ATI Fundamentals 1

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

"It sounds like your pain is intermittent."

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

"Tell me more about how you feel about dying"

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of action should the nurse plan to take? (Move the steps into the box to the right, placing them in the order of performance. Use all the steps.)

1) Remove the soil dressing and perform hand hygiene. 2) turn off the vacuum on the NPWC device and administer the prescribed and analgesic. 3) apply sterile or clean gloves and irrigate the lawn. 4) apply skin protection or a barrier around to the wound 5) Play prepared fall into the wound bed and cover with a transparent dressing 6) Connect the TV to transparent film and turn on the NPWT unit

A nurse is preparing to administer 700 ML of 0.9% sodium chloride ID to a child to do it over 24 hours. Drop factor of the manual IV tubing 60 drop them in again. The nurse said that the manual IV infusion take another how many GTT/minute?

29

A nurse on an oncology unit received report at the beginning of the shift about four clients who are post operative. Which of the following client should the nurse he first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following action should the nurse?

Call suction catheter back 1 cm (0.5 inches) if the client starts coughing

And there's a sign for a client who has a stage three pressure ulcer on the heel. When preparing to irrigate the wound, which of the following action should the nurse take first?

Check the client's pain level

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

Client's level of comfort and ability to participate in the interview

A nurse is caring for a client who has a terminal illness. Which of the following findings indicate that the client death is imminent?

Cold extremities ; The presence of cold extremities, first in the feet and then in the hands, is a physical change that occurs when the client death is imminent

A nurse is going for a client who has terminal cancer. The client is still feeding my plans to build a new home. The nurse should identify that this behavior typically indicate which of the following stages of grief?

Denial

While admitting a client to the medical unit, the nurse asked him if he has advanced directives. Client stated, "I have a document with me that name someone who can make healthcare decisions for me if I am not available." The nurse should identify that the client is referring to west of the following document?

Durable power of attorney document

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous Enternal feedings. Which of the following actions should the nurse perform to reboot the clients rid of operation?

Elevate the head of the bed to 30° or 45°

A nurse is performing I'll irrigation for a client who was exposed smoke and ash. Which of the following action should the nurse take?

Expert pressure on the bony prominences when holding the Eyelid open

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following action should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring. The nurse should hold a multidose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible

A nurse is providing teaching about crutches to a client who has a fracture of the right foot,. Which of the following instruction should the nurse include?

Keep the rubber crutch tips securely in place.

A nurse on a mental health Unit Assess herring to terminate the nurse client relationship with a client who is no longer required here. Which of the following concepts should the nurse and the client discuss in the termination phase of the relationship?

Loss; At the close of a relationship, even when plants, Los is an expressive feeling for both the client and the nurse. It is important for both the north and the claim to terminate the relationship without feeling of guilt or anxiety

A nurse is providing oral care for A client who is conscience. Which of the following action should the nurse?

Place the client in a lateral position with the head turned to the side before beginning the procedure

A nurse is a pain in the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Play the bladder of the stuff over the posterior aspect of Best Buy thigh

A nurse is preparing to administer a cleansing enema to a client. Which of the following action should the nurse plan to take?

Position the client on his left side

A nurse is monitoring a client's laboratory results.. Which of the following results should the nurse report to the provider

Potassium 3.0 mEq/L

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following action should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day

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), a heart rate of 105/ min, a soft nontender abdomen, and menses overdue by 2 Days. Which of the following findings should be the nurses priority?

Temperature 102.6°F, 39.2°C

A nurse is teaching range of motion exercises to a client who has has osteoarthritis. Which of the following clients emotion demonstrate an understanding of supination of the hand?

The client holds the hand with the plum up

A hospice nurse is visiting with the family member of a client. The family member states that the plan has Banya almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia?

The client watches television in her bed during the day. To promote weight, the client should avoid watching TV in bed. She should use the bed only for sleep.

A nurse is teaching an assistive personnel a P 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 rub to clean my hands

A nurse observes a assistive personnel AP preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanation should the nurse give the AP?

Using a cuff that is too small will result in an inaccurately high reading

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following option indicates the nurse is maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction

A nurse is teaching an assistive personnel AP calculus tame a capillary singer take blood sample. Which of the following actions by the AP requires a nurse to intervene?

elevating the finger above the heart Level

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?

faint pedal pulses; can indicate poor circulation and tissue perfusion, which puts the client at rest of them here in integrity

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

tachycardia; Due to the decreased circulation blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood Is review. The body attempt to the Lisa hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate.