ATI Fundamental Practice Assessment B

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?

"I will be sure to remove my hearing aid before taking a shower." Reason: Clients should remove any hearing devices before showering because exposure to water can damage them.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates the teaching has been effective?

"I will hire someone to trim the tree that overhangs the front porch stairs." Reason: Clearing stairwells of any object that could cause the client to trip or the need to bend over will decrease the risk for falls.

A nurse is providing teaching to a client who is on protective isolation precautions. Which of the following client statements indicates an understanding of the teaching?

"I will wear a face mask when leaving my hospital room." Reason: The client is encouraged to wear a face mask because of increased risk for exposure to micro-organisms.

A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse?

"That must be frustrating for you. How can I help you right now?" Reason: This response is therapeutic because the nurse is acknowledging the client's feelings and offering help.

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

"The pain is like a dull ache in my stomach." Reason: The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness." Reason: Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." Reason: Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

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 client is experiencing spiritual distress?

"What could I have done to deserve this illness?" Reason: The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

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 the teaching?

"When descending stairs, I will first shift my weight to my right leg." Reason: To descend stairs, the client should first shift their body weight to their right, unaffected leg.

A nurse in a clinic is caring for a middle adult client 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?

"You should have a fecal occult blood test every year." Reason: Colorectal cancer screening for clients who are at average risk begins at age 45. One option for screening is a fecal occult blood test annually.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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

8 oz of ice chips Reason: The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively. Reason: Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance Reason: An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

Acupuncture Reason: The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen. Reason: The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

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

Apply an ankle-foot orthotic device to the client's feet. Reason: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter. Reason: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Apply transparent dressing over the IV insertion site and securement device Reason: Transparent dressing prevents infection by protecting the IV site.

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?

Ask another nurse to observe the medication wastage. Reason: A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is preparing to transfer a client 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 client for orthostatic hypotension. Reason: The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.

Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary. Administer a cleansing enema is correct. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds is correct. The nurse should auscultate the client's bowel sounds to determine the sta

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

Auscultate lung sounds. Reason: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet?

Avocados Reason: The nurse should suggest the client eat avocados, which are an excellent dietary source of potassium.

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

Breath sounds Reason: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse is caring for a client who has COPD.

Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not require follow-up by the nurse. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse. Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to 100/min and does not require follow-up by the nurse.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries. Reason: The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and their family? (Select all that apply.)

Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 1.2 m (4 ft) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and repor

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

Cleanse the wound from the center outward. Reason: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse is caring for a client who had a spinal cord injury and has paraplegia.

Client is repositioned every 2 hr is incorrect. The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. Therefore, this finding does not require intervention at this time. Passive range-of-motion exercises to lower extremities performed once each day is correct. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. Feet warm. Pedal pulses 2+ bilaterally is incorrect. The nurse should identify that the client has adequate circulation to their feet. Therefore, this finding does not require intervention at this time. Plantar flexion contractures noted bilaterally is correct. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct. The client

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first?

Determine the client's learning style. Reason: Using the nursing process, the first action the nurse should take is to assess the client's learning style.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer. Reason: The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.

A nurse is caring for a client who is receiving a unit of packed RBCs.

Drop Down 1: Allergic reaction is correct. The nurse should identify the client has manifestations of an allergic reaction as evidenced by itching, flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the provider. Febrile reaction is incorrect. A febrile reaction has manifestations of fever, chills, headache, flushing of the face, and muscle pain. Fluid overload is incorrect. Fluid overload has manifestations of cough, crackles heard in bases of the client's lungs, shortness of breath, and distended neck veins. Drop Down 2: Itching is correct. The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider. Temperature is incorrect. The client's temperature is within the expected reference range. An increase in temperature is a manifestation of febrile or hemolytic reaction to blood administrati

A nurse in a medical-surgical unit is caring for six clients.

Drop Down 1: Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein is greater than the expected reference range, which is an indication of inflammation. However, there is another client the nurse should assess first. Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level is greater than the expected reference range, which places them at risk for coronary heart disease. However, there is another client the nurse should assess first. Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Drop Down 2: Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess.

A nurse is caring for a client.

Drop Down 1: Dysrhythmias is incorrect. The client's potassium level is within the expected reference range. Therefore, the client is not at an increased risk for dysrhythmias. Bleeding is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Infection is incorrect. The client's WBC count is within the expected reference range. Therefore, the client is not at an increased risk for infection. Drop Down 2: Platelet count is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. WBC count is incorrect. The client's WBC count is within the expected reference range. Therefore, the client is not at an increased risk for infection. Potassium level is incorrect. The client's potassium level is within the expected reference range. Therefore, the client is not at an increased risk for dysrhythmias.

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

Erythema on pressure points Reason: Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

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

Have the client stand with their arms at their sides and their feet together. Reason: A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus. Reason: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety. Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impa

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves. Reason: The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.

A nurse is reviewing a client'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?

Medication dose Reason: In the prescription, the medication 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.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Place a client who has tuberculosis in a room with negative-pressure airflow. Reason: A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position. Reason: The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions Reason: Practice sessions require psychomotor skills when learning.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear. Reason: Pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief. Reason: During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Reason: Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

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

Select a suction catheter that is half the size of the lumen. Reason: The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

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

Skin blanching Reason: Skin blanching, edema, and coolness at the IV site indicate infiltration.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.

Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort. Place a pressure dressing over the IV site is incorrect. The nurse should not apply pressure to the IV site, because this can cause tissue damage. Start a new IV in the client's left hand is incorrect. The nurse should start a new IV in a different extremity to reduce the risk of tissue damage.

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?

The caregiver insists on remaining in the room. Reason: A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A 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?

The client holds the cane on the stronger side of their body. Reason: The client should hold the cane on the stronger side of their body to increase support and maintain alignment.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. Reason: The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

A 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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. Reason: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery. Reason: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is teaching a client and their family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors. Reason: Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

A nurse is teaching an older adult client 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?

Walking briskly Reason: Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is admitting a client to a health care facility.

Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection. Wear a sterile, wate

A nurse is caring for a client in a medical-surgical unit.

When evaluating outcomes, the nurse should identify that the assessment findings of granulation tissue covering the wound bed, no odor present, increased comfort level, and the decrease in size of the wound bed and tunneling indicate an improvement of the client's condition. Granulation tissue is comprised of new blood vessels, a lack of odor indicates infection is not suspected, and the decrease in the wound bed size and length of tunneling are associated with healing of the client's pressure injury.