ATI RN
Fundamentals
1. a nurse in a clinical is caring for a middle age adult who states, "the doctor says that
since I am at an average risk for colon
... [Show More] cancer, I should have a routine screening. what
does that involve?" which of the following responsesshould the nurse make?
A. "I'll get a blood sample from you and send it for a screening test."
B. "beginning at age 60, you should have a colonoscopy."
C. "you should have a decal occult blood test every year."
D. "the recommendation is to have a sigmoidoscopy every 10 years."
"You should have a fecal occult blood test every year."
Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for
screening is a fecal occult blood test annually.
2. a nurse is caring for a client who is having difficulty breathing. the client is laying in
bed with a nasal cannula delivering oxygen. which of the followingintervention should
the nurse take first?
A. suction the client's airway
B. administer a bronchodilator
C. increase the humidity in the client's room
D. assist the client to an upright position
assist the client to an upright position
When providing client care, the nurse should first use the least invasive intervention.
Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high
Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas
exchange and prevents pressure on thediaphragm from abdominal organs.
3. 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?
A. gently shake the container of medication prior to administration
B. transfer the medication to a medicine cup
C. place the client in a semi-fowlers position to medication administration
D. verify the dosage by measuring the liquid before administering it
Gently shake the container of medication prior to administration.
The nurse should gently shake the liquid medication to ensure the medication ismixed.
4. a nurse is planning care to improve self-feeding for a client who has visionloss. which
of the following interventions should the nurse include in the plan of care?
A. tell the client which food she should eat first
B. provide small-handle utensils for the client
C. thicken liquids on the client's tray
D. use a clock pattern to describe food on the client's plate
Use a clock pattern to describe food on the client's plate.
Use a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location
of the food on the plate by using a clock patternallows the client to have greater independence
during meals.
5. a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a
program of regular physical activity. which of the following types of activity should the
nurse recommend?
A. walking briskly
B. riding a bicycle
C. performing isometric exercises
D. engaging in high-impact aerobics
walking briskly
Weight-bearing exercises are essential for maintaining bone mass, which helps toprevent
osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.
6. a nurse is assessing a client's readiness to learn about insulin administration.which of the
following statements should the nurse identify as an indication that the client is ready to
learn?
A. "I can concentrate best in the morning."
B. "it is difficult to read the instructions because my glasses are at home."
C. "I'm wondering why I need to learn this."
D. "you will have to talk to my wife about this."
"I can concentrate best in the morning."
The client's statement indicates a readiness to learn because he is verbalizing thebest time for
him to learn.
7. a nurse is giving discharge instructions to a client who will require oxygen therapy at
home. which of the following statements should the nurse identifyas an indication that
the client understands how to manage this therapy at home?
A. "I'll make sure that, when my friend comes by, she smokes at least 6 feetaway from
my oxygen tank."
B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen."
C. "I'll check the wires and cables on my TV to make sure they are in goodworking
order."
D. "I'll lay my oxygen tank down on the floor when the grandchildren visit
so they don't knock it over."
"I'll check the wires and cables on my TV to make sure they are in good workingorder."
Oxygen is a highly flammable gas. The client should make sure any electricalequipment
in the room where she is using supplemental oxygen is functioningproperly so it does not
create any electrical sparks.
8. a nurse is caring for a client who is reporting difficulty falling asleep. whichof the
following measures should the nurse recommend?
A. drink a cup of hot cocoa before bedtime
B. exercise 1 hr before going to bed
C. use progressive relaxation techniques at bedtime
D. reflect on the day's activities before going to bed
Use progressive relaxation techniques at bedtime.
Progressive relaxation promotes sleep by decreasing stress and reducing muscletension.
9. a nurse is assisting a client who is postoperative with the use of an incentivespirometer.
into which of the following positions should the nurse place theclient?
A. side-lying
B. supine
C. semi-fowlers
D. trendelenburg
Semi-Fowler's
Positioning the client in semi-Fowler's or high-Fowler's position allows formaximum
expansion of the lungs.
