhea and may have right ear infection. Which route should be used to measure temperature? Rectal tympanic oral temporal - Temporal- oral temp. is not suitable for kids under 3 A nurse is witnessing a client sign an informed consent form for surgery. What describes what the nurse is affirming this action? The client fully understands the provider's explanation of this procedure. The client has been informed about risks/benefits of procedure The nurse witnessed provider's explanation of procedure The signature on pre-op consent form is the client's - The signature on the pre-op consent form is the client's Nurse on a med-surg unit is admitting a client. Which of the following does the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress - Assessment Nurse on a med-surg unit is washing her hands prior to assisting in a surgical procedure. Which action indicates proper surgical handwashing? Nurse washes each part of her hands with 5 strokes Nurse washes from elbows down to hands Nurse washes with hands held higher than elbows Nurse uses minimal friction when washing her hands - Nurse washes with hands held higher than elbows A nurse at a screening clinic is assessing a client who reports a history of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse use stethoscope to auscultate aortic valve? 5th IC space just medial to MCL 2nd IC space to L of sternum 5th IC space to L of sternum 2nd IC space to R of sternum - 2nd IC space to R of sternum A nurse notices an irregularity in the pulse when measuring patient's vital signs. Which action should the nurse take? Measure pulse using Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds. - Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. A nurse is caring for an an older adult client who becomes agitated when the nurse requests that the dentures must be removed prior to surgery. Which response should the nurse make? It's for your safety- dentures can slip and block your airway during surgery. You wouldn't want your teeth to be broken or lost during surgery, would you? The anesthesiologist requires everyone to remove their dentures. What worries you about being without your teeth? - What worries you about being without your teeth? A nurse is caring for a client who has a terminal illness. The client asks several questions regarding the nurse's religious beliefs related to death and dying. How should the nurse respond? Change the topic because the client is trying to divert attention from the illness. Encourage the client to express his thoughts about death and dying. Tell the client that religious beliefs are a personal matter. Offer to contact the client's minister or facility's chaplain. - Encourage the client to express his thoughts about death and dying. A nurse is caring for a client who has T1DM and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? Tell me what I can do to help you overcome your fear of giving yourself injections. I am sure your provider will not be pleased that you refuse to give yourself injections. It's okay- your partner will be able to learn to give you injections. You won't be able to go home without learning how to give yourself injections. - Tell me what I can do to help you overcome your fear of giving yourself injections. A nurse is teaching CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance Begin chest compressions Confirm unresponsiveness Give rescue breaths - Confirm unresponsiveness [Show Less]
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ATI fundamentals practice A – UPDATED 2022 - 57 Questions & Answers(Download to score A+)
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 1. The top of th... [Show More] e cane is parallel to the client's waist. 2. When walking, the client moves the cane 46 cm (18 in) forward. 3. The client holds the cane on the stronger side of her body. 4. The client moves her stronger limb forward with the cane. - 3 The client should hold the cane on the stronger side of her body to increase support and maintain alignment. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions should the nurse take first? 1. Reposition the client. 2. Document the client's IV intake in the medical record. 3. Request a new IV fluid prescription. 4. Check the IV tubing for obstruction. - 4 The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. 2. Remove the NG tube if the client begins to gag or choke. 3. Apply suction to the NG tube prior to insertion. 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus. - 4 Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L - 4 This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1."I can place an extension cord across my living room to plug in my television." 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." 3. "I will place my alarm clock on my bedroom dresser across the room." 4. "I will replace the old throw rug in my kitchen with a new one." - 2 Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? SATA 1. Assist the client with a partial bed bath. 2. Measure the client's BP after the nurse administers an antihypertensive medication. 3. Test the client's swallowing ability by providing thickened liquids. 4. Use a communication board to ask what the client wants for lunch. 5. Irrigate the client's indwelling urinary catheter. - 1, 2, 4 Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function. Using a communication board poses minimal risk to the client and is within the AP's range of function. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer. 2. Focus teaching on what the client will need to do in the future to manage his illness. 3. Provide the client with written information about the phases of loss and grief. 4. Reassure the client that this is an expected response to grief. - 4 During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid - 4 Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure the medication reaches the inner ear? 1. Press gently on the tragus of the client's ear. 2. Pack a small piece of cotton deep into the client's ear canal. 3. Move the client's auricle down and back toward her head. 4. Tilt the client's head backward for 5 min. - 1 Pressing gently on the tragus of the ear will help the medication get into the inner ear. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? 1. Place the client in a side-lying position. 2. Instill 15 mL of irrigation fluid into the catheter with each flush. 3. Subtract the amount of irrigant used from the client's urine output. 4. Perform the irrigation using a 20-mL syringe. - 3 The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 1. Make sure the client's room has at least six air exchanges per hour. 2. Make sure the client wears a mask when outside her room if there is construction in the area. 3. Place the client in a private room with negative-pressure airflow. 4. Wear an N95 respirator when giving the client direct care. - 2 An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? 1. Combine client care tasks when caring for multiple clients. 2. Wait until the end of the shift to document client care. 3. Use the planning step of the nursing process to prioritize client care delivery. 4. Allow for interruptions in tasks to discuss client care issues with colleagues. - 3 Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. A nurse caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? 1. Assist the client into a prone position. 2. Place a sleeve over the top of each leg with the opening at the knee. 3. Make sure two fingers can fit under the sleeves. 4. Set the ankle pressure at 65 mm Hg. - 3 The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? 1. Insert the suction catheter while the client is swallowing. 