ATI PROCTORED FUNDAMENTALS EXAM QUESTIONS WITH 100% CORRECT ANSWERS AND EXPLANATIONS NEW VERSION 2022!!!!
A nurse is collecting data on four clients.
... [Show More] Which of the following findings should the nurse report to the provider
1.Heart rate 62/min
2.Urine output of 200 mL over 8 hr
3.Pulse oximetry 95% on room air
4.BP 112/76 mm Hg
2.Urine output of 200 mL over 8 hr
-A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider.
A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
a."I'll keep my oxygen tank lying on the floor next to my recliner."
b."I'll keep my oxygen at least 4 feet away from any source of heat."
c."When my brother visits, I'll make sure he smokes in the next room."
d."I'll avoid wearing any wool or synthetic fabric when my oxygen is on."
d."I'll avoid wearing any wool or synthetic fabric when my oxygen is on."
-The nurse should verify that the client understands that wool and synthetic fabrics can generate static electricity, which could cause a spark and, therefore, combustion. The nurse should instruct the client to wear cotton clothing and use cotton bedding.
a nurse is collecting data from a postoperative client and notes that the clients oxygen saturation has decreased from 95% to 88%. Which of the following actions should the nurse take first
a.Cover the sensor with a towel.
b.Elevate the head of the client's bed.
c.Observe the client for cyanosis and restlessness.
d.Move the sensor to another location with optimal blood flow.
c.Observe the client for cyanosis and restlessness.
-The first action the nurse should take when using the nursing process is to collect data from the client. If the client's pulse oximeter is generating a measurement that is significantly different from the client's baseline, the nurse should collect data to determine the client's respiratory status. The nurse should check for tachycardia, anxiety, cyanosis, and restlessness.
a nurse is performing point of care fecal occult blood testing for a client. which of the following actions should the nurse take?
a.Swipe the guaiac paper over the surface of the stool.
b.Wait 15 min before applying the developing solution.
c.Apply five drops of solution to each box.
d.Report a blue color as positive result.
d.Report a blue color as positive result.
-After applying the developing solution to the boxes on the back of the card, the nurse should interpret a color change to blue as an indication of blood in the client's stool.
a nurse is caring for a client who has an infilatrated iv. Which of the following actions should the nurse take?
a.decrease the rate of the iv
b.obtain a cultrue specimen for the iv site of the infiltration
c.insert a new iv in the other extremity
d.Keep the arm with the iv infiltration velow the level of the hear
c.insert a new iv in the other extremity
-The nurse insert a new IV in the other extremity. This will allow the affected extremity to heal.
a nurse is assisiting in the plan of care for a client who has a chest tube. Which of thefollowing recommendations should the nurse include in the plan of care.
a..Elevate the head of bed 10° while lying supine.
b.Immerse a disconnected chest tube in a glass of sterile water.
c.Clamp the chest tube while ambulating.
d.Loop the chest tube several times on the bed.
b.Immerse a disconnected chest tube in a glass of sterile water.
-The nurse should immerse the open end of a disconnected chest tube in a glass of water to temporally reestablish a water seal until the client's tube can be reconnected.
a nurse in a long term care facility is assisting with the admission of a client who had a stroke. The nurse should report which of the following findings as a possible manifestation of dysphagia
a. rapid speech
b.dry mouth
c.pocketing food
d. hiccups
c.pocketing food
-Incomplete oral clearance, or retaining food in the cheeks, under the tongue, or on the hard palate, is a common manifestation of dysphagia.
a nurse is caring for a client who is immobile. To help prevent hip flexion contractures, the nurse should periodically assisist the client into which of the following possionts
a.Prone
b.supine
c,latteral
d.High-fowlers
a. Prone -position is the only bed position in which the client has full extension of the hip and knee joints. The nurse should use this position to help prevent flexion contractures of the hip and knee joints while the client is immobile. The nurse should ensure that the client's back is correctly aligned when the client is placed in this position.
A nurse is performing a Romberg test for a client who reports episodes of dizziness.Which of the following instructions should the nurge give the client
a."Walk in a straight line, placing the toes of one foot against the heel of the other foot."
b."Stand with your feet together."
c."Close your eyes and stand on your right foot."
d."Hold your arms out in front of you."
b."Stand with your feet together."
-The Romberg test measures clients' stability when standing with their feet together, first with eyes open, then with eyes closed. The test is negative if clients can remain upright and keep their balance with minimal swaying and without moving their feet to another position for 5 seconds.
A nurse is collecting data from a client during a physical examination. What finding should the nurse report to the provider as an indication of an underlying systemic disorder?
a.Dark tinted macules
b.Clubbing
c.Bronchovesicular lung sounds
d.Red tinted angiomas
b.Clubbing-Clubbing is an abnormal nail shape, where the angle the nail forms beyond the expected angle of 160°. Early clubbing occurs at an angle of 180°; late clubbing exceeds an angle of 180°. It is an indication of long-term inadequate oxygenation. The nurse should report this finding to the provider because it is an indication of pulmonary or cardiovascular disease.
a client is about to give a bed bath to a client who requires bed trest. Which of the following actions should the nurse take first?
a.Provide as much privacy as possible.
b.Determine the client's ability to assist with the bath.
c.Expose only one area of the client's body at a time.
d.Offer the client a bedpan before beginning the bath.
b.Determine the client's ability to assist with the bath.
-The first action the nurse should take using the nursing process is to collect data from the client. Instead of performing every step of hygiene for the client, the nurse should encourage the client's independence by first determining what actions the client is able to perform.
a nurse is caring for a client who states "I believe that my teenagers is using drugs" Which of the following responses should the nurse make?
a."If I were you, I'd ask your child directly if they are using drugs."
b."I think you're right. Substance use would explain the changes in your child's behavior."
c."You suspect that your child's behavior changes could indicate substance use."
d."Why do you think your child would want to use drugs?"
c."You suspect that your child's behavior changes could indicate substance use."
-The nurse is using the therapeutic communication technique of paraphrasing by restating the client's message in the nurse's own words. This lets the client know that the nurse is interested in understanding their concerns and hearing more about them.
a nurse is caring for a client who is grebing following the death of a family member which actions should the nurse take?
a.Refer the client for psychological care if they are not eating or sleeping well.
b.Avoid discussion of the facts surrounding the death.
c.Discourage the client from reminiscing about past experiences with the family member.
d.Offer personal presence and silence.
d.Offer personal presence and silence. [Show Less]