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ATI FUNDAMENTALS FUNDAMENTALS OF NURSING EXAM 1 FULLY REVISED
Participants of health care systems - correct answer 1. consumers (clients) 2. licensed providers (RN, LPN, MD, PT, OT, etc.) 3. unlicensed providers (a... [Show More] ssistive personnel) Settings of the health care delivery system - correct answer hospitals, homes, assisted-living, schools, hospices, occupational health clinics, urgent care, etc. Regulatory agencies of health care delivery systems - correct answer 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 - correct answer medicare (65 or older and those who have permanent disabilities), medicaid (low income), private plans Levels of health care - correct answer 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 - correct answer 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 - correct answer 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 - correct answer use of current knowledge from research and other credible sources on which to base clinical judgement and client care Informatics - correct answer the use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically-based nursing practice Quality improvement - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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) a. Intensive care unit b. Oncology treatment center c. Burn center d. Cardiac rehabilitation e. Home health care - correct answer a. Intensive care unit b. Oncology treatment center c. Burn center interprofessional personnel (non-nursing) - correct answer spiritual support staff, registered dietitian, laboratory technician, occupational therapist, pharmacist, physical therapist, provider, radiologic technologist, respiratory therapist, social worker, speech-language pathologist nursing personnel - correct answer 1. RN (registered nurse) 2. PN (practical nurse) 3. AP (assistive personnel) 4. APN (advanced practical nurse) - CNS (clinical nurse specialist) - NP (nurse practitioner) - CRNA (certified registered nurse anesthetist) - CNM (certified nurse-midwife) 5. Nurse educator 6. Nurse administrator 7. Nurse researcher 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 requests hospice care for the home b. A client asks about community resources available for older adults c. A client states, "I would like to have my child baptized before surgery." d. A client requests an electric wheelchair to use after discharge e. A client states, "I do no - correct answer a. A client who has terminal cancer requests hospice care for the home b. A client asks about community resources available for older adults d. A client requests an electric wheelchair to 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 - correct answer d. 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) a. provider b. certified nursing assistant c. pharmacist d. registered nurse e. respiratory therapist - correct answer a. provider c. pharmacist d. 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? a. social worker b. certified nursing assistant c. occupational therapist d. speech-language pathologist - correct answer d. 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 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 that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - correct answer A. Bathing B. Ambulating C. Toileting E. Measuring vital signs basic principles of ethics - correct answer advocacy, responsibility, accountability, confidentiality autonomy - correct answer the right to make one's own personal decisions, even when those decisions might not be in that person's best interests beneficence - correct answer action that promotes good for others, without any self-interest fidelity - correct answer fulfillment of promises justice - correct answer fairness in care delivery and use of resources nonmaleficence - correct answer a commitment to do no harm veracity - correct answer a commitment to tell the truth ethics committee - correct answer generally address unusual or complex ethical issues moral distress - correct answer occurs when the nurse is placed in a difficult situation where the actions taken are different from what the nurse feels is ethically correct 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? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence - correct answer 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 - correct answer d. Beneficence A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that the 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 - correct answer 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 - correct answer d. 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. 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 the bed, she will have to apply restraints c. A family has conflicting feelings about the initiation of e - correct answer c. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill Federal regulations - correct answer Health Insurance Portability and Accountability Act (HIPAA), Americans with Disabilities Act (ADA), Mental Health Part Act (MHPA), Patient Self-Determination Act (PSDA) unintentional torts: negligence - correct answer a nurse fails to implement safety measures for a client at risk for falls unintentional torts: malpractice - correct answer a nurse administers a large dose of medication due to a calculation error, the client has cardiac arrest and dies quasi-intentional torts: breach of confidentiality - correct answer a nurse releases a client's medical diagnosis to a member of the press quasi-intentional torts: defamation of character - correct answer a nurse tells a coworker that they believe the client has been unfaithful to their partner intentional torts: - correct answer assault, battery, false imprisonment 5 elements to prove negligence - correct answer 1. duty to provide care as defined by a standard 2. breach of duty by failure to meet standard 3. foreseeability of harm 4. breach of duty has potential to cause harm 5. harm occurs refusal of treatment - correct answer PSDA stipulates that staff must inform clients of their right to accept or refuse care, including the right to leave a facility without a discharge prescription from the provider living will - correct answer legal document that expresses that client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues power of attorney - correct answer client designates health care proxy to make health care decisions for them if they are unable to provider's order regarding DNR and AND - correct answer unless a provider writes a "do not resuscitate" (DNR) or "allow natural death" (AND), then the nurse initiates CPR when the client has no pulse or respirations 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 - correct answer a. 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? a. assault b. false imprisonment c. negligence d. breach of confidentiality - correct answer b. false imprisonment A nurse in a surgeon's office is providing preperative 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 - correct answer c. "I plan to write that I don't 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? (select all) 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 - correct answer a. Make sure the surgeon obtained the client's consent b. Witness the client's 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? 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 - correct answer c. report the observations to the nurse manager on the unit The Joint Commision (TJC) - correct answer mandates the use of computerized databases to expedite the accreditation process elements of documentation - correct answer factual, accurate and concise, complete and current, organized flow charts - correct answer show trends in vital signs, blood glucose levels, pain level, and other frequent assessments narrative documentation - correct answer records information as a sequence of events in a story-like manner charting by exception - correct answer uses standardized forms that identify norms and allows selective documentation of deviations from those norms problem-oriented medical records - correct answer are organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes. Examples include SOAP, PIE, and DAR. electronic health record - correct answer replacing manual formats in many settings change of shift report - correct answer nurse gives this report at the conclusion of each shift to the nurse assuming responsibility for the clients telephone reports - correct answer useful when contacting the provider or other members of the interprofessional team. important to have all the data ready prior to contacting any member of the interprofessional team, use a professional demeanor, use exact, relevant, and accurate information, document the name of person, time, content of the message, and the instructions or information received during the report. telephone or verbal prescriptions - correct answer best to avoid these, but they are sometimes necessary during emergencies and at unusual times. have a second nurse listen to a telephone prescription, repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. question any prescription that may seem inappropriate for the client. make sure the provider signs the prescription in person within the time frame the facility specifies typically 24 hrs. transfer (hand-off) reports - correct answer include demographic information, medical diagnosis, providers, etc. most recent vitals, medications and last doses, allergies, diet, etc. incident report - correct answer document facts without judgment or opinion, do not refer an incident report in a client's medical record SOAP - correct answer subjective, objective, assessment, plan PIE - correct answer problem, intervention, evaluation DAR - correct answer data, action, response A nurse is preparing information for a 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 - correct answer c. Bone scan scheduled for today A nurse manager is discussing the HIPAA privacy rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (select all) a. A single electronic records password is provided for nurses on the same unit b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurses' station d. A client can request a copy of their medical record e. A nurse can - correct answer b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurses' station d. A client can request a copy of their medical record e. A nurse can photocopy a client's 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 client's record? (select all) a. Cover errors with correction fluid and write in the correct information b. Put the date and time on all entries c. Document objective data, leaving out opinions d. Use as many abbreviations as possible e. Wait until the end of the shift to document - correct answer b. Put the date and time on all entries c. Document objective data, leaving out opinions A nurse is discussing occurrences that require completion of an incident report with newly licensed nurses. Which of the following should the nurse include in the teaching? (select all) a. medication error b. needle-sticks c. conflict with provider and nursing staff d. omission of prescription e. missed specimen collection of a prescribed laboratory test - correct answer a. medication error b. needle-sticks d. 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) a. repeat the details of prescription back to provider b. have another nurse listen to the phone call c. obtain the provider's signature on the prescription within 24 hr d. decline the verbal prescription because it is not an emergency e. tell the charge nurse that the provider has prescribed morphi - correct answer a. repeat the details of prescription back to provider b. have another nurse listen to the phone call c. obtain the provider's signature on the prescription within 24 hr RNs can delegate to - correct answer other RNs, PNs and AP delegation factors - correct answer -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 - correct answer right task, right circumstance, right person, right direction and communication, right supervision and evaluation 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 (AP)? a. updating the plan of care for a client who is postoperative b. reinforcing teaching with a client who is learning to walk using a quad cane c. reapplying a condom catheter for a client who has urinary incontinence d. applying a sterile dressing to a pressure injury - correct answer c. 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? a. Charge nurse b. RN c. practical nurse PN d. assistive personnel AP - correct answer b. RN A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? (select all) a. the roommate ambulates independently b. The client ambulates with his slippers on over his antiembolic stockings c. The client uses a front wheeled walker when ambulating d. The client had pain meds 30 minutes ago e. The client is allergic to codeine f. the client ate 50 % of his breakfast this morning - correct answer b. The client ambulates with his slippers on over his antiembolic stockings c. The client uses a front wheeled walker when ambulating d. The client had pain meds 30 minutes ago A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? a. creating a plan of care for a client who is recovering following a stroke b. assessing a pressure injury on a client who is on bed rest c. providing nasopharyngeal suctioning for a client who has pneumonia d. teaching a client who has asthma to use a metered-dose inhaler - correct answer c. 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 fiver rights of delegation? (select all) a. right place b. right supervision and evaluation c. right direction and communication d. right documentation e. right circumstances - correct answer b. right supervision and evaluation c. right direction and communication e. right circumstances nursing process - correct answer five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating 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? a. reassess the client to determine the reasons for inadequate pain relief b. wait to see whether the pain lessens during the next 24 hr c. change the plan of care to provide different pain relief interventions d. teach the client about the plan of care for managing pain - correct answer a. 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? a. assessment b. planning c. intervention d. evaluation - correct answer a. 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) a. respiratory rate is 22/min with even, unlabored respirations b. the client's partner states, "they said they hurt after walking about 10 minutes" c. the client's pain rating is 3 on a scale of 0 to 10 d. the client's skin is pink, warm and dry e. the assistive personnel reports that the client walked with a limp - correct answer a. respiratory rate is 22/min with even, unlabored respirations d. the client's skin is pink, warm and dry e. 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) a. writing a prescription for morphine sulfate as needed for pain b. inserting a nasogastric (NG) tube to relieve gastic distention [Show Less]