2. Apply intermittent suction when withdrawing the catheter. 3. Place the catheter in a location that is clean and dry for later use. 4. Hold the suction catheter with her clean, nondominant hand. - 2 The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? 1. "Is your pain constant or intermittent?" 2. "What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?" - 4 Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? 1. Insert the needle at a 15° angle. 2. Aspirate for blood return prior to administration. 3. Administer the medication into the abdomen. 4. Massage the site following the injection. - 3 The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps 1. Place a name tag on the body 2. Obtain the pronouncement of death from the provider 3. Remove the tubes and indwelling lines 4. Wash the clients body 5. Ask the clients family member if they would like to view the body - 2,3,4,5,1 A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 1. Remove the outer cannula cautiously for routine cleaning. 2. Use tracheostomy covers when outdoors. 3. Use sterile technique when performing tracheostomy care at home. 4. Cleanse irritated skin with full-strength hydrogen peroxide. - 2 Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions. Which of the actions should the nurse take? 1. Turn the client every 2 hr. 2. Administer an antiemetic every 6 hr. 3. Hold oral care. 4. Increase the room's temperature. - 1 The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations. A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? 1. Examine personal values about the issue. 2. Tell the parents that this is a necessary procedure. 3. Inform the parents that the staff does not require their consent. 4. Contact a spiritual support person to explain the importance of the procedure. - 1 Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? 1. Administer the medication with the needle at a 45° angle. 2. Administer the medication into the client's nondominant arm. 3. Pull the client's skin laterally or downward prior to administration. 4. Massage the injection site after administration. - 1 The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family - 1 Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. [Show Less]
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ATI PN FUNDAMENTALS – 61 QUESTIONS WITH 100% CORRECT ANSWERS – UPDATED 2022
1. A nurse is caring for a client who just died and practiced the islamic faith. Which of the following cultural practices should the nurse expect? - The c... [Show More] lient face should be toward mecca. 2. A nurse is assisting with a client who has active Tb. Which of the following actions should the nurse plan to take? - Assign the client to a negative pressure airflow room. 3. A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistant oral temperature of 38.9 * C (102 F). Which of the following interventions should the nurse include in the plan of care to treat the fever? - Administer acetaminophen 4. A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? - Ensure that the client wears a surgical mask during transportation thoughout the facility. 5. A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? - Place the client in a room near the nurses station. Ensure that the client is wearing non skid slippers. Reinforce teaching about how to use the call bell. 6. A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? - Pad bony prominences on the wrist. 7. A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? - Flashing smoke alarm 8. A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? - An 18 year old client who has acute appendicitis. 9. A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? - BUN 8mg/dL 10. A nurse is moving a client up in bed with assistance of a second nurse. Which of the following actions should the nurse take? - Place feet apart with the foot nearest the clients bed in front of the other foot. 11. A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? - I will keep the crutch tips dry. 12. A charge nurse smells smoke, enters the visitors restroom, and sees flames in the trashcan. What is the sequence of actions that the nurse should take? - Evacuate Alarm Confine Extinguish 13. A nurse is calculating the input and output for a client over the last 8 hours. The client is receiving a continuous IV infusion at 150mL/ hr and had 4 oz of juice and 0.5L of water. How many mL of fluid should the nurse document as the clients intake for the last 8 hr? - 1820 mL 14. A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? - Beneficence ( acting in the clients best interest) 15. A charge nurse is reinforcing teaching with an assistive personel about performing pulse oximetry. Which of the following information should the nurse include in the teaching? - remove polish from the clients fingernail before applying the oximentry probe. 16. A nurse is reinforcing dietary teaching w/ a pt who has chronic kidney disease & requires a low potassium diet. Which of the following food choices by the pt demonstrates an understanding of the teaching? - 1 cup of applesauce 17. A nurse is preparing to admin O2 to a Pt who has heart failure & is having severe difficulty breathing. Which of the following O2 delivery equipment should the nurse select to provide the highest concentration of O2 to the Pt? - Nonrebreather mask 18. A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age related changes? - Circulation becomes less efficient with age 19. A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? - Shred the paper in a secure container 20. A nurse is assisting with the admission of a pt who has brought her meds to the facility. Which of the following actions should the nurse take? - Compare the meds the provider has prescribed with the clients meds from home 21. A nurse is preparing to admin a topical med to a PT. Which of the following actions should the nurse take? - Compare the label of the med container w/ the med admin record x3. 22. A nurse is palpating the pulse located on the top of the pts foot. Which of the following pulses should the nurse document that she is palpitating? - Dorsalis pedis 23. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection? - Drain urine from the tubing before ambulation 24. A nurse is explaining ethics & values to a newly licensed nurse. The nurse should explain that allowing a Pt to make a decision about treatment is an example of which of the following ethical principles? - Autonomy 25. A nurse is reinforcing pre-op teaching w/ a pt who does not speak the same language as the nurse. Which of the following actions should the nurse take? - Provide handouts written in the clients primary language [Show Less]
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ATI Fundamentals of nursing test Fall 2021/22 -190 Questions & Answers(100% CORRECT)