10. a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse
should identify that which of the following findings requiresfurther intervention?
A. erythema on pressure points
B. lower-extremity pulse strength on 2+
C. fluid intake of 3,000 mLper day
D. a bowel movement every other day
Erythema on pressure points
Erythema on pressure pointsrequires promptrelief of pressure and additionalmeasures to
protect the skin from further breakdown.
11. a nurse is caring for a client who requires a 24-hour urine collection. which
of the following statement by the client indicates an understanding of the
teaching?
A. "I had a bowel movement, but I was able to save the urine."
B. "I have a specimen in the bathroom from about 30 minutes ago."
C. "I flushes what I urinated at 7 am and have saved all urine since."
D. "I drink a lot, so I will fill up the bottle and complete the txt quickly."
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
For a 24-hr urine collection, the client should discard the first voiding and saveall subsequent
voidings.
12. a nurse is caring for a client who has herpes zoster and asks the runs aboutthe use of
complementary and alternative therapies for pain control. the nurse should inform
inform the client that his condition is a contraindication for which of the following
therapies?
A. biofeedback
B. aloe
C. feverfew
D. acupuncture
Acupuncture
The nurse should inform the client that the use of acupuncture is contraindicatedfor a client
who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface,
which could increase the risk of further infection.
13. a nurse is preparing to transfer a client who has right-sided weakness fromthe bed to a
chair. in what order should the nurse take the following actionsto assist the client?
1. ask the client is he can bear weight
2. use the stand-pivot technique to move the client to the chair
3. position the chair on the left side of the bed
4. have the client sit and dangle his feet at the bedside
1. ask the client is he can bear weight
3. position the chair on the left side of the bed
4. have the client sit and dangle his feet at the bedside
2. use the stand-pivot technique to move the client to the chair
14. a nurse is preparing to administer an injection of an opioid medication to aclient. the
nurse draws out 1 mL of the medication from a 2 mL vial. which of the following
actions should the nurse take?
A. ask another nurse to observe the medication wastage
B. notify the pharmacy when eating the medication
C. lock the remaining medication in the controlled substance cabinet
D. dispose of the vial with the remaining medication in a sharps container
Ask another nurse to observe the medication wastage.
A second nurse must witness the disposal of any portion of a dose of a controlledsubstance.
15. a nurse is preparing a herparing infusion for a client who was hospitalizedwith deepvein thrombosis. the orders read: 25,000 units of heparin in 250mL of 0.9% sodium
chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion
pump? (round to the nearest whole number)
8mL/hr
16. a nurse is caring for a client who has a prescription for 5 units of regularinsulin and
10 units of NPH insulin to mix together and administer subcutaneously. determine
the correct order of steps for this procedure.
1. inject 5 units of air into the bottle of regular insulin
2. withdraw the correct dose of NPH insulin from the bottle
3. inject 10 units of air into the bottle of NPH insulin
4. withdraw the correct dose of regular insulin from the bottle
3. inject 10 units of air into the bottle of NPH insulin
1. inject 5 units of air into the bottle of regular insulin
4. withdraw the correct dose of regular insulin from the bottle
2. withdraw the correct dose of NPH insulin from the bottle
17. a nurse is caring for a client who is postoperative and refused to use anincentive
spirometer following major abdominal surgery. which of the following is the
nurse's priority action?
A. request that a respiratory therapist discuss the technique for incentive
spirometer
B. determine the reasons why the client is refusing to use the onetime
spirometer
C. document the client's refusal to participate in health restorative activities
D. administer a pain medication to the client
Determine the reasons why the client is refusing to use the incentive spirometer.
The first action the nurse should take when using the nursing process is to assessthe client;
therefore, the priority action is for the nurse to determine why the client is refusing the
treatment.
18. a nurse is reviewing a client's medication prescription, which reads, "digoxi [Show Less]