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ATI - FUNDAMENTALS PRACTICE QUIZ 1 WITH REVISED ANSWERS
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. - correct answer 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 - correct answer 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 - correct answer 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. - correct answer 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 - correct answer 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." - correct answer "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. - correct answer 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. - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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. - correct answer 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? - correct answer 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. - correct answer 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. - correct answer 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 - correct answer Confirm unresponsiveness A community health nurse is preparing a campaign about seasonal influenza. Which plan should nurse include as secondary prevention? Holding community clinic for flu shots Screening groups of older adults in skilled nursing facilities for early signs of influenza Educating parents of young children about dangers of influenza Finding rehab programs for older adults with complications from the flu - correct answer Screening groups of older adults in skilled nursing facilities for early signs of influenza Nurse is preparing to provide tracheostomy care for patient. Which action should nurse take first? Open all sterile supplies and solutions. Sterilize tracheostomy tube don sterile gloves perform hand hygiene - correct answer perform hand hygiene Nurse is obtaining BP in client's lower extremity. Which of the following actions should the nurse take? Ausculate for BP at dorsalis pedis artery Measure BP with client sitting at edge of bed. Place cuff 3 in above popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh - correct answer Place the bladder of the cuff over the posterior aspect of the thigh Nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which action should the nurse take FIRST? Explain procedure to client. Help client into wheelchair before the transporter arrives Ask if client has any questions Identify the client using 2 identifiers - correct answer Identify the client using 2 identifiers An ED nurse is assessing a client who reports diarrhea and decreased urination for 4 days. Which action should the nurse take to assess for skin turgor- results from dehydration? Push fingernail bed until it blanches, release, observe how long it takes for it to regain color. Grasp a skin fold on chest under clavicle, release, not whether tenting occurs. Press skin in above ankle for 5 seconds, release, note the depression. Measure skin fold thickness at upper arm using calipers. - correct answer Grasp a skin fold on chest under clavicle, release, not whether tenting occurs. Teaching for an older adult who has constipation should include which of the following recommendations? Drink a minimum of 1000 mL fluid daily Increase intake of refined-fiber foods. Sit on toilet 30 minutes after eating a meal Take a laxative every day to maintain regularity - correct answer Sit on toilet 30 minutes after eating a meal (To prevent constipation, must drink 1500 mL or more, and increase intake of coarse-fiber foods/whole-grains). Which action should nurse take first when using nursing process to care for a new client? Identify goals for client care Obtain client information Document nursing care needs Evaluate effectiveness of care - correct answer Obtain client information Nurse on rehab unit is preparing to transfer a client who is unable to ambulate from bed to wheelchair. Which technique should nurse use? Stand on client's strong side Instruct client to lean backward from hips Place wheelchair at 45 degree angle to bed Assume narrow stance - correct answer Place wheelchair at 45 degree angle to bed A nurse is planning weight-loss strategies for a group of obese clients. Which of the following actions by the nurse will improve the clients' commitment to long-term weight loss? Attempt to increase clients' self-motivation Keep detailed records of each client's progress Test client learning after each teaching session Avoid discussing areas that might cause client anxiety - correct answer Attempt to increase clients' self-motivation The provider prescribes soft wrist restraints for an older adult client who is violent and attempting to pull out IV lines. Which action is appropriate for client in restraints? Tie restraints to side rails Perform wrist ROM every 3 hr Remove restraints one at a time Obtain PRN order for restraints - correct answer Remove the restraints one at a time A nurse is caring for a client who is in the terminal stage of cancer. Which action should the nurse take when she observes the client crying? Contact family and ask them to stay with the client Offer to call client's minister Sit and hold client's hand Leave the room and allow the client to cry privately. - correct answer Sit and hold client's hand A nurse in oncology clinic is assessing pt. undergoing treatment for ovarian cancer. Which statement indicates she is undergoing psychological distress? My parents are retired and they have to come help me with children I'm going to ask my husband to go to counseling with me. I keep having nightmares about my upcoming surgery My girlfriends bought me a nice wig - correct answer I keep having nightmares about my upcoming surgery Correct order of abdominal assessment of adult client - correct answer Inspection, auscultation, percussion, palpation Which of the following actions of a newly licensed nurse performing tracheostomy care would require intervention by the charge nurse (must be corrected)? Obtaining hydrogen peroxide for trach care Obtaining cotton balls for trach care Obtaining sterile gloves for trach care Obtaining sterile brush for trach care - correct answer Cotton balls- can be aspirated into trach opening A nurse is admitting a client with decreased circulation in left leg. Which action should nurse take first? Evaluate pedal pulses Obtain medical history measure vitals assess for leg pain - correct answer evaluate pedal pulses A nurse is prepping a client who is scheduled for a hysterectomy for transport to OR when the client states she no longer wants to have surgery. Which action should nurse take? Tell client it is too late to change her mind before surgery Telephone OR and cancel surgery Inform client's family about situation Notify provider about client's decision - correct answer Notify provider about client's decision Following a procedure that will happen next month, a client may require a blood transfusion. The client expresses concern to the nurse that they may acquire infection from it. Which response is appropriate from the nurse? Ask provider to order EPO before surgery You should ask provider about iron supplements prior to surgery Request family member to donate blood Donate autologous blood before surgery - correct answer Donate autologous blood before surgery Nurse is demonstrating post-op deep breathing and cough exercises to client who will have emergency surgery for appendicitis. Which client statement indicates lack of readiness to learn? Client asks for nurse to repeat instructions before attempting exercises client reports severe pain Client asks how often deep breathing should be done post-op Client tells the nurse that this exercise will probably be painful after surgery - correct answer Client reports severe pain Nurse observes another staff member using a regular size BP cuff for a client who is obese. Which explanation should she give? Reading will be inaudible if cuff is too small Width of cuff bladder should be 75% of circumference of arm As long as cuff will circle arm, reading is accurate Using cuff that is too small results in inaccurately high reading - correct answer Using cuff that is too small results in inaccurately high reading Nurse is inserting IV catheter for client that results in blood spill on her gloved hand. Client has no documented bloodstream infection. Which of the following actions should the nurse take? Wash gloved hands and then throw away gloves Prepare an incident report to document the vent Carefully remove the gloves and follow with hand hygiene Ask a provider to order a blood culture to determine the risk of infection - correct answer Carefully remove the gloves and follow with hand hygiene A nurse is receiving client from PACU who is post-op following abdominal surgery. Which action should nurse take to transfer client from stretcher to bed? Lock wheels of bed and stretcher Instruct client to raise arms above head Elevate stretcher 1 inch above height of bed Log roll client - correct answer lock wheels of bed and stretcher A nurse is performing mouth care for unresponsive client. Which action should nurse plan to take? Place client supine Keep both side rails up Raise level of bed Inspect client's mouth using finger sweep - correct answer Raise level of bed [Show Less]
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ATI FUNDAMENTALS PRACTICE TEST C QUESTIONS TOGETHER WITH WELL EXPLAINED ANSWERS
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the fol... [Show More] lowing routes should the nurse use to obtain the temperature? - correct answer Temporal A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse takes when she observes the client crying? - correct answer Sit and hold the client's hand A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? - correct answer Screening groups of older adults in nursing care facilities for early influenza manifestations A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? - correct answer "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. - correct answer - Inspection - Auscultation - Percussion - Palpation A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? - correct answer Second intercostal space to the right of the sternum A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? - correct answer Count the apical pulse rate for 1 minute, and describe the rhythm in the chart A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? - correct answer "Using a cuff that is too small will result in an inaccurately high reading." A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? - correct answer Evaluate pedal pulses A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? - correct answer Perform hand hygiene A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? - correct answer Identify the client using two identifiers A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - correct answer Place the bladder of the cuff over the posterior aspect of the thigh A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? - correct answer The nurse washes with her hands held higher than her elbows A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notes the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? - correct answer Disconnect the machine, and measure the blood pressure manually every 15 minutes A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? - correct answer Raise the level of the bed A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? - correct answer Carefully remove the gloves and follow with hand hygiene A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? - correct answer Pericardial friction rub A nurse is teaching a group of older adults about expected changes of aging. Which of the following statement by a group member indicates that the teaching had been effective? - correct answer "I should expect my heart rate to take longer to return to normal after exercise as I get older." A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? - correct answer Confirm unresponsiveness A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? - correct answer "Donate autologous blood before the surgery." A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? - correct answer Attempt to increase the clients' self-motivation A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? - correct answer Lock the wheels on the bed of the stretcher A nurse is witnessing a client sign an informed consent for surgery. Which of the following describes what the nurse is affirming by this action? - correct answer The signature on the preoperative consent form is the client's A nurse is demonstrating postoperative deep breathing and cough exercised to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? - correct answer The client reports severe pain A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? - correct answer Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? - correct answer Encourage the client to express his thoughts about death and dying A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft non-tender abdomen, and menses overdue my 2 days. Which of the following findings should be the nurse's priority? - correct answer Temperature A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? - correct answer The involvement of the client in planning the change A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removes prior to surgery. Which of the following responses should the nurse make? - correct answer "What worries you about being without your teeth?" A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? - correct answer Absent bowl sounds with distention A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? - correct answer Place the wheelchair at a 45 degree angle to the bed A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? - correct answer Administer analgesics to the child on routine schedule throughout the day and night A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? - correct answer Remove the restraints one at a time A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? - correct answer "Sit on the toilet 30 minutes after eating a meal." A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse required intervention? - correct answer Obtaining cotton balls for the tracheostomy A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? - correct answer Assessment A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? - correct