A nurse is discussing restorative health care with a newly licenced nurse. Which of the following examples should the nurse include in the teaching? - -H... [Show More] ome health care -Rehab facilities -Skilled nursing facilities A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? - -Medicare -Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? - -Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? - -Ensuring that health care providers comply with regulations A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? - -ICU -Oncology treatment center -Burn center A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) - -A client who has terminal cancer requests hospice care in the home. -A client asks about community resources available for older adults. -A client requests an electric wheelchair for use after discharge. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? - Occupational therapist A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) - Provider Pharmacist Registered nurse A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? - Speech-language pathologist A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAS) can perform, which of the following client activities should the nurse include? (Select all that apply.) - Bathing Ambulating Toileting Measuring vital signs A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? - Autonomy A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? - Beneficence A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? - Justice A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? - Nonmaleficence A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise, Which of the following situations should the newly licensed nurses identify as an ethical dilemma? - A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? - Assault A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? - False imprisonment A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? - "I plan to write that i dont want them to keep me on a breathing machine." A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? - -Make sure the surgeon obtained the clients consent -Witness the clients signature on the consent form A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? - Report the observations to the nurse manager on the unit A nurse is preparing information for a change of shift report. Which of the following information should the nurse include in the report? - Bone scan scheduled for today A nurse manager is discussing the HIPPA privacy rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? Select all that apply - -Family members should provide a code prior to receiving client health information -Communication of client information can occur at the nurses station -A client can request a copy of their medical record -A nurse can photocopy a clients medical record for transfer to another facility A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? Select all that apply - -Put the date and time on all entries -Document objective data, leaving out opinions A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? Select all that apply - Medication error Needlesticks Omission of prescription A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) - -Repeat the details of the prescription back to the provider. -Have another nurse listen to the telephone prescription. -Obtain the provider's signature on the prescription within 24 hr. A nurse on a medical-surgical unit has received change of shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel? - -Reapplying a condom catheter for a client who has urinary incontinence A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? - -RN A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) - -The client ambulates wearing slippers over antiembolic stockings. -The client uses a front-wheeled walker when ambulating. -The client had pain medication 30 min ago. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a Practical Nurse? - Providing nasopharyngeal suctioning for a client who has pneumonia A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) - -Right supervision and evaluation -Right direction and communication -Right circumstances By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? - Reassess the client to determine the reasons for inadequate pain relief A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? - Assessment A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) - -respiratory rate is 22/min with even, unlabored respirations -the clients skin is pink, warm and dry -the assistive personnel reports that the client walked with a limp A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) - -Showing a client how to use progressive muscle relaxation -Performing a daily bath after the evening meal -Repositioning a client every 2 hr to reduce pressure injury risk A nurse is discussing the nursing process a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? - "I will determine the most important client problems that we should address." A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? - Basic [Show Less]
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ATI Fundamentals test UPDATED 2022- 45 Questions & Answers(100% CORRECT)
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe ... [Show More] care of this client? A. Supine B. Semi Fowler's C. Semi-Prone D. Trendelenburg - B A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for help with transfer C. Use transfer belt to assist client back to bed D. Determine clients ability to help with transfer - D A nurse is completing discharge instrucitons for pt with COPD. What demonstrates pt understanding with difficulty breathing at night? A. lie on back with head and shoulders on pillow B. Lie flat on stomach with head to one side. C. Sit on side of bed with arms over pillows on bedside table. D. Lie on side with weight on hip and should with arms flexed in front of her - C A nurse manager is reviewing guidelines for preventing injury with staff nurses. which of the following instructions should the nurse manager include. Select all that apply A. Request assistance when re-positioning client B. Avoid twisting spine or bending at waist C. Keep knees slightly lower than hips when sitting for extended periods D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hrs to flex and stretch joints and muscles - A B D A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements shoudl the nurse identify as an indication that an attendee understands the teaching. Select all that apply A. My line of gravity should fall outside my base of support B. The lower the center of gravity the more stable I am C. To broaden my base of support, I should spread my feet apart D. When I lift an object I should hold it as close to my body as possible E. When pulling an object I should move my front foot forward - BCD A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority? A.A client who received crush injuries to the chest and abdomen and is expected to die B.A client who has a 4-inch laceration to the head C.A client who has partial-thickness and full-thickness burns to his face, neck, and chest D.A client who has a fractured fibula and tibia - c A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (Select all that apply.) A.A client who is dehydrated and receiving IV fluid and electrolytes B.A client who has a nasogastric tube to treat a small bowel obstruction C.A client who is scheduled for a transurethral resection of the prostate (TURP)D.A client who is 24 hr postoperative following a mastectomy E.A client who is scheduled for an appendectom - cd A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) A.Open doors to client rooms. B.Place blankets over clients who are confined to beds C.Move beds away from the windows. D.Draw shades and close drapes. E.Relocate ambulatory clients in the hallways back into their room - bcd An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A.Irrigate the affected area with running water. B.Wash the affected area with antibacterial soap. C.Brush the chemical off the skin and clothing. D.Apply a neutralizing agent. - c A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?A."I will get the caller off the phone as soon as possible so I can alert the staff." B."I will use overhead paging to alert the entire facility." C."I will not ask any questions and just let the caller talk." D."I will listen for background noises. - d A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.) A.Place a belt restraint on the client when