ATI Fundamental
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
"Donate autologous blood before the surgery."
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
"I am going to listen to your abdomen."
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
"I keep having nightmares about my upcoming surgery."
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal after exercise as I get older."
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
"Sit on the toilet 30 minutes after eating a meal."
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
"Using a cuff that is too small will result in an inaccurately high reading."
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
"What do you think caused the onset of your pain?"
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?
"What worries you about being without your teeth?"
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
(upper thigh) Lower Abdomen
A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
A halo of erythema on the surrounding skin
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
Absent bowel sounds with distention
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day and night.
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?
Attempt to increase the clients' self-motivation.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
Remove the restraints one at a time.
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
Confirm unresponsiveness
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
Carefully remove the gloves and follow with hand hygiene.
A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked.
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
Clamp the tubing below the collection port.
A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?
Cleanse the skin around the stoma with warm water.
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
Collapse the device of air after emptying.
A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?
Collect the specimen upon arising in the morning.
A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?
Weigh the client on arising. (after voiding, before breakfast, on the same scale, and wearing the same clothes)
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?
Determine whether the client is able to breathe.
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
Disconnect the machine, and measure the blood pressure manually every 15 min.
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing.
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?
Drop the eye medication into the lower conjunctival sac.
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Elevate the client's head of bed 45° before the feeding.
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
Encourage the client to express his thoughts about death and dying.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open.
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Explain the procedure to the client.
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
Face the client when speaking
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?
Granulation tissue fills the wound during healing.
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?
Purulent exudate
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
Raise the level of the bed.
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?
Hold breath for 5 seconds after goal volume is reached (inhale slowly and do for 10-20 breaths every hour)
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Hold the linens away from the body and clothing.
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Identify the client using two identifiers.
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?
Inability of the toddler to cry or speak
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Insert the tip of the tubing 8 cm (3.1 in) (lubricate 2-3 in, left side sims, hold 18 in above rectum)
Normal Assessment
Inspect, Palpate, Percuss, Auscultate
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?
Lock the wheels on the bed and stretcher.
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
Montgomery straps
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
Notify the provider about the client's decision.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
Obtain client information.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining cotton balls for the tracheostomy care
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
Offer the client tart or sour foods first.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
Pericardial friction rub
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
Pinch the NG tube while removing the tube
The signature on the preoperative consent form is the client's.
Place the bladder of the cuff over the posterior aspect of the thigh.
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Place the stool specimen collection container in a biohazard bag (clean container)
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45° angle to the bed.
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing (3 passes with 1 min wait in between and 100% O2 for 2 mins)
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?
Remove the sleeve of the gown from the arm without the IV line.
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?
Renew the prescription for the use of restrains within 24 hr.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
Screening groups of older adults in nursing care facilities for early influenza manifestations.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Sit and hold the client's hand.
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Wipes the labia minora in an anteroposterior direction
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
Start chest compressions
A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?
Taut skin around the IV catheter site that is cool to the touch
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2° C (102.6° F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?
Temperature
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
Temporal
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
The client reports severe pain.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
The nurse washes with her hands held higher than her elbows.
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?
The side hip between the iliac crest and anterior iliac spine (ventrogluteal-preferred site for adults)
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client's.
A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?
Turn the stocking inside out up to the heel before applying.
A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?
Use a gait belt during ambulation
A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?
Use the pain scale to determine the client's pain level.
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?
Vitamin C and Zinc
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
assessment
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?
check client's perineum.
"Tell me what I can do to help you overcome your fear of giving yourself injections."
evaluate pedal pulse
AB Assessment
inspect auscultate percussion palpate
Screening groups of older adults in nursing care facilities for early influenza manifestations.
preform hand hygiene