answer Notify the provider about the client's decision A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? - correct answer Obtain client information A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? - correct answer "I keep having nightmares about my upcoming surgery." A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learnings self-injection of insulin. Which of the following statements should the nurse make? - correct answer "Tell me what I can do to help you overcome your fear of giving yourself injections." A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following action should the nurse take? - correct answer Don clean gloves to remove the old dressing A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? - correct answer Collapse the device of air after emptying A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? - correct answer Clamp the tubing below the collection port A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? - correct answer Granulation tissue fills the wound during healing A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? - correct answer Cleanse the skin around the stoma with warm water A nurse is helping a client charge his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? - correct answer Remove the sleeve of the gown from the arm without the IV line A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decease skin irritation? - correct answer Montgomery straps A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injections - correct answer The side hip between the iliac crest and anterior iliac spine A nurse is caring for a client who had an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? - correct answer Elevate the client's head of bed 45 degrees before the feeding A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? - correct answer A halo of erythema on the surrounding skin A nurse is performing eye irrigations for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? - correct answer Exert pressure on the bony prominences when holding the eyelids open A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? - correct answer "What do you think caused the onset of your pain?" A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? - correct answer A client who has heart failure and is receiving 100 oxygen via partial rebreather mask A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? - correct answer Offer the client tart or sour foods first A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying stockings? - correct answer Turn the stocking inside out up to the heel before applying A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? - correct answer Determine whether the client is able to breathe A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? - correct answer Use a gait belt during ambulation A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? - correct answer Start chest compressions A nurse is planning to collect stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? - correct answer Place the stool specimen collection container in a biohazard bag A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? - correct answer Pull suction catheter back 1cm (0.5 inch) if the client starts coughing A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse including in the teaching? - correct answer Hold breath for 5 seconds after goal volume is reached A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plans to take? - correct answer Hold the linens away from the body and clothing A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? - correct answer Pinch the NG tube while removing the tube A nurse is caring for a client who is postoperative following vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? - correct answer "I am going to listen to your abdomen." A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? - correct answer Vitamin C and zinc A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? - correct answer Explain the procedure to the client A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? - correct answer Lower abdomen A nurse is caring for a toddler at the well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicated the toddler has an airway obstruction? - correct answer Inability of the toddler to cry or speak A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? - correct answer Collect the specimen upon arising in the morning A nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which of the following actions should the nurse take first? - correct answer Check the client's perineum A nurse is changing the dressings for a client who is 2 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? - correct answer Purulent exudate A nurse is planning care for a client who is confused and required a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? - correct answer Renew the prescription for the use of restraints within 24 hours A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? - correct answer Weigh the client on arising A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? - correct answer Face the client when speaking A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? - correct answer Drop the eye medication into the lower conjunctival sac A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? - correct answer Use the pain scale to determine the client's pain level A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? - correct answer Insert the tip of the tubing 8 cm (3.1 inches) A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? - correct answer Check to determine if the catheter tubing is kinked A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? - correct answer Taut skin around the IV catheter site that is cool to the touch A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? - correct answer Wipes the labia minora in an anteroposterior direction [Show Less]
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ATI PROCTORED FUNDAMENTALS EXAM 2023 WITH GRADED A+ ANSWERS
A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?... [Show More] - correct answer You can decline to have certain medical procedures performed in your living will. A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the client indicates in understanding of the teaching? - correct answer "I might have headaches due to a decline in my estrogen levels. A nurse in a provider's office is calculating a client's BMI. Which of the following pieces of the client data should the nurse use as a part of the calculation? - correct answer Height A nurse is reinforcing teaching with a client about the use of a peak flow meter. Which of the following actions should the nurse make first? - correct answer Determine the client's knowledge of the use of the peak flow meter A nurse is collecting data about a client's oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores? - correct answer Wears dentures while sleeping at night. A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to make? - correct answer Use a filter needle to aspirate the medication. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard? - correct answer An assistive personnel raises all four side rails of a client's bed before leaving the room A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss? - correct answer I need to learn how to perform a dressing change on my leg. A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse make? - correct answer Measure the client's BP in the other arm A nurse is assisting with the admission of a client who has streptococcal pharyngitis. Which of the following precautions should the nurse make? - correct answer Wear a surgical mask when giving the client direct care A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following images indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration - correct answer non-rebreather mask mask with bag A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has difficulty swallowing during meals. Which of the following actions should the nurse take to prevent the client from aspiration while eating? - correct answer Add liquid to foods to thin consistency A nurse in a provider's office performs a fecal occult blood test with a positive result on a client. Which of the following clients may have a false positive result? - correct answer A client who takes an iron supplement. A nurse is caring for a client who is flushed and has temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? - correct answer Remove blankets from the client A nurse is caring for a client who has a hip fracture and plans to administer a pain medication prior to turning the client. Which of the following ethical principles is the nurse implementing? - correct answer Beneficence A nurse is caring for a client who was recently admitted to hospice care and tells the nurse "I am going to die, and my family is hoping for a cure. I am mad that they behave like everything will be fine." Which of the following responses should the nurse make? - correct answer You are feeling angry that your family continues to wish for a cure? A nurse in a provider's office is reviewing the medical record of an older adult who report's having nausea and vomiting for the last 48 hrs. Which of the following findings indicate fluid volume deficit? (Select all that apply.) - correct answer Dry mucous membranes. Decreased skin turgor. Blood pressure 88/62 mm Hg A nurse is caring for a client who refuses a prescribed medical procedure. Which of the following actions should the nurse take to act as the client's advocate? - correct answer Evaluate the client's concerns and communicate them to the provider A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis? - correct answer Unequal height of the shoulders. A nurse is disinfecting the room of a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use? - correct answer Chlorine bleach A nurse is reinforcing teaching with a client who follows a vegan diet and is interested in ways to increase protein to promote healing after a recent surgery. Which of the following suggestions is appropriate? - correct answer Grilled salmon. A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, "I don't know what to do because he's not eating." Which of the following responses should the nurse make? - correct answer tell me more about what happens at mealtime. A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? - correct answer Reinforce teaching with a client about crutch-gait walking. A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for the procedure. Which of the following actions should the nurse take? - correct answer Obtain verbal consent from the client. A nurse is planning to place a client into the Sims' position. Which of the following actions should the nurse plan to take? - correct answer Place a pillow under the client's flexed leg A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include? - correct answer Avoid placing the toilet tissue in the bedpan after defecation. A nurse is planning to apply a belt restraint to a client who is confused and at risk for falls. Which of the following actions should the nurse make - correct answer Fasten the client's restraint using a quick-release tie A nurse is collecting data from a client following lumbar puncture. For which of the following adverse effects of the procedure should the nurse monitor the client? - correct answer Headache. A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider? - correct answer Calf swelling A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following interventions should the nurse give the client to prevent orthostatic hypotension? - correct answer dangle your legs over the side of the bed. A nurse is caring for a client who speaks a different language than the nurse and is 6 hrs postoperative. Which of the following actions should the nurse take to determine the client's level of pain? - correct answer Use a communication board to interact with the client. A nurse is performing a wound irrigation for a client who has methicillin-resistant. Staphylococcus aureus. When removing personal equipment, which of the following pieces should the nurse remove first? - correct answer Gloves While performing hygiene care for a client, a nurse notices a frayed electrical cord on the clients electronic BP monitor. Which of the following actions should the nurse take first? - correct answer Remove the device from the room A nurse is reinforcing teaching with a male client about collecting a mid-stream urine specimen. Which of the following interactions should the nurse include? - correct answer urinate into the toilet and then place the cup into the stream to collect urine. A nurse is reinforcing teaching with a client who has a new ileostomy about nutrition therapy. Which of the following food choices by the client demonstrates an understanding of the teaching? - correct answer Bananas. A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk? - correct answer Throw rugs over electrical cords on the floor. A nurse is collecting data from a client who had a stroke and is unable to name common items. The nurse should recognize that the client's experiencing which of the following types of aphasia? - correct answer Expressive aphasia. A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect? - correct answer Hyponatremia A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider? - correct answer Gastric contents are present in the air vent. A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious which of the following actions by the AP requires intervention by the nurses? - correct answer Using two gloved fingers to open the client's mouth for cleaning A nurse is reinforcing teaching with a client who is learning to use a walker and his left- leg weakness. Which of the following instructions should the nurse include in the teaching? - correct answer Move your right leg forward as you advance the walker" A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique? - correct answer I'll think about my grandfather's farm to reduce pain A nurse is assisting a client who is 4hr postoperative to get out of bed. The client states, "Do not touch me! I can get up by myself." Which of the following response should the nurse make? - correct answer i will be right next you and i will help you if you need to A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during death and dying. Which of the following information should the nurse include? - correct answer Devout practitioners of Islam prefer to have their heads turned toward Mecca at death A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend? - correct answer walking A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to promote commucation? - correct answer Decrease background noise A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur? - correct answer The sterile solution is poured with the bottle held over the field A nurse is reinforcing teaching with the adult children of a client who is receiving palliative care. Which of the following statements by one of the adult children indicates an understanding of the teaching? - correct answer We will receive emotional support during our mother's illness" A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps - correct answer Separate the labia with the nondominant hand 2) Clean around the urinary meatus from front to back 3) Insert the catheter into the urethral meatus 4) Inflate the catheter balloon 5) Secure the catheter to the client's thigh A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take? - correct answer Ask the partner about any rituals they would like to be performed A nurse is reinforcing teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object? - correct answer Tighten the abdominal muscles A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take? - correct answer Ask the caller to contact the client directly for information A nurse is caring for a client who is experiencing fecal incontinence. Which of the following actions should the nurse take? - correct answer Increase the client's intake of raw fruits and vegetables A nurse is caring for a client who has difficulty swallowing following a stroke. Which following actions should nurse take when administering an oral medication to this client? - correct answer Place the client in high-Fowler's position A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take? - correct answer Have the client sign an against medical advice form A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration? - correct answer Speech A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record - correct answer Oral temperature elevated at 0800 A nurse is in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate - correct answer mcg A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy - correct answer I will speak with your provider on your behalf" A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include? - correct answer Restrict visitors during meals A nurse is monitoring a client's oxygen saturation using a pulse oximeter. The client's oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take? - correct answer Reposition the sensor probe A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C - correct answer 1 small pink grapefruit A nurse in an acute care center is caring for a client who just died. The client's family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make? - correct answer I will assist you in any way I can during this process A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands - correct answer Interlock her fingers and hold her hand away from her body above her waist A nurse is assisting in the transfer of a client who has left-side weakness from a bed to chair. Which of the following actions should the nurse take? - correct answer Flex hips and knees when assisting the client to a standing position [Show Less]
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ATI FUNDAMENTALS PRACTICE TEST A WITH AVAILABLE ANSWERS
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 of ... [Show More] the following actions should the nurse take? - correct answer Ask another nurse to observe the medication wastage 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) - correct answer 107... 750mL/7hr = 107.14 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? - correct answer we would give you oxygen through a tube in your nose 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? - correct answer determine the reasons why the client is refusing to use the incentive spirometer 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? - correct answer pad the clients wrists before applying the restraints 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? - correct answer let's talk about how the change in your job status will affect you a nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? - correct answer droplet a nurse is caring for a group of clients. which of the following actions should the nurse take to prevent the spread of infection? - correct answer place a client who has tuberculosis in a room with negative-pressure airflow 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) - correct answer pupil clarity, visual fields, visual acuity 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. - correct answer 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 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? - correct answer it might help me to listen to music while i'm lying in bed 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? - correct answer use tracheostomy covers when outdoors 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? - correct answer during the admission process 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? - correct answer is your pain sharp or dull? 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? - correct answer examine personal values about the issue a nurse is reviewing a client's fluid and electrolyte status. which of the following findings should the nurse report to the provider? - correct answer potassium 5.4 mEq/L 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? - correct answer apply intermittent suction when withdrawing the catheter 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? - correct answer abdominal cramping 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? - correct answer i can concentrate best in the morning 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? - correct answer situation, background, assessment, and recommendation (SBAR) 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? - correct answer i am available to talk if you should change your mind 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? - correct answer notify the nursing manager a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? - correct answer advocacy ensures client's safety, health and rights 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? - correct answer i will hire someone to trim the tree that hangs low over the stairs of my front porch 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? - correct answer have the client take sips of water to promote insertion of the NG tube into the esophagus a nurse is caring for a client who has diarrhea due to shigella. which of the following precautions should the nurse implement for this client? - correct answer wear a gown when caring for the client a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client? - correct answer use a bed exit alarm system a nurse is caring for a client who is postoperative. when the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." which of the following interventions is the nurse's priority action? - correct answer administer pain medication 45 min before changing the client's dressing a nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first? - correct answer check the client for injuries a nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that this condition is a contraindication for which of the following therapies? - correct answer acupuncture a nurse us admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? - correct answer compare the client's home medications with the provider's prescriptions a nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of the following types of transmission precautions should the nurse initiate? - correct answer contact precautions 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 in their airway. which of the following actions should the nurse take? - correct answer turn the client every 2 hr a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement? - correct answer use the planning step of the nursing process to prioritize client care delivery a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include? - correct answer regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol? - correct answer the client uses nonacetone nail polish remover 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? Select all that apply? - correct answer 1) assist the client with a partial bed bath 2) measure the client's BP after the nurse administers an antihypertensive medication 3) use a communication board to ask what the client wants for lunch 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? - correct answer make sure the client wears a mask when outside her room if there is construction in the area 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? - correct answer place the client's arm in a dependent position a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of a thigh-length sequential compression device. which of the following actions should the nurse take? - correct answer make sure two fingers can fit under the sleeves a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? - correct answer stand close to the cabinet when lifting it a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should the nurse manager plan to include in the teaching? - correct answer use the complete name of the medication magnesium sulfate 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? - correct answer subtract the amount of irrigant used from the client's urine output 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 the client has developed thrombophlebitis? - correct answer calf swelling a nurse is administering 1 L of 0.9% NaCl 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? - correct answer decrease in heart rate a nurse is assessing four adult clients. which of the following physical assessment techniques should the nurse use? - correct answer ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm a nurse is auscultating the anterior chest of a client newly admitted to a medical-surgical unit. listen to the audio clip of what the nurse auscultates through his stethoscope and identify the type of breath he hears - correct answer normal breath sounds a nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to ensure that the medication reaches the inner ear? - correct answer press gently on the tragus of the client's ear a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which of the following types of dressing should the nurse use? - correct answer hydrocolloid a nurse is performing a skin assessment for a client who expresses concern about skin cancer. which of the following findings should the nurse identify as a potential indication of a skin malignancy? - correct answer a mole with an asymmetrical appearance 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? - correct answer the client holds the cane on the stronger side of her body 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? - correct answer administer the medication into the abdomen a nurse is preparing to administer enoxaparin subcutaneously to a client. which of the following actions should the nurse take? - correct answer administer the medication with the needle at a 45 degree angle [Show Less]
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ATI FUNDAMENTALS PRACTICE TEST B QUESTIONS AND ANSWERS
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 reconc... [Show More] iliation process? - correct answer compare prescriptions with medications the client received while are the facility a nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider? - correct answer medication dose a nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? - correct answer a client who has asthma a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate? - correct answer droplet a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? - correct answer gently shake the container of medication prior to administration a nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following? - correct answer narrowed arterial lumen a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? - correct answer withhold the blood transfusion a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include? - correct answer current medications a nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene? - correct answer erythema on pressure points a nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning? - correct answer practice sessions 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? - correct answer the pain is like a dull ache in my stomach a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? - correct answer initiate an enteral feeding through a gastrostomy tube 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? - correct answer evacuate the client a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use? - correct answer i can take echinacea to improve my immune system 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? - correct answer client found lying on floor a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use? - correct answer have the client stand with their arms at their sides and their feet together 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? - correct answer when descending the stairs, i will first shift my weight to my right leg a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? - correct answer flush the tube with 15 mL of sterile water a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension? - correct answer a client who smokes one pack of cigarettes each day a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding? - correct answer arrange food in a consistent pattern on the client's plate a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include? - correct answer you should receive a pneumococcal immunization every 10 years 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? - correct answer rapid heart rate a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? - correct answer auscultate lung sounds a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? - correct answer apply an ankle-foot orthotic device to the client's feet a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client? - correct answer N95 respirator a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? - correct answer wrap monitoring cords with stockinette and tape them in place a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? - correct answer distended neck veins a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown? - correct answer have the client use a trapeze bar when changing position a nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take? - correct answer instruct the family to refrain from pushing the button for the client while she is asleep a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement? - correct answer an x-ray shows the end of the tube above the pylorus a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse? - correct answer the caregiver insists on remaining in the room a nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next? - correct answer assess the client for orthostatic hypotension a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care? - correct answer wrap blankets around all four sides of the bed a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family? - correct answer 1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia 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? - correct answer tell the client to keep the head of the bed elevated at least 30 degrees a nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advance directives. which of the following responses should the nurse make? - correct answer we can talk about advance directives, and i can also give you some brochures about them A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? - correct answer 8 oz of ice chips a nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining blood pressure? - correct answer the one close to 120 mm Hg a nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take? - correct answer cleanse the wound from the center outward A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting - correct answer have family members wear a gown and gloves when visiting a nurse is caring for a client who requires a 24 hr urine collection. which of the following statements by the client indicates an understanding of the teaching? - correct answer i flushed what i urinated at 7 am and have saved all urine since a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure - correct answer 1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle a nurse is preparing to delegate client care tasks to an assistive personnel. which of the following tasks should the nurse delegate? - correct answer ambulating a client who is postoperative a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? select all that apply - correct answer 1)place the client in a room with negative-pressure airflow 2) wear gloves when assisting the client with oral care 3) use antimicrobial sanitizer for hand hygiene a nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has a myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? - correct answer 0.3 mg a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse? - correct answer the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field a nurse is caring for a group of medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity? - correct answer a client is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively a nurse is caring for a client who requires consent for a surgical procedure. which of the following actions is the nurse's responsibility? - correct answer witness the client's signature on the consent form a nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? - correct answer a nurse asks a nurse from another unit to assist with documentation for a client a middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? - correct answer people in middle adulthood often find satisfaction in nurturing and guiding young people a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make? - correct answer maintain a consistent time to wake up each day a nurse is caring for a client who is receiving fluids through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration? - correct answer skin blanching a nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does this involve?" which of the following responses should the nurse make? - correct answer you should have a fecal occult blood test every year a nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? - correct answer what could i have done to deserve this illness? a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take? - correct answer select a suction catheter that is half the size of the lumen 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? - correct answer i will be sure to remove my hearing aid before taking a shower a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend? - correct answer walking briskly a nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide? - correct answer breath sounds a nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? - correct answer 8 mL/hr a nurse is caring for a client who has an indwelling catheter. which of the following findings indicates that the catheter requires irrigation? - correct answer bladder scan shows 525 mL of urine [Show Less]
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FUNDAMENTALS FINAL TEST BANK WITH CORRECT ANSWERS
A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dr... [Show More] essing material? A. Discard the dressing in the bedside trash receptacle. B. Dispose of the dressing in a biohazardous waste container. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. - correct answer B. Dispose of the dressing in a biohazardous waste container. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." B. "The last time I voided it was painful and red-tinged." C. "My period ended 2 days ago." D. "I don't eat shellfish because it gives me hives." - correct answer D. "I don't eat shellfish because it gives me hives." A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) CALCULATION - correct answer 125 mL/hr A nurse working for a home agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? A. Swollen gums B. Pruritus C. Urinary Hesitancy D. Dysphagia - correct answer D. Dysphagia A nurse is going to give a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) BMI of 20 Recent long flight Hypertension High calcium intake Immobility - correct answer Flights Immobility A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? A. Determine the pH of the gastric secretions. B. Supply nutrients via tube feedings. C. Decompress the stomach. D. Administer medications. - correct answer C. Decompress the stomach. A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.) The shoulders droop. The facial muscles relax. The respiratory rate increases. The pulse is within the expected range. The client draws his legs up into a fetal position. - correct answer The shoulders droop. The facial muscles relax. The pulse is within the expected range. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea - correct answer A. Fatigue A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mmHg D. PaCO2 above 45 mmHg - correct answer A. pH below 7.35 A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.) Provide skin care with a moisture barrier cream. Administer artificial tear PRN. Obtain vital signs every 2 hr. Perform mouth care every hour. Administer oxygen 2L/min via nasal cannula. - correct answer Provide skin care with a moisture barrier cream. Administer artificial tear PRN. Perform mouth care every hour. Administer oxygen 2L/min via nasal cannula. A nurse is planning care for a client who is postoperative and at risk of paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis? A. Increase ambulation. B. Decrease fluid intake. C. Increase protein intake. D. Offer the client the bedpan every 2 hr. - correct answer A. Increase ambulation. A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? A. Mask B. Gloves C. Gown D. Goggles - correct answer A. Mask A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? A. "I will tie restraints in double knots." B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." C. "I will ensure that restraints fit tightly against the client." D. "I will put four side rails up if a client is confused." - correct answer B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. "If you wear gloves, you do not have to wash your hands." B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." C. "Use an alcohol rub when your hands are visibly soiled." D. "If you don't have an infection, your hands won't infect others." - correct answer B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply). Notify the provider immediately if mucus is present in the urine. Maintain the client on a fluid restriction. Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output. - correct answer Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Contact B. Droplet C. Protective D. Airborne - correct answer D. Airborne A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? A. Assuring the current health status of the client. B. Explaining the operative procedure, risks, and benefits. C. Reviewing preoperative laboratory test results. D. Ensuring that a signed surgical consent was completed. - correct answer B. Explaining the operative procedure, risks, and benefits. A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan? A. Vital sign management B. The client's self-report of pain intensity. C. Visual observation for nonverbal signs of pain. D. The nature and invasiveness of the surgical procedure. - correct answer B. The client's self-report of pain intensity. A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? A. Measuring vital signs. B. Removing the abdominal dressing. C. Helping the client into the shower. D. Ambulating the client in the hallway. - correct answer B. Removing the abdominal dressing. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mmHg, and temperature 36.8ºC (98.2ºF). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin. - correct answer A. Complete a neurological check. A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? A. Emphasize four important points at each session. B. Use a passive voice to explain the information. C. Refer to the client in the third person during the session. D. Have short teaching sessions. - correct answer D. Have short teaching sessions. A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI? A. The client had an appendectomy 6 months ago. B. The client has bipolar disorder. C. The client is a male. D. The client is 71 years old. - correct answer D. The client is 71 years old. A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) Assist the client to cough and deep breathe every hour. Administer PRN analgesics as needed. Encourage the client to turn every 4 hr. Give the client a back massage. Teach the client relaxation techniques. - correct answer Assist the client to cough and deep breathe every hour. Administer PRN analgesics as needed. Give the client a back massage. Teach the client relaxation techniques. A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? A. "I know that I will get a kidney transplant. I am a good candidate." B. "I can now eat whatever I want. The dialysis will remove it from my system." C. "I just can't believe that this dialysis is going to ruin my whole life." D. "I know that kidney disease runs in my family, but I can prevent it." - correct answer C. "I just can't believe that this dialysis is going to ruin my whole life." A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? A. Check the client's medical record for the provider's prescription. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Inform - correct answer A. Check the client's medical record for the provider's prescription. A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? A. Pain B. Hearing loss C. The client's culture D. Motor impairment - correct answer A. Pain A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry. - correct answer C. Provide the client with a diet high in protein. A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals? A. Five years B. Ten years C. One year D. Two years - correct answer B. Ten years A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry, most clients dislike the prep more than the procedure itself." B. "Before the examination, your provider will give you a sedative that will make you sleepy." C. "I know you're anxious, but this procedure - correct answer B. "Before the examination, your provider will give you a sedative that will make you sleepy." A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take? A. Give the ordered KCL as prescribed. B. Omit the KCL dose and document that it was not given. C. Call the prescribing physician and inform her of the client's serum potassium level results. D. Call the lab to verify the client's - correct answer C. Call the prescribing physician and inform her of the client's serum potassium level results. A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all the apply.) The date of the incident The name of the provider who prescribed the medication The potential adverse effects of the medication The time the client was to receive the medication The client's vital signs - correct answer The date of the incident The time the client was to receive the medication The client's vital signs A client was given a narcotic pain med at 0800. At 0900 the nurse finds the client slumped in the chair, hard to arouse, with respirations of 6/minute. Arterial blood gases are ordered what would you expect to see in the ABG results? A. pH less than 7.35 B. pH higher than 7.45 C. CO2 of about 35 D. Co2 lower than 45 - correct answer A. pH less than 7.35 A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) CALCULATION - correct answer 0.2 mL A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? A. "The laxative will prevent the absorption of magnesium." B. "The laxative helps eliminate the barium." C. "The laxative is the protocol at this facility." D. "The laxative makes the barium turn brown." - correct answer B. "The laxative helps eliminate the barium." A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mmHg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis - correct answer C. Respiratory acidosis A nurse is providing postmortem care to a hospitalized patient. Nursing interventions include? (Check all that apply) Prepare the death certificate Bathe the patient Place patient in anatomical position Remove endotracheal tube - correct answer Bathe the patient Place patient in anatomical position Remove endotracheal tube A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use? A. Ask the client to perform a return demonstration of insulin injection. B. Review the action of insulin therapy. C. Explore the client's feelings about dietary modifications. D. Have the client practice blood-glucose monitoring using a glucometer. - correct answer C. Explore the client's feelings about dietary modifications. A 70 year old client is admitted to the PACU with an intravenous (IV) solution of 0.9% NaCl which is running as 123cc/hour. The nurse detects new onset of crackles in the lung bases and distended neck veins. What is nurses the priority action? A. Notify a health care provider B. Immediately document findings in the medical record C. Decrease the IV flow rate D. Discontinue the IV - correct answer C. Decrease the IV flow rate A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? A. Urine specific gravity 1.035 B. Hematocrit 44% C. BUN 19 mg/dL D. Sodium 155 mEq/L - correct answer A. Urine specific gravity 1.035 A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? A. Cover the wound with a sterile-saline dressing. B. Place the client in high-Fowler's position. C. Auscultate all quadrants of the abdomen for bowel sounds. D. Gently reinsert the protruding tissue. - correct answer A. Cover the wound with a sterile-saline dressing. A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Use sterile gauze to place gentle pressure on the exposed organs. C. Cover the area with saline-soaked sterile dressings. D. Apply an abdominal binder. - correct answer C. Cover the area with saline-soaked sterile dressings. A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous - correct answer D. Serosanguineous A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? A. Hypoactive bowel sounds in two quadrants B. Request for a cup of tea and some toast C. Passage of flatus D. Abdominal distention - correct answer C. Passage of flatus A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mmHg B. Straw-colored urine from an indwelling urinary catheter C. Yellow-green drainage on the surgical incision D. Respiratory rate 18/min - correct answer C. Yellow-green drainage on the surgical incision The nurse is caring for a new diabetic client who is being taught how to administer insulin. The nurse knows that the patient care objectives have been met when the patient is able to? A. Verbalize the method of insulin administration and how insulin works B. Teach back what precautions are to take when taking insulin C. State the value and importance self insulin injection for diabetics D. Demonstrate how fill insulin syringe and give insulin injection - correct answer D. Demonstrate how fill insulin syringe and give insulin injection A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching? A. Yogurt B. Popsicle C. Gelatin D. Broth - correct answer A. Yogurt A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. Now many mL should the nurse record in the medical record as the client's output? CALCULATION - correct answer 1,370 mL A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A. Expect ringing in your ears. B. Take the medication with food. C. Store the medication in the refrigerator. D. Monitor for weight loss. - correct answer B. Take the medication with food. [Show Less]
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ATI FUNDAMENTALS FINAL EXAM (F1) ANSWERS AVAILABLE
A nurse is caring for a client who has a new RX for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic databa... [Show More] se to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A) Knowledge B) Experience C) Intuition D) Competence - correct answersA) Knowledge A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A) Check to see whether the catheter is patent. B) Reassure the client that it is not possible for her to urinate. C) Recatheterize the bladder with a larger-gauge catheter. D) Collect a urine specimen for analysis - correct answersA) Check to see whether the catheter is patent. A nurse is caring for a client who has a RX for a 24-hr urine collection. Which of the following actions should the nurse take? A) Discard the first voiding B) Keep the urine in a singe container at room temp C) Ask the client to urinate and pour the urine into a specimen container D) Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. - correct answersA) Discard the first voiding A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain med 6 hr ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed n - correct answersA. Assessment 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? (SATA) 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 handli - correct answersB. 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 may result in contamination from secretions. A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment B. Put the client in a room with a client who has hearing loss C. Provide a quiet room and limit stimulation D. Speak at a higher volume to the client and encourage ambulation. - correct answersC. Provide a quiet room and limit stimulation A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (SATA) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear - correct answersA. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (SATA) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone - correct answersA. Furosemide B. Ibuprofen A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aid - correct answersD. "I take the batteries out of my hearing aids when I take them off at night." A nurse is caring for an adolescent who client who is 2 days post-op following an appendectomy and has type I DM. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the fo - correct answersB. Impaired circulation C. Impaired/suppressed immune system A nurse is collecting data from a client who is 5 days post-op following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (SATA) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - correct answersA. Increase in incisional pain B. Fever and chills C. Reddened wound edges A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (SATA) A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - correct answersA. Stage III pressure ulcer E. Open burn area A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (SATA) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with his hips and knees b - correct answersA. Cover the area with saline-soaked sterile dressings. D. Position the client supine with his hips and knees bent. A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (SATA) A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed. - correct answersA. Keep the head of the bed elevated 30 degrees. D. Have the client sit on a gel cushion when in a chair. 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? (SATA) 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 clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall- - correct answersC. Make sure that the clients 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 a 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." - correct answersB. "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 priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are near by D. Close all open doors on the unit - correct answersC. Move clients who are near by A nurse is caring for a client who has a history of falls. Which of the following is the nurses priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the clients environment D. Make sure the client uses assistive aids in his possession - correct answersA. 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 post-op following a laproscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is post-op following an open reduction internal fixation of the ankle D. An older adult who is post-op following a below-the-knee am - correct answersD. An older adult who is post-op following a below-the-knee amputation A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (SATA) 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 - correct answersB. 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 that the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - correct answersA. Hypotension A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 F." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will place my baby on his stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib." - correct answersD. "Once my infant starts to push up, I will remove the mobile from over the crib." A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body. - correct answersD. Carbon monoxide binds with hemoglobin in the body. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (SATA) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. D. Healthy individuals usually recover from the illness in a few weeks - correct answersB. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning. A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg - correct answersB. Semi-Fowler's A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer. - correct answersD. Assess the client's ability to help with the transfer. A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow. B. Lie flat on her stomach with her head to one side. C. Sit on the side of her bed and rest her arms over follows on top of her bedside table. D. Lie on her side with her weight on her - correct answersC. Sit on the side of her bed and rest her arms over follows on top of her bedside table. A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (SATA) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscle - correct answersA. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals. - correct answersB. Instruct the client to tuck her chin when swallowing. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (SATA) A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should c - correct answersA. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the fo - correct answersA. "Water helps clear the tube so it doesn't get clogged." A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented. - correct answersB. Verify the placement of the NG tube. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (SATA) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents. - correct answersA. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. The specimen cannot be contaminated with urine. - correct answersD. The specimen cannot be contaminated with urine. A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (SATA) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts. - correct answersA. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts. Which of the following actions should the nurse take each time he provides tracheostomy care? (SATA) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder. - correct answersA. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. A nurse in a providers office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the clients difficulty sleeping? (SATA) A. "Does your lack of sleep interfere with your ability to function during the day?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" - correct answersA. "Does your lack of sleep interfere with your ability to function during the day?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds when you are asleep?" E. "Tell me about any personal stress you are experiencing." A nurse is caring for an older adult client who has been following the facilities routines and bathing in the morning. However, at home, she always takes a warm bath just before bed time. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the clients back for 15 minutes before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for a sleeping medication - correct answersC. Allow the client to take a bath in the evening A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction - correct answersC. Alarm reaction A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain - correct answersA. Role conflict Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse-client communication no time limit D. Allow communication to occur spontaneously throughout the nurse-client relationship - correct answersB. Encourage the client to communicate his thoughts and feelings A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (SATA) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea - correct answersC. Bradypnea D. Orthostatic hypotension E. Nausea A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A. The client's input and output for the shift B. The client's blood pressure from the previous day C. A bone scan that is scheduled for today D. The medication routine from the medication administration record - correct answersC. A bone scan that is scheduled for today A nurse is reviewing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (SATA) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of her medical record E. A nurse may photocopy a clients medical record fo - correct answersB. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of her medical record E. A nurse may photocopy a clients medical record for transfer to another facility [Show Less]
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ATI FUNDAMENTALS PRACTICE TESTS 2023
After reviewing the information in the infant's chart, the nurse should anticipate a provider prescription for - correct answer IV antibiotics; NG tube ... [Show More] A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. - correct answer inspection auscultation superficial palpation deep palpation A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following - correct answer blood A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? - correct answer move any clients in the immediate vicinity A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first? - correct answer Date of the client's last tetanus immunization A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control - correct answer Places clean linen that touched the floor in the soiled linen bag A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? - correct answer interpersonal Nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for what - correct answer to identify delayed gastric emptying A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? - correct answer warm at site A nurse is planning care for an older adult client risk for developing pressure ulcers. Which of the following interventions should the nurse u se t o help maintain the integrity of the client's skin? - correct answer use a transfer device to lift the client up in bed. The nurse should first - correct answer assess the area where the restraint is to be placed on the client; attach the restraints to the moveable part of the bedframe The nurse should fist address the client's - correct answer oxygen saturation, hypotension Administer an enteral feeding via NG tube - correct answer verify tube placement, check residual feeding, administer feeding, evaluation [Show Less]
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ATI RN FUNDAMENTALS PROCTORED EXAM WITH WELL SORTED ANSWERS
Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? - correct answer Yes. A nurse on a med-surg unit has received cha... [Show More] nge-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer - correct answer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP 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. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning - correct answer B, C, D An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24hr postop to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump - correct answer D. Replacing the cartridge and tubing on a PCA pump Rationale: The RN is responsible for the PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances - correct answer B, C, E A and D are rights of medication administration A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurse B. RN C. LPN D. AP - correct answer B. RN A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for this, especially if the client is potentially unstable. A nurse observes an 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 - correct answer A. Assault By threatening the client, the AP is committing assault. An adult client who is competent 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 administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality - correct answer B. False imprisonment The nurse gave the med as a chemical restraint to keep the client from leaving the facility against medical advice. The client did not consent. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands 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 w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to ke - correct answer C. The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arrives A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all. 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 - correct answer A, B The rest of the choices are the surgeon's responsibility, not the nurse 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? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that h - correct answer C. Any nurse who notices behavior that could possibly jeopardize client care or indicate a substance abuse problem has a duty to report the situation immediately to the nurse manager A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record - correct answer C. A bone scan that is scheduled for today This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A. The client fell in the shower. B. The client states he fell in the shower & was able to get himself back into his chair C. The nurse should not document this info because she did not witness the fall D. The client fell in the shower & is now resting comfortably - correct answer B. By writing what the client states, the info is subjective data A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all. A. Cover errors w/correction fluid, & write in the correct info B. Put the date & time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document - correct answer B, C The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The w - correct answer A, B, D 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. A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the - correct answer A, B, C A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist C. Physical therapist D. Social worker - correct answer D. social worker A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - correct answer D. An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A client who is postop following a 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 may assist the client in understanding the medication's effects? Select all. A. Provider B. CNA C. Pharmacist D. RN E. Respiratory therapist - correct answer A, C, D A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. CNA C. Occupational therapist D. Speech-language pathologist - correct answer D A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks 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 - correct answer A, B, C, E Determining pain level requires assessment, which is the job of the licensed personnel. A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all. A. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side - correct answer C, E A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items? A. A word she whispers 30cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand - correct answer D. Stereognosis is tactile recognition A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink - correct answer C. Fastening a bra from behind requires internal rotation of the shoulder, so this activity will illicit pain A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test - correct answer A, B C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to shrug shoulders without complication. A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation - correct answer B, C, D A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A. Family members who smoke must be at least 10 ft from the client when the 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 & clothing should be replaced w/ite - correct answer B, C, E Family members that smoke should do so outside, and wool creates static electricity so it should be avoided. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temp of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed." - correct answer B Although the baby can hold his head above the water by sitting up, this does not make the baby safe in the tub. Parents should never leave a child unattended in a tub. A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds w/hemoglobin in the body - correct answer D. Carbon monoxide is a very dangerous gas because it binds w/hemoglobin & ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless, has no scent, and cannot be seen. The water heaters, gas-burning furnances, and appliances should be inspected annually The lungs are not damaged in the process of inhalation 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? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - correct answer A. Hypotension Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Hand - correct answer B, C, E Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals usually recover in a few days. A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks - correct answer A, B, C, E Not D because endemic disease is already prevalent within a population, so reporting is not necessary A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr 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 dept is unavoidable D. Use sterile gloves when handling soiled lin - correct answer B, C, E Private room w/droplet precautions indicated for this client. The nurse should wear a gown when contamination from body fluids might happen A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles w/some crustings. Which of the following should the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster - correct answer D. Herpes zoster pink body rash=allergic reaction red circles w/white centers=ringworm red cheek rash bilaterally=lupus A nurse is caring for a client who reports severe sore throat, pain when swallowing, & swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness - correct answer D. Illness specific s/s present is the illness stage A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate - correct answer A, B, E Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I sh - correct answer B. routine health screenings are important at any age A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between & being responsi - correct answer C. Exploring and establishing career options & establishing oneself is important developmental task in a young adult A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I - correct answer C. Applying Erikson stages of development, knowing oneself is done in adolescence, and this requires the most urgent help A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. A. Install bath rails & grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home - correct answer B, C, D A is recommended for older adults and E as well for risk of falls A nurse is reviewing the CDC's immunization recommendations w/a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all. A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio - correct answer A, B, C D is not for after 18 months of age and polio is also given as a child and not usually beyond 18 yrs old A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to limit activity & rest D. Allow the client to shiver to dispel excess heat E. Assist the client w/oral - correct answer A, C, E The nurse should prevent shivering & encourage the client to increase fluids. Why E-Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips. A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Don't measure the client's temp rectally." B. "Count the client's radial pulse for 30 sec & multiply by 2." C. "Don't let the client know you are counting her respirations." D. "Let the client rest for 5 mins before you measure her BP." - correct answer A. "Don't measure the client's temp rectally." The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this way increases the risk for bleeding. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates - correct answer A, B, C For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety med D. Return in 30min to recheck the client's BP - correct answer B Perform a pain assessment would be the appropriate action to take next A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? - correct answer 16/min the pulse deficit is the difference between the apical & radial pulse rates. 84-68=16 A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following info should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated - correct answer D. The stool specimens cannot be contaminated with water or urine A nurse is talking w/a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni & cheese B. Fresh fruit & whole wheat toast C. Rice pudding & ripe bananas D. Roast chicken & white rice - correct answer B. A high-fiber diet promotes normal bowel elimination A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all. A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor E. Peripheral edema - correct answer B, C, D fever=caused by dehydration tachycardia not brady hypotension because of decreased BP from dehydration fluid overload=peripheral edema A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all. A. Warm the enema prior to instillation B. Position the client on the left side w/the right leg flexed forward C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 2 inches [Show Less]
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ATI FUNDAMENTALS PRACTICE QUESTIONS WITH GRADED A+ ANSWERS
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 that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - correct answer A, B, D 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 (PPO) B. Medicare C. Long term care insurance D. Exclusive provider organization (EPO) E. Medicaid - correct answer 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 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 acute - correct answer 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 that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining if medications are safe for administration to clients - correct answer B 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 that apply.) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - correct answer A, B, C Chapter 2 - correct answer Interprofessional team 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. A client who has terminal cancer requests hospice care in her home. B. A client asks 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. A client states t - correct answer A, B, D 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 - correct answer D 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 medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist - correct answer A, C, D A client who has had a cerebrovascular accident has persistent problems with dysphagia (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 - correct answer D 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 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 that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - correct answer A, B, C, E Chapter 3 - correct answer Ethical responsibilities 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 - correct answer 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 - correct answer D 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 - correct answer 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 - correct answer D 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 feeding - correct answer C Chapter 4 - correct answer Legal responsibilities 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 - correct answer A 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 - correct answer 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 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 pr - correct answer 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. - correct answer 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, 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. - correct answer C Chapter 5 - correct answer Information technology 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 - correct answer C A nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of her medical record. E. A nurse may photocopy a cl - correct answer B, C, D A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document. - correct answer B, C 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). A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Complaint from a client's family member - correct answer A, B, D 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.) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge n - correct answer A, B, C Chapter 6 - correct answer Delegation and supervision A nurse on a medical surgical unit has received change of shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer - correct answer C A nurse manager of a medical surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PA CU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP) - correct answer B 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.) A. The roommate ambulates independently. B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this - correct answer B, C, D An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? A. Assisting a client who is 24 hr postoperative to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered dose inhaler - correct answer D A nurse is preparing an in service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation (Select all that apply.) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances - correct answer B, C, E Chapter 7 - correct answer Nursing processes 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? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain. - correct answer A A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly - correct answer A 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.