he is sitting on the bedside commode. B.Keep the bed in low position with full side rails up. C.Ensure that the client's call light is within reach. D.Provide the client with nonskid footwear. E.Complete a fall-risk assessmen - c d e A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A."I will place the client on his side." B."I will go to the nurses' station for assistance." C."I will administer medications as prescribed." D."I will be prepared to insert an airway. - b A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A.Extinguish the fire. B.Pull the fire alarm. C.Evacuate the clients. D.Close all open doors on the unit - c A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station? A.A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B.A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C.A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle D.A 79-year-old client who is postoperative following a below-the-knee amputatio - d A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A.Complete a fall-risk assessment. B.Educate the client and family on fall risks. C.Complete a physical assessment. D.Survey the client's belonging - a When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A.keep the sterile field at least 6 ft away from the client's bedside.B.instruct the client to refrain from coughing and sneezing during the dressing change. C.place a mask on the client to limit the spread of micro-organisms into the surgical wound. D.keep a box of facial tissues nearby for the client to use during the dressing change - C A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A.A bottle containing a sterile solutionB.The edge of the sterile drape at the base of the field C.The inner wrapping of an item on the sterile field D.An irrigation syringe on the sterile field E.One gloved hand with the other gloved hand - C D E A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A.The flap closest to the body B.The right side flap C.The left side flap D.The flap farthest from the body - D A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A.Apply 3 to 5 mL of liquid soap to dry hands. B.Wash the hands with soap and water for at least 15 seconds. C.Rinse the hands with hot water. D.Use a clean paper towel to turn off hand faucets. E.Allow the hands to air dry after washing - B D A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A.The provider drops a sterile instrument onto the near side of the sterile field. B.The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C.The procedure is delayed 1 hr because the provider receives an emergency call. D.The nurse turns to speak to someone who enters through the door behind the nurse. E.The client's hand brushes against the outer edge of the sterile field - B C D A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A.Planning and evaluating control and prevention strategies B.Determining public health priorities C.Ensuring proper medical treatment D.Identifying endemic disease E.Monitoring for common-source outbre - A B C E A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.) A.Place the client in a room that has negative air pressure of at least six exchanges per hour. B.Wear a mask when providing care within 3 ft of the client. C.Place a surgical mask on the client if transportation to another department is unavoidable. D.Use sterile gloves when handling soiled linens. E.Wear a gown when performing care that may result in contamination from secretions - B C E A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect? A.Allergic reaction B.Ringworm C.Systemic lupus erythematosus D.Herpes zoste - D A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?A.Prodromal B.Incubation C.Convalescence D.Illnes - D A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.) A.Fever B.Malaise C.Edema D.Pain or tenderness E.Increase in pulse and respiratory rate - A B E A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill in 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the fac - A D E A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive dryness and wrinklin - B C D A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (Select all that apply.) A. Range of motion [Show Less]
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ATI Fundamentals Practice A, B, & Final, ATI Fundamentals Review UPDATED 2022-100% CORRECT (A+)
1. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescr... [Show More] iption should the nurse question? - The dose 2. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? - Observe the rate, depth, and character of the client's respirations. 3. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? - Lower the client to the floor and place a pad under the client's head. 4. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? - Educating clients about the recommended immunization schedule for adults 5. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? - Assessment 6. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? - Edema at the infusion site 7. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? - Washing dishes 8. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? - Daily weight 9. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? - Inspection 10. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? - A client who has a prescription for a transfusion of packed red blood cells 11. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? - "It must be difficult to care for someone who is confined to bed." 12. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? - Bounding pulse 13. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? - Cover the incision with a moist sterile dressing. 14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? - "Bear weight on both of your legs." 15. A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? - Liver Damage 16. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? - PC for after meals 17. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? - A 10-month-old infant can pull up to a standing position. 18. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? - The AP hangs the collection bag at the level of the bladder. 19. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? - Consult the medication reference book available on the unit. 20. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? - Place the client in a lateral position with the head turned to the side before beginning the procedure. 21. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? - Repeat each joint motion five times during each session. 22. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? - Cough deeply after each use. 23. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning? - Have the client demonstrates the procedure. 24. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? - Gelatin 25. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? - Romberg test 26. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? - WBC 15,000 mm3 27. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? - Ventrogluteal 28. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? - Fill the bag two-thirds full with ice. 29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? - Impaired peristalsis of the intestines 30. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? - Wear cotton clothing to avoid static electricity. 31. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? - "I can see that this is upsetting you." 32. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? - Position the client on his left side. 33. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? - Airway 34. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? - Tie the restraint with a quick-release knot. 35. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? - Oil retention 36. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? - People who practice Judaism stay with the body of the deceased until burial. 37. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? - 38. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? - Place the client in Trendelenburg's position. 39. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? - Provide a protein intake of 1.5 g/kg of body weight per day. 40. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? - Cold extremities 41. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? - Hemolytic 42. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? - Loss 43. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? - Sit at the bedside while feeding the client. 44. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? - Wear gloves when changing the client's gown. 45. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) - -Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. 46. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? - Fidelity 47. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? - Tachycardia 48. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? - Decreased calcium 49. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? - "Tell me more about how your friends discourage you." 50. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? - When lifting an object, spread your feet apart to provide a wide base of support. 51. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? - "All of this equipment can be frightening." 52. A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? - "The pain is like a dull ache in my stomach." 53. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? - evacuate the client 54. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? - Rapid heart rate 55. A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? - 0.3 mg 56. A nurse is preparing a heparin solutionA nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 8 mL/hr 57. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? - Cleanse the wound from the center outward 58. The nurse is caring for a client who is receiving fluid through a peripheral IV catheter.. Which of the following findings at the IV site should the nurse identify as indicating infiltration? - Skin blanching 59. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - "When descending stairs, I will first shift my weight to my right leg." 60. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? - Tell the client to keep the head of the bed elevated at least 30 degrees 61. A nurse is reviewing a client's medication prescription that reads "digoxin 0.25 by mouth everyday." Which of the following components of the prescription should the nurse verify with the provider? - Medication dose 62. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? - "I will be sure to remove my hearing aid before taking a shower" 63. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? - "Client found lying on floor" 64. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process. - Compare prescriptions with medications the client received while at the facility. 65. A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? - Witness the client's signature on the consent form. [Show Less]
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ATI - NURSING FUNDAMENTALS STUDY GUIDE-UPDATED 2022 DOWNLOAD TO SCORE A+
Regulatory agencies - US Dept of Health and Human Services FDA State and local public health agencies State icensing boards Joint Commission-JCAHO Pro... [Show More] fessional Standards Review Organizations Review committees Healthcare financing mechanisms - publically federally funded progams -Medicare -Medicaid -Private pay Levels of Healthcare - Preventive Health-immunization, stress management Primary-nutrition counseling Secondary-emergency Tertiary-techincal care, cancer centers Restorative-home health, rehab Continuing-long-term, chronic Interdisplinary Personnel-Non-Nursing - Clergy-spiritual Registered Dietitian-educate on nutrition Lab Tech-obtain specimens Occupational Therapist-regain ADLs Pharmacist-provide/monitor medications Physical Therapist-increase musculoskeletal function Provider-assess, diagnose, treat client Radiologic Techs-perform xrays Respiratory Therapist-evaluate respiratory status Social Worker-equip client/family with community resources Speech Therapist-assist with regaining speech Autonomy (Ethical Responsibilities) - ability of the client to make personal diecisins, even when those decissions may not be in the clients best interest Beneficence (Ethical Responsibilities) - agreement that the care given is in the best interest o the client; taking positive actions to help others Fidelity (Ethical Responsibilities) - agreement to keep one's promise to the client about care that was offered Justice (Ethical Responsibilities) - fair treatment in matters related to physical an psychosocial care and use of resources Nonmaleficnce (Ethical Responsibilities) - avoidance of harm of pain as much as possible when giving treatments Ethical dilemna (Ethical Responsibilities) - it cannot be solved solely by a review of scientiic data; it involves a conflict between two moral imperatives; the answer will have a profound effect on the situation/client Nurses basic code of ethics (Ethical Responsibilities) - advocacy, responsibility, accountability and confidentiality nurses role in ethical decision making (Ethical Responsbilities) - 1. an agent fo the client facing and ethical decision-helping decision of abortion for adolscent; discussing blood transfusion w/JW; 2. the decison maker in regard to nursing practice-witnessing surgeon provide options but not dangers Sources of Law (legal responsibilities) - Health Insurance Portablity and Accountability Act-HIPAA; The Americans with Disabilities Act-ADA; The Mental Health Parity Act-MHPA; The Patient Self-Determination Act-PSDA Criminal law - subsection of public law and relates to the relationship of an individual with the govenment-nurse who falsifies medical record Civil law - protects the individual rights of people-provision of nursing care is tort law Negligence - Unintentional Torts - nurse fails to implement safety measures for a client who has been identified as at risk for falls Malpractice - Unintentional Torts - nurse administers a large dose of medication due to a calculation error. Client has a cardiac arrest and dies Breach of Confidentiality - Quasi-Intentional Tort - a nurse release the medical diagnosis of a client to a member of the press Defamation of Character - Quasi-Intentional Tort - a nurse tells a coworker that she believes the clienthas been unfaithful to her spouse Assault - Intentional Torts - the conduct of one person makes another person fearful-threatening Battery - Intentional Tort - intentional and wrong physical contact that involves injury or offensive contact-restraining of a client False Imprisionment - Intentional Tort - a person is confined/restrained against their will-competent client put in restraints to prevent leaving facility Professional Negligence - failure of a person with professional training to act in a reasonable and prudent manner Responsiblities for informed consent - Provider-obtain consent; Client-give consent; Nurse-witnesses consent Types of Advance Directives - Living Will-expressin clients wishes regarding medical treatment; Durable Power of Attorney for Healthcare-designates a healthcare proxy; Providers Order-DNR-do not resuscitate; AND-allow natural death; CPR-cardiopulmonary resuscitation Chart Information - assessments; medication administration; treatments geven and the clients responses; client education Chart documentation - subjective data-what the client says in quotation marks; objective data-what you see; accurate/concise-info documented must be precise; complete/current-info is comprehensive and timely; organized-communicate in logical order Delegation and Supervision - RNs to RNs, LPNs and Nursing assistants Delegation Factors - Predictability of outcome; Potential for harm; Complexity of care; need for problem solving and innovation; level of interaction with the client Five Rights of Delegation - Right Task-identify task; Right Circumstance-access health status/complexity of care; Right person-verify compentencey of delegatee; Right direction/communication-data to collect; Right supervision/evaluation-provide direct/indirect supervision [Show Less]
