ATI Fundamental 2019 Version B Practice Assessment

droplet includes: influenza, meningococcal pneumonia, and streptococcal pharyngitis

a nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Erythema on pressure points

a nurse is assessing an adult who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Place the patient in a room with negative-pressure airflow. Wear gloved when assisting the patient with oral care. Use antimicrobial sanitizer for hand hygiene.

a nurse is caring for a a patient who has tuberculosis. Which of the following actions should the nurse take?

"maintain a consistent time to wake up each day."

a nurse is caring for a patient who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the patient indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 am and have saved all urine since"

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands that teaching

"When descending stairs, I will first shift my weight to my right leg"

A 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 in the patient's medical record?

0.3 mg

a nurse is providing a discharge teaching for a patient who has a n new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the patient and his family?

1. Check the cord routinely for frays or tearing 2. consider purchasing a generator for power backup 3. observe for signs of hypoxia

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the patient's plan of care?

Wrap blankets around all four sides of the bed.

have family members wear a gown and gloves when visiting

a charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium Difficile infection. Which of the following information should the nurse include in the teaching?

an x-ray showing the end of the tube above the pylorus indicated gastric placement

a nurse has just inserted an NG tube for a patient. Which of the following finding should the nurse expect to confirm correct tube placement?

apply an ankle- foot orthotic device to the patient's feet. maintain dorsiflexion. Place foot board perpendicular to the mattress

a nurse is caring for a patient who has decreased mobility. Which of the following actions should the nurse take to decrease the patient's risk of developing plantar flexion contractures?

have the patient stand with their arms at their sides and their feet together helps identify alterations in balance

a nurse is performing a Romberg test during the physical assessment of a patient. Which of the following techniques should the nurse use?

a patient who has asthma can cause bronchospasms

a nurse is teaching a group of staff nurses about the use of essential oils aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following patients

walking briskly weight baring exercises are essential for maintaining bone mass.

a nurse is teaching an older adult patient who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

a patient who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

evacuate the patient Rationale: RACE

a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

rapid heart rate tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days

a nurse in an acute care facility is preparing a discharge summary for a patient who is transferring to a long term care facility. Which of the following documentation should the nurse include?

current medications

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the patient is experiencing spiritual distress?

"What could I have done to deserve this illness?"

a middle adult patient tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

"people in middle adulthood often find satisfaction in nurturing and guiding young people." Erik Erikson, the task of middlehood is generativity versus self-absorption and stagnation.

a nurse is caring for a patient 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 air into the vial of NPH insulin without touching the needle to the solution. 2. Inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. 3. Insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin.

a nurse is calculating a patient's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the patient's intake and output record as 120ml fluid?

8 oz of ice chips the nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips.

a nurse is assessing a patient who received an IV fluid bolus for dehydration. Which of the following finding should the nurse identify as an indication of fluid volume excess?

Distended neck veins In addition to edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

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?

Flush the tube with 15 mL of sterile water

the caregiver insists on remaining in the room

a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

"You should have a fecal occult blood test every year."

a nurse in a clinic is caring for a middle adult patient who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

wrap monitoring cords with stockinette and tape them in place

a nurse in a surgical suite notes documentation on a patient's medical record that he has a latex allergy. In preparation for the patient's procedure which of the following precautions should the nurse take?

Auscultate lung sounds ABC approach monitor for fluid volume excess. manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and SOB.

a nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as a priority?

tell the patient to keep the head of the bed elevated at least 30 degrees To prevent reflux of the formula into the esophagus ABC approach

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following action should the nurse take first?

"I will be sure to remove my hearing aid before taking a shower."

a nurse is caring for a client who has recently started using a behind-the-ear-hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device

a patient who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively

a nurse is caring for a group of patients on a medical-surgical unit. Which of the following situations does the nurse demonstrate the ethical principle of veracity?

"the pain is like a dull ache in my stomach."

a nurse is caring for a patient for a patient who reports pain. When documenting the quality of the patient's pain on an initial pain assessment, the nurse should record which of the following patient statements?

cleanse the wound from the center outward

a nurse is caring for a patient who has a prescription for wound irrigation. Which of the following actions should the nurse take?

skin blanching also, edema, and coolness can indicate infiltration

a nurse is caring for a patient who is receiving fluid through a peripheral IV catheter. Which of the following finding at the IV site should the nurse identify as indicating infiltration?

A. instruct family to refrain from pushing button for client while she is asleep

a nurse is caring for a patient who is receiving pain medication through a patient- controlled analgesic (PCA) pump. Which of the following actions should the nurse take?

withhold the blood transfusion

a nurse is caring for a patient who is refusing a blood transfusion for religious reasons. The patient's partner want the client to have the blood transfusion. Which of the following actions should the nurse take?

"I can take echinacea to improve my immune system." reduced the risk of infection.

a nurse is discussing the use of herbal supplements for health promotion with a patient. Which of the following patient statement indicates an understanding of herbal supplement use?

breath sounds ABC approach

a nurse is giving change-of-shift report about a client admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

practice sessions

a nurse is giving change-of-shift report about a client admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

narrowed arterial lumen blowing sounds- Bruit

a nurse is performing a peripheral vascular assessment for a patient. When placing the bell of the stethoscope on the patient's neck, the nurse hears the following sound. This sound indicate which of the following?

N95 respirator

a nurse is planning care for a patient who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the patient?

gently shake the container of medication prior to administration

a nurse is preparing to administer 0.5 ml of oral single-dose liquid medication to a client. Which of the following actins should the nurse take?

medication dose

a nurse is reviewing a patient's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes

a nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa

a nurse is reviewing protocol in preparation for suctioning secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

a nurse asks a nurse from another unit to assist with documentation for a patient

a nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

a nurse is preparing to delegate patients care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

ambulating a patient who is postoperative

a nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

assess the patient for orthostatic hypotension Rationale: the nurse should determine the patients risk for falling or fainting during transfer by assisting the patient to sit and dangle the feet on the side of the bed. the nurse should assess for dizziness and significant drop in blood pressure before assisting the patient to stand and transfer into the chair.

a nurse on a medical unit is preparing to discharge a patient to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

compare prescriptions with medication the patient received while at the facility