NURSING NUR 165 ATI FUNDAMENTALS PROCTORED EXAM TEST BANK 100- CORRECT QUESTIONS & ANSWERS VERIFIED GUARANTEED A+
A nurse is interviewing a family as
... [Show More] part of a family assessment. The nurse identifies the family unit as a husband, a wife, and three children. One child is biological from this marriage and the other two are from the wife‟s previous marriage. The nurse should identify this as which of the following family forms?
Extended Blended Nuclear Alternative
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
• Obtain a replacement pump
• Notify the biomedical department to fix the pump
• Label the pump with a defective equipment sticker
• Unplug the pump- unplugging will remove the source of potential fire started .
A nurse is preparing to insert IV catheter for an adult client. Which of the following actions should the nurse take?
• Choose the most proximal site on the extremity selected (distal first)
• Apply a cool compress for several minutes before insertion of the IV catheter (warm it)
• Stroke the extremity for several minutes before insertion of the IV catheter
• Place the tourniquet below the proposed insertion site (above it)
A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching
• I will place the bed in the lowest position (place at your hip level)
• I will tighten my abdominal muscles prior to moving
• I will keep my legs straight to provide more power in the lift (bend)
• I will twist at the waist while pulling the draw sheet (avoid)
Rationale PDF p71: Avoid twisting your thoracic spine and bending your back while your hips and knees are straight; When lifting an object from the floor, flex your hips, knees, and back; tighten the abdominal muscles to increase support to the back muscles
A nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report?
• Frequency of previous vital sign measurement
• Number of family members who have visited
• Time of the clients last bath
• Effectiveness of the last dose of pain medication
Rational PDF p39: Transfer documentation:
-Medical diagnosis and care providers
a. Demographic information
-Overview of health status, plan of care, and recent progress
b. Alterations that can precipitate an immediate concern
-Notification of assessments or care essential within the next few hours
-Most recent vital signs and medications, including PRN
c. Allergies
d. Diet and activity orders
-Specific equipment or adaptive devices (oxygen, suction, wheelchair)
-Advance directives and emergency code status
e. Family involvement in care and health care proxy, if applicable
A nurse is assessing a client‟s bowel sounds. Which of the following actions should the nurse take?
• Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate, percuss palpate)
• Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes)
• Place the diaphragm of the stethoscope over each quadrant
• Ask the client to cough upon auscultation (for lung assessment)
A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate?
A. Evaluating healing of an incision
B. Inserting a NG Tube
C. Performing a simple dressing change.
D. Changing IV tubing.
A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?
A. HR 105/min
B. BMI 25 kg/m2
C. BP 148/92
D. Glucose 45mg/dl
A nurse is assessing a client‟s extraocular eye movements. Which of the following actions should the nurse take?
A. Position the client 6.1m(20ft) away from the Snellen chart.
B. Instruct the client to follow finger through the six cardinal position of gaze,
C. Ask the client to cover her right eye during assessment of her left eye.
D. Hold a finger 46cm (18inch) in front of the client‟s eye.
A nurse is interviewing a family as part of a family assessment. The nurse identifies the family unit as a husband, a wife, and three children. One child is biological from this marriage and the other two are from the wife‟s previous marriage. The nurse should identify this as which of the following family forms?
Extended Blended Nuclear Alternative
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
• Obtain a replacement pump
• Notify the biomedical department to fix the pump
• Label the pump with a defective equipment sticker
• Unplug the pump- unplugging will remove the source of potential fire started .
A nurse is preparing to insert IV catheter for an adult client. Which of the following actions should the nurse take?
• Choose the most proximal site on the extremity selected (distal first)
• Apply a cool compress for several minutes before insertion of the IV catheter (warm it)
• Stroke the extremity for several minutes before insertion of the IV catheter
• Place the tourniquet below the proposed insertion site (above it)
A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching
• I will place the bed in the lowest position (place at your hip level)
• I will tighten my abdominal muscles prior to moving
• I will keep my legs straight to provide more power in the lift (bend)
• I will twist at the waist while pulling the draw sheet (avoid)
Rationale PDF p71: Avoid twisting your thoracic spine and bending your back while your hips and knees are straight; When lifting an object from the floor, flex your hips, knees, and back; tighten the abdominal muscles to increase support to the back muscles
A nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report?
• Frequency of previous vital sign measurement
• Number of family members who have visited
• Time of the clients last bath
• Effectiveness of the last dose of pain medication
Rational PDF p39: Transfer documentation:
-Medical diagnosis and care providers
a. Demographic information
-Overview of health status, plan of care, and recent progress
b. Alterations that can precipitate an immediate concern
-Notification of assessments or care essential within the next few hours
-Most recent vital signs and medications, including PRN
c. Allergies
d. Diet and activity orders
-Specific equipment or adaptive devices (oxygen, suction, wheelchair)
-Advance directives and emergency code status
e. Family involvement in care and health care proxy, if applicable
A nurse is assessing a client‟s bowel sounds. Which of the following actions should the nurse take?
• Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate, percuss palpate)
• Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes)
• Place the diaphragm of the stethoscope over each quadrant
• Ask the client to cough upon auscultation (for lung assessment)
A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate?
A. Evaluating healing of an incision
B. Inserting a NG Tube
C. Performing a simple dressing change.
D. Changing IV tubing.
A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?
A. HR 105/min
B. BMI 25 kg/m2
C. BP 148/92
D. Glucose 45mg/dl
A nurse is assessing a client‟s extraocular eye movements. Which of the following actions should the nurse take?
A. Position the client 6.1m(20ft) away from the Snellen chart.
B. Instruct the client to follow finger through the six cardinal position of gaze,
C. Ask the client to cover her right eye during assessment of her left eye.
D. Hold a finger 46cm (18inch) in front of the client‟s eye. [Show Less]