ATI FUNDAMENTALS FINAