ATI FUNDAMENTALS PRACTICE TEST A A nurse is evaluating a client's use of a cane. Which
... [Show More] of the following actions should
the nurse identify as an indication of correct use?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the
cane. 3
The client should hold the cane on the stronger side of her body to increase
support and maintain alignment.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV
at 125mL/hr. When the nurse performs the initial assessment, he notes that the
client has received only 80mL over the last 2 hr. Which of the following actions
should the nurse take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for
obstruction. 4
The first action the nurse should take using the nursing process is to assess the
client. If checking the IV tubing and verifying an obstruction, the nurse might be
able to facilitate the flow of fluid through the tubing. This could re-establish the
infusion rate the provider prescribed.
A nurse is caring for a client who requires an NG tube for stomach
decompression. Which of the following actions should the nurse take when
inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to insertion of
the NG tube.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion of the NG tube
into the esophagus.
4
Taking sips of water as the NG tube passes through the oropharynx will close the
epiglottis over the trachea and prevent the tube from passing into the trachea.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following
findings should the nurse report to the provider?
1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4
mEq/L 4
This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse
should report this finding to the provider. This client is at risk for dysrhythmias [Show Less]