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ATI Fundamentals: Fundamentals of Nursing Exam 1 UPDATED 2022 103 TERMS
participants of health care systems - 1. consumers (clients) 2. licensed providers (RN, LPN, MD, PT, OT, etc.) 3. unlicensed providers (assistive pers... [Show More] onnel) settings of the health care delivery system - hospitals, homes, assisted-living, schools, hospices, occupational health clinics, urgent care, etc. regulatory agencies of health care delivery systems - department of health and human services, FDA, state licensing boards, the Joint Commission (set quality standards for accreditation of health care facilities), etc. health care financing mechanisms - medicare (65 or older and those who have permanent disabilities), medicaid (low income), private plans levels of health care - preventative: focus on educating to reduce and control risk factors primary: emphasizes health promotion secondary: includes the diagnosis and treatment of acute illness and injury tertiary: acute care; involves provision of specialized and highly technical care restorative: intermediate follow-up care for restoring health and promoting self-care continuing: addresses long-term or chronic health care needs over a period of time safety in health care delivery - minimization of risk factors that could cause injury or harm while promoting high-quality care and maintaining a secure environment for clients, self, and others patient-centered care - caring and compassionate, culturally sensitive care that addresses clients' physiological, psychological, sociological, spiritual and cultural needs, preferences, and values. the client is included in the decision making process evidence based practice - use of current knowledge from research and other credible sources on which to base clinical judgement and client care informatics - the use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically-based nursing practice quality improvement - care-related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients' needs teamwork and collaboration - the delivery of client care in partnership with interprofessional members of the health care team to achieve continuity of care and positive client outcomes A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (select all) a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities e. oncology centers - a. Home health care b. Rehabilitation facilities d. Skilled nursing facilities A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (select all) a. Preferred provider organization (PPO) b. Medicare c. Long-term care insurance d. Exclusive provider organization (EPO) e. Medicaid - b. Medicare e. Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits b. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity c. Providing specialized intraoperative training in surgical treatments for obesity d. Educating acute care nurses about postoperative complications related to obesity - a. Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. Monitoring evidence-based practice for clients who have a specific diagnosis b. Ensuring that health care providers comply with regulations c. Setting quality standards for accreditation of health care facilities d. Determining whether medications are safe for administration to clients - b. Ensuring that health care providers comply with regulations A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (select all) [Show Less]
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ATI Fundamentals of Nursing practice-55 Questions & 100% CORRECT ANSWERS(A+)
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Selec... [Show More] t all) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - A. home health care B. rehabilitation facilities D. skilled nursing facilities A nurse is explaining the various types of healthcare coverage clients might have To a group of nursing students. Which of the following healthcare financing mechanisms are federally funded? (Select all) A. Preferred provider organization (PPO) B. Medicare C. Long term care insurance D. Exclusive provider organization (EPO) E. Medicaid - B. Medicare E. Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating active care nurses on post operative complications related to obesity - A. Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administration to clients - B. ensuring that healthcare providers comply with regulations Rationale: The nurse should identify that state licensing boards are responsible for ensuring that healthcare providers and agencies comply with state regulations A nurse is caring for a group of clients on a medical-surgical unit. for which of the following client care needs should the nurse initiate a referral for a social worker? (Select all) A. A client who has terminal cancer request hospice care in her home B. A client asked about community resources available for older adults C. A client states that she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. Client states that he does not understand how to use a nebulizer - A. A client who has terminal cancer I request hospice care in her home B. A client asked about community resources available for older adults D. A friend request an electric wheelchair for use after discharge A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - D. Occupational Therapist A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications effects? (Select all) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist - A. provider C. pharmacist D. registered nurse A client who has had a cerebral vascular accident has persistent problems with dysphasia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist - D. speech-language pathologist A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - B. Autonomy A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence - D. Beneficence A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - C. Justice A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - D. Nonmaleficence A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form. - C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill Rationale: Making the decision about initiating internal team feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue and it is not easy to resolve. The decision will have a profound effect on the situation and on the client A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the healthcare team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - A. Bathing B. Ambulating C. Toileting E. Measuring vital signs 1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy - A. Assault Rationale: by threatening the client, the AP is committing assalt. Her threats could make the client become fearful and apprehensive. A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality - B. False imprisonment Rationale: The nurse gave the medication as a chemical restraint to keep a client from leaving the facility against medical advice. This is false imprisonment because the client neither requested nor consented to receiving the sedative A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week, The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C."I plan to write that I don't want them to keep me on a breathing machine." D."I will get my regular doctor to approve my plan before I hand it in at the hospital." - C."I plan to write that I don't want them to keep me on a breathing machine." Rationale: The client has a right to decide and specify which medical procedures he wants when a life-threatening situation arises A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply) A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery - A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form Rationale: A. It is the nurses responsibility to verify that the surgeon obtained the clients consent and that he understands the information the surgeon gave him. B. It is the nurses responsibility to witness the client signing of the consent form and to verify that he is consenting voluntarily and appears to be competent to do so. The nurse also should verify that he understands information the surgeon gave him A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep. - C. Report the observations to the nurse manager on the unit Rationale: any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as Tertiary care? Select all that apply A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - A. Intensive care unit B. Oncology treatment center C. Burn center A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift. B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record - C) Bone scan scheduled for today [Show Less]
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Fundamentals ATI Questions - Exam 1 updated 2022 40 Questions & Answers(100% CORRECT ANSWERS)
A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the... [Show More] side. B. Place two fingers in the client's mouth to open. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth. - A. Turn the client's head to the side. A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotion on the feet. C. Washing the feet with warm water and let them air dry. D. Use over-the-counter products to treat abrasions. E. Wear cotton socks. - A. Inspect the feet daily. B. Use moisturizing lotion on the feet. E. Wear cotton socks. A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client. - A. Schedule rest periods during morning care. A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms - A. Face A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry, storage container after cleaning them. - B. Brush the dentures with a toothbrush and denture cleaner. A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. D. Identifying endemic disease. E. Monitoring for common-source outbreaks. - A. Planning and evaluating control and prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. E. Monitoring for common-source outbreaks. A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster - D. Herpes zoster A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness - D. Illness A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malasia C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate - A. Fever B. Malasia E. Increase in pulse and respiratory rate A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of that at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. - B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that might result in contamination from secretions. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. - C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. A nurse manager is reviewing with nurses on the unit the care of a client who has had seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer his medications." D. "I will prepare to insert an airway." - B. "I will go to the nurses' station for assistance." A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurses's priority. A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. - C. Move clients who are nearby. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the clients and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession. - A. Complete a fall-risk assessment. A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy. B. A middle adult who requires telemetry for a possible myocardial infarction. C. A young adult who is postoperative following an open reduction internal fixation of the ankle. D. An older adult who is postoperative following a below-the-knee amputation. - D. An older adult who is postoperative following a below-the-knee amputation. A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. - B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following. [Show Less]
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Fundamentals of Nursing 10th Edition Potter Perry Test Bank 2022
Fundamentals of Nursing 10th Edition Potter Perry Test Bank
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TESTBANK Fundamentals_of_Nursing_9th_Edition_Taylor
Chapter 1, Introduction to Nursing 1. An oncology nurse with 15 years of experience, certification in the area of oncology nursing, and a master’s degr... [Show More] ee is considered to be an expert in her area of practice and works on an oncology unit in a large teaching hospital. Based upon this description, which of the following career roles best describes this nurse’s role, taking into account her qualifications and experience? A) Clinical nurse specialist B) Nurse entrepreneur C) Nurse practitioner D) Nurse educator Ans: A Feedback: A clinical nurse specialist is a nurse with an advanced degree, education, or experience who is considered to be an expert in a specialized area of nursing. The clinical nurse specialist carries out direct patient care; consultation; teaching of patients, families, and staff; and research. A nurse practitioner has an advanced degree and works in a variety of settings to deliver primary care. A nurse educator usually has an advanced degree and teaches in the educational or clinical setting. A nurse entrepreneur may manage a clinic or health-related business. 2. What guidelines do nurses follow to identify the patient’s health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes? A) Nursing process B) ANA Standards of Professional Performance C) Evidence-based practice guidelines D) Nurse Practice Acts Ans: A Feedback: The nursing process is one of the major guidelines for nursing practice. Nurses implement their roles through the nursing process. The nursing process is used by the nurse to identify the patient’s health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes. 3. Which of the following organizations is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice? A) American Nurses Association (ANA) B) American Association of Colleges in Nursing (AACN) C) National League for Nursing (NLN) D) International Council of Nurses (ICN) Ans: A Feedback: The ANA produces the 2003 Nursing: Scope and Standards of Practice, which defines the activities specific and unique to nursing. The AACN addresses educational standards, while the NLN promotes and fosters various aspects of nursing. TEST BANK FOR FUNDAMENTALS OF NURSING 9TH EDITION BY TAYLOR TESTBANKWORLD.ORGN The ICN provides a venue for national nursing organizations to collaborate, but does not define standards and scope of practice. 