NCLEX RN ATI FUNDAMENTALS OF NURSING PROCTORED EXAM 2024-2025 WITH NGN QUESTION WITH RATIONALES AND ANSWERS A+ GRADE
QUESTION 10
10. A nurse is
... [Show More] assessing an adult client who has been immobile for the past 3 week. The nurse should identify that which of the following findings requires further intervention?
A. erythema on pressure points
B. lower-extremity pulse strength on 2+
C. fluid intake of 3,000 mL per day
D. a bowel movement every other day
Erythema on pressure points
Erythema on pressure points requires prompt relief of pressure and additional measures 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 save all subsequent voidings.
12. A nurse is caring for a client who has herpes zoster and asks the runs about the use of complementary and alternative therapies for pain control. the nurse should 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 contraindicated for 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 from the bed to a chair. In what order should the nurse take the following actions to 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 a client. 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 controlled substance.
15. A nurse is preparing a herparing infusion for a client who was hospitalized with deep- vein 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. 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.
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 an incentive 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 assess the 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, "digoxin 0.25 by mouth every
day." which of the following components of the prescription should the runs question?
A. the medication
B. the route
C. the dose
D. the frequency The dose
The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.
19. 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?
A. place the client in high-flowers position
B. increase the client's intake of carbohydrates
C. massage the reddened areas with unscented lotion
D. have the client use a trapeze bar when changing positions Have the client use a trapeze bar when changing position.
By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure ulcer development.
20. 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 on the client's medical record?
A. .3 mg B.
0.3 mg
C. 0.30 mg
D. 3/10 mg
0.3 mg
The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.
21. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following filings at the IV site should the nurse identify as infiltration?
A. purulent exudate
B. warmth
C. skin blanching
D. bleeding
Skin blanching, edema, and coolness at the IV site indicate infiltration.
22. 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? A.
dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe
C. push the syringe plunger gently when feeling resistance
D. flush the tube with 15 mL of sterile water Flush the tube with 15 mL of sterile water.
The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.
23. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with
this client?
A. allow extra time for the client to respond to questions
B. expect the client to have difficulty understanding the information
C. avoid references to the lento's past experiences
D. keeping the learning session private and one-on-one
Allow extra time for the client to respond to questions.
Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to askquestions and absorb the information.
24. 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?
A. the top of the cane is parallel to the client's waist
B. when walking, the client move the cane 46 cm (18 in) forward
C. the client holds the cane on the stronger side of her body
D. the client moves her stronger limb forward with the cane The client holds the cane on the stronger side of her body. [Show Less]