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "He said he hurts after walking about 10 minutes." C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry. E. The assistive personnel reports the client walked with a limp. - correct answer A, D, E 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.) A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a nasogastric (NG) tube to relieve gastric distention. C. Showing a client how to use progressive muscle relaxation. D. Performing a daily bath after the evening meal. E. Repositioning - correct answer C, D, E A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C. "I will go carry out the new prescriptions from the provider." D. "I will ask the client if his nausea has re - correct answer A Chapter 8 - correct answer Critical thinking and clinical judgment 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 that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity - correct answer A A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk taking D. Creativity - correct answer B A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply.) A. The client seems easily agitated. B. The client is nonadherent with coughing, deep breathing, and dangling. C. The client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr. D. The client reports tenderness in his right lower leg. E. The client's - correct answer B, C, E A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence - correct answer A A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline - correct answer D Chapter 9 - correct answer Admissions, transfers, and discharge 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 his room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care. - correct answer 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. Provide information about advance directives. D. Document the client's wishes about organ donation. E. Introduce the client to his roommate. - correct answer A, B, C, 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 his valuables. B. Confirm that the rehabilitation center has a room available at the time of transfer. C. Assess how the client tolerates the transfer. D. Give a verbal transfer report via telephone. E. Complete a transfer form f - correct answer 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.) A. Advance directives status B. Follow up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency - correct answer B, C, E As part of the admission process, a nurse at a long term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing - correct answer D Chapter 10 - correct answer Medical and surgical asepsis When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? 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 - correct answer C 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 - correct answer D 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 field E. One gloved hand with the other gloved hand - correct answer C, D, E 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. - correct answer 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 spe - correct answer B, C, D Chapter 11 - correct answer Infection control 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 - correct answer A, B, C, E 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 - correct answer 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. Illness - correct answer C 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. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate - correct answer A, B 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 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 - correct answer B, C, E Chapter 12 - correct answer Client safety 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 footwea - correct answer C, D, E A nurse manager is reviewing with nurses on the unit the care of a client who has had a 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." [Show Less]
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ATI FUNDAMENTALS PRACTICE A, B, & FINAL REVIEW 2023 QUESTIONS AND ANSWERS
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 prescript... [Show More] ion should the nurse question? - correct answer The dose 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? - correct answer Observe the rate, depth, and character of the client's respirations. 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? - correct answer Lower the client to the floor and place a pad under the client's head. 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? - correct answer Educating clients about the recommended immunization schedule for adults 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? - correct answer Assessment 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? - correct answer Edema at the infusion site 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? - correct answer Washing dishes 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? - correct answer Daily weight 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? - correct answer Inspection 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? - correct answer A client who has a prescription for a transfusion of packed red blood cells 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? - correct answer "It must be difficult to care for someone who is confined to bed." 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? - correct answer Bounding pulse 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? - correct answer Cover the incision with a moist sterile dressing. 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? - correct answer "Bear weight on both of your legs." 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? - correct answer Liver Damage A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? - correct answer PC for after meals 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? - correct answer A 10-month-old infant can pull up to a standing position. 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? - correct answer The AP hangs the collection bag at the level of the bladder. 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? - correct answer Consult the medication reference book available on the unit. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? - correct answer Place the client in a lateral position with the head turned to the side before beginning the procedure. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? - correct answer Repeat each joint motion five times during each session. 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? - correct answer Cough deeply after each use. 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? - correct answer Have the client demonstrates the procedure. 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? - correct answer Gelatin 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? - correct answer Romberg test 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? - correct answer WBC 15,000 mm3 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? - correct answer Ventrogluteal 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? - correct answer Fill the bag two-thirds full with ice. 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? - correct answer Impaired peristalsis of the intestines 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? - correct answer Wear cotton clothing to avoid static electricity. 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? - correct answer "I can see that this is upsetting you." A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? - correct answer Position the client on his left side. 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? - correct answer Airway A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? - correct answer Tie the restraint with a quick-release knot. 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? - correct answer Oil retention 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? - correct answer People who practice Judaism stay with the body of the deceased until burial. 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? - correct answer 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? - correct answer Place the client in Trendelenburg's position. 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? - correct answer Provide a protein intake of 1.5 g/kg of body weight per day. 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? - correct answer Cold extremities 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? - correct answer Hemolytic 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? - correct answer Loss 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? - correct answer Sit at the bedside while feeding the client. 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? - correct answer Wear gloves when changing the client's gown. 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.) - correct answer -Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. 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? - correct answer Fidelity 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? - correct answer Tachycardia 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? - correct answer Decreased calcium 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? - correct answer "Tell me more about how your friends discourage you." A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? - correct answer When lifting an object, spread your feet apart to provide a wide base of support. 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? - correct answer "All of this equipment can be frightening." 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? - correct answer "The pain is like a dull ache in my stomach." 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? - correct answer evacuate the client 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? - correct answer Rapid heart rate 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? - correct answer 0.3 mg 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.) - correct answer 8 mL/hr A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? - correct answer Cleanse the wound from the center outward 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? - correct answer Skin blanching 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? - correct answer "When descending stairs, I will first shift my weight to my right leg." 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? - correct answer Tell the client to keep the head of the bed elevated at least 30 degrees 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? - correct answer Medication dose 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? - correct answer "I will be sure to remove my hearing aid before taking a shower" 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? - correct answer "Client found lying on floor" 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. - correct answer Compare prescriptions with medications the client received while at the facility. 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? - correct answer Witness the client's signature on the consent form. A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? - correct answer "You should receive a pneumococcal immunization every 10 years." A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? - correct answer Withhold the blood transfusion A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? - correct answer Droplet A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? - correct answer "People in middle adulthood often find satisfaction in nurturing and guiding young people." A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply) - correct answer Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia The nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? - correct answer Instruct the family to refrain from pushing the button for the client while she is asleep. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? - correct answer Wrap blankets around all four sides of the bed A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? - correct answer A nurse asks a nurse from another unit to assist with documentation for a client A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? - correct answer Have the client use a trapeze bar when changing position. a nurse is preparing to delegate client care tasks to an assistive personnel (ap). which of the following tasks should the nurse delegate? - correct answer Ambulating a client who is postoperative a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? - correct answer current medications A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? - correct answer "What could I have done to deserve this illness?" A nurse is calculating a client's fluid intake over the past 8 hour. Which of the following items should the nurse plan to document on the client's intake and output record as 120ml of fluid? - correct answer 8 oz of ice chips A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? - correct answer practice sessions a nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure - correct answer add 30 mm Hg a nurse is caring for a client who has a terminal diagnosis and whos health is declining. Advanced directives. - correct answer we can talk about advanced directives brochures A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? - correct answer Initiate an enteral feeding through a gastrostomy tube. a nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? - correct answer distended neck veins A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? - correct answer Wrap monitoring cords with stockinette and tape them in place. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oil is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? - correct answer A client who has asthma. A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? - correct answer N95 respirator A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - correct answer 3) Inject 10 units of air into the bottle of NPH insulin1) Inject 5 units of air into the bottle of regular insulin4) Withdraw the correct dose of regular insulin from the bottle2) Withdraw the correct dose of NPH insulin from the bottle A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? - correct answer The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? - correct answer "You should have a fecal occult blood test every year." A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? - correct answer "I can take echinacea to improve my immune system." indwelling urinary catheter - correct answer bladder scan a nurse is giving a change of shift report about a client admitted earlier who has pneumonia - correct answer breath sounds a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse - correct answer the caregiver insists on remaining in the room [Show Less]
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