4. Who is considered to be the founder of professional nursing? A) Dorothea Dix B) Lillian Wald C) Florence Nightingale D) Clara Barton Ans: C Feedback: Florence Nightingale is considered to be the founder of professional nursing. She elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. Although the other choices are women who were important to the development of nursing, none of them is considered the founder. 5. Which of the following nursing pioneers established the Red Cross in the United States in 1882? A) Florence Nightingale B) Clara Barton C) Dorothea Dix D) Jane Addams Ans: B Feedback: Clara Barton volunteered to care for wounds and feed union soldiers during the civil war, served as the supervisor of nurses for the Army of the James, organized hospitals and nurses, and established the Red Cross in the United States in 1882. 6. A nurse practitioner is caring for a couple who are the parents of an infant diagnosed with Down Syndrome. The nurse makes referrals for a parent support group for the family. This is an example of which nursing role? A) Teacher/Educator B) Leader C) Counselor D) Collaborator Ans: C Feedback: Counseling skills involve the use of therapeutic interpersonal communication skills to provide information, make appropriate referrals, and facilitate the patient’s problem-solving and decision-making skills. The teacher/educator uses communication skills to assess, implement, and evaluate individualized teaching plans to meet learning needs of clients and their families. A leader displays an assertive, self-confident practice of nursing when providing care, effecting change, and functioning with groups. The collaborator uses skills in organization, communication, and advocacy to facilitate the functions of all members of the health care team as they provide patient care. 7. A nurse is providing nursing care in a neighborhood clinic to single, pregnant teens. Which of the following actions is the best example of using the counselor role as a nurse? TEST BANK FOR FUNDAMENTALS OF NURSING 9TH EDITION BY TAYLOR TESTBANKWORLD.ORGN A) Discussing the legal aspects of adoption for teens wishing to place their infants with a family B) Searching the Internet for information on child care for the teens who wish to return to school C) Conducting a client interview and documenting the information on the client’s chart D) Referring a teen who admits having suicidal thoughts to a mental health care specialist Ans: D Feedback: The role of the counselor includes making appropriate referrals. Discussing legal issues is the role of the advocate and searching for information on the Internet is the role of a researcher. Conducting a client interview would fall under the role of the caregiver. 8. A nurse instructor explains the concept of health to her students. Which of the following statements accurately describes this state of being? A) Health is a state of optimal functioning. B) Health is an absence of illness. C) Health is always an objective state. D) Health is not determined by the patient. Ans: A Feedback: Health is a state of optimal functioning or well-being. As defined by the World Health Organization, one’s health includes physical, social, and mental components and is not merely the absence of disease or infirmity. Health is often a subjective state; a person may be medically diagnosed with an illness but still consider himself or herself healthy. 9. A nurse incorporates the health promotion guidelines established by the U.S. Department of Health document: Healthy People 2010. Which of the following is a health indicator discussed in this document? A) Cancer B) Obesity C) Diabetes D) Hypertension Ans: B Feedback: The 10 leading indicators of health established by Healthy People 2010 are: physical activity, excessive weight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunizations, and access to health care. 10. Which of the following is a criteria that defines nursing as profession? A) an undefined body of knowledge B) a dependence on the medical profession C) an ability to diagnose medical problems D) a strong service orientation TEST BANK FOR FUNDAMENTALS OF NURSING 9TH EDITION BY TAYLOR TESTBANKWORLD.ORGN Ans: D Feedback: Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge; strong service orientation; recognized authority by a professional group; code of ethics; professional organization that sets standards; ongoing research; and autonomy. 11. After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice? A) Enrolling in an advanced degree program B) Filing NCLEX results in the county of residence C) Being licensed by the State Board of Nursing D) Having a signed letter confirming graduation Ans: C Feedback: The Board of Nursing in each state has the legal authority to allow graduates of approved schools of nursing to take the licensing examination. Those who successfully meet the requirements for licensure are given a license to practice nursing in the state. It is illegal to practice nursing without a license issued by the State Board of Nursing. A nurse does not have the legal right to practice nursing by enrolling in an advanced degree program, filing NCLEX results, or having a letter confirming graduation. 12. A health care facility determined that a nurse employed on a medical unit was documenting care that was not being given, and subsequently reported the action to the State Board of Nursing. How might this affect the nurse’s license to practice nursing? A) It will have no effect on the ability to practice nursing. B) The nurse can practice nursing at a less-skilled level. C) The nurse’s license may be revoked or suspended. D) The nurse’s license will permanently carry a felony conviction. Ans: C Feedback: The license and the right to practice nursing can be denied, revoked, or suspended for professional misconduct, such as a crime. Other areas of professional misconduct include incompetence, negligence, and chemical impairment. Committing a felony does affect the legal right to practice nursing, does not allow the nurse to practice at a lower level, and is not attached to the license. 13. While providing care to the diabetic patient the nurse determines that the patient has a knowledge deficit regarding insulin administration. This nursing action is described in which phase of the nursing process? A) evaluation B) implementation C) planning D) nursing diagnosis Ans: D TEST BANK FOR FUNDAMENTALS OF NURSING 9TH EDITION BY TAYLOR TESTBANKWORLD.ORGN Feedback: Nursing focuses on human responses to actual or potential health problems. Identifying the problems occur in the nursing diagnosis phase. Mutually establishing expected outcomes with the patient occurs in the planning phase. Implementation of the individualized interventions, and evaluation of outcomes are also phases in the nursing process. 14. A nurse is caring for a client who is a chronic alcoholic. The nurse educates the client about the harmful effects of alcohol and educates the family on how to cope with the client and his alcohol addiction. Which of the following skills is the nurse using? A) Caring B) Comforting C) Counseling D) Assessment Ans: C Feedback: The nurse is using counseling skills to educate the client about the harmful effects of alcohol. The nurse can also suggest rehabilitative care for the client. The nurse uses therapeutic communication techniques to encourage verbal expression and to understand the client’s perspective. Caring, comforting, and assessment may require active listening, but counseling is based upon the active listening and interaction between the client and the counselor. 15. A nurse is caring for a client with quadriplegia who is fully conscious and able to communicate. What skills of the nurse would be the most important for this client [Show Less]
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