ATI RN FUNDAMENTALS
1. A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should
... [Show More] the nurse expect? (Select all that apply.)
a. Reddened gums
b. Lowered vocal pitch
c. Tooth loss
d. Glare intolerance
e. Thickened eardrums
2. A nurse in a provider’s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.)
a. Smaller nipples
b. Less adipose tissue
c. Nipple discharge
d. More pendulous
e. Nipple inversion
3. A nurse in a provider’s office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)
a. Rhonchi
b. Crackles
c. Resonance
d. Tactile fremitus
e. Bronchovesicular sounds
4. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
a. Fat
b. Fluid
c. Flatus
d. Hernias
5. During a cardiovascular examination, a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.)
a. Ventricular gallop
b. Closure of the mitral valve
c. Closure of the pulmonic valve
d. Apical heart rate
e. Murmur
6. Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?
Yes
7. A nurse on a med-surg unit has received change-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
8. 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
9. Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?
Yes
10. A nurse on a med-surg unit has received change-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
11. 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
12. 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
13. 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
14. 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 that apply.)
a. A single electronic record passwords is provided for nurse 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 copy of their medical record.
e. A nurse can photocopy a client’s medical record for transfer to another facility.
15. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines sold 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.
16. 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. Missed specimen collection of a prescribed laboratory test
17. 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 proscription within 24 hr.
d. Decline the verbal prescription because it is not an emergency situation.
e. Tell the charge nurse that the provider has prescribed morphine by telephone.
18. 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
19. 8. 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
20. 9. 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 keep me on a breathing machine."
D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
21. 10. 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
22. 11. 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 her coworker's fatigue is not her problem to solve
23. 12. 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
24. 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 wearing slippers over 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.
25. 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.
26. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.)
a. Right place
b. Right supervision and evaluation
c. Right direction and communication
d. Right documentation
e. Right circumstances
27. 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 the pain.
28. 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
29. 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
30. 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 provider has prescribed morphine by telephone
31. 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
32. 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
33. 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
34. A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquid well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?
a. Basic
b. Commitment
c. Complex
d. Integrity
35. A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client’s medical record, discovers that the client is allergic to the antibiotic, and call 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
36. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.)
a. Find a mentor.
b. Use a journal to write about the outcomes of clinical judgments.
c. Review articles about evidence-based practice.
d. Limit consultations with other professionals involved in a client’s care.
e. Make quick decisions when unsure about a client’s needs.
37. 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
38. 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 did the nurse demonstrate?
a. Confidence
b. Perseverance
c. Integrity
d. Discipline
39. 24. 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
40. 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 directive 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.
41. 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
42. 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 microorganisms into the surgical wound.
d. Keep a box of facial tissue for the client to use during the dressing change.
43. A nurse as 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
44. 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
45. 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.
46. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?
a. Complete a fall-risk assessment.
b. Educate the client and family about fall risks.
c. Eliminate safety hazards from the client’s environment.
d. Make sure the client uses assistive aids in their possession.
47. A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?
a. Open the windows in the client’s room to allow smoke to escape.
b. Obtain a class C fire extinguisher to extinguish the fire.
c. Remove all electrical equipment from the client’s room.
d. Place wet towels along the base of the door to the client’s room.
48. A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.)
a. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
b. Nail polish should not be used near a client who is receiving oxygen.
c. A “No Smoking” signs should be placed on the front door.
d. Cotton bedding and clothing should be replaced with items made from wool.
e. A fire extinguisher should be readily available in the home.
49. A nurse educator is presenting module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?
a. Hypotension
b. Bradycardia
c. Clammy skin
d. Bradypnea
50. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?
a. “I will set my water heater at 130oF.”
b. “Once my baby can sit up, they should be safe in the bathtub.”
c. “I will place my baby on their stomach to sleep.”
d. “Once my infant starts to push up, I will remove the mobile from over the crib.”
51. A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.)
a. Assembling puzzles.
b. Pulling wheeled toys.
c. Using musical toys.
d. Playing with puppets.
e. Coloring with crayons.
52. A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child’s cooperation in taking medications? (Select all that apply.)
a. Reassure the child an injection will not hurt.
b. Mix oral medications in a large glass of milk.
c. Offer the child choices when possible.
d. Have the guardians bring in a favorite toy from home.
e. Engage the child in pretend play with a toy medical kit.
53. A nurse is reviewing the Centers for Disease Control and Prevention’s (CDC) immunization recommendations with the guardian of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply.)
a. Heamophilus influenzae type B
b. Varicella
c. Polio
d. Hepatitis A
e. Seasonal influenza
54. A nurse is talking with guardians who are concerned about several issues with their preschooler. Which of the following issues should the nurse identify as the priority?
a. “My child mimics the way my partner and I dress.”
b. “My child has temper tantrums every time we tell them to do something they don’t want to do.”
c. “I think my child truly believes that toys have personalities and can talk.”
d. “I feel bad when I see my child trying so hard to button their shirt.”
55. A nurse is caring for a client who has left-sided hemiplegia resulting from a CVA 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 describes the client’s role problem?
a. Role conflict
b. Role overload
c. Role ambiguity
d. Role strain
56. A nurse is caring for a client who has a new diagnosis of type 2 DM. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.)
a. Suggest coping skills for the client to use in this situation.
b. Allow the client to provide input in the treatment plan.
c. Assist the client with time management, and address the client’s priorities.
d. Provide extensive instructions on the client’s treatment regimen.
e. Encourage the client in the expression of feelings and concerns.
57. A nurse is caring for a family who is experiencing crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?
a. Prescribing tasks unilaterally.
b. Delegating care to one member
c. Speaking to the primary client privately
d. Convening a family meeting
58. A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that there has been a decreased desire for sexual relations since the surgery, stating “My body is so different now.” Which of the following responses should the nurse make?
a. “Really, you look just fine to me. There’s no need to feel undesirable.”
b. “I’m interested in finding out more about how your bod feels to you.”
c. “Consider an afternoon at a spa. A facial will make you feel more attractive.”
d. “It’s still too soon to expect to feel normal. Give it a little more time.”
59. A nurse is caring for a group of clients on a medical surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.)
a. A client who had a laparoscopic appendectomy.
b. A client who had a mastectomy.
c. A client who had a left above-the-knee amputation.
d. A client who had a cardiac catheterization.
e. A client who had a stroke with right-sided hemiplegia.
60. A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor-vehicle crash. Which of the following statements indicates that the client has a distorted body image?
a. “I’ll be able to function exactly as I did before the accident.”
b. “I just can’t stop crying.”
c. “I am so mad at that guy who hit us. I wish he lost a leg.”
d. “I don’t even want to look at my leg. You can check the dressing.”
61. A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure?
a. “I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood.”
b. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
c. “I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle.”
d. “I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location.”
62. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and “not feeling well.” The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?
a. Obtain a specimen for culture.
b. Apply a warm compress.
c. Administer analgesics.
d. Discontinue the infusion.
63. During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?
a. “I will leave the IV catheter in place after the client completes the course of IV antibiotics.”
b. “As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt.”
c. “If my client needs to use the rest room, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab.”
d. “I will replace any IV catheter when I suspect contamination during insertion.”
64. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?
a. A client who has nasogastric suctioning
b. A client who has chronic constipation
c. A client who has syndrome of inappropriate antidiuretic hormone
d. A client who took an toxic dose of sodium bicarbonate antacids
65. A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.)
a. Hct 55%
b. Blood osmolarity 260 mOsm/kg
c. Blood sodium 150 mEq/L
d. Urine specific gravity 1.035
e. Blood creatinine 0.6 mg/dL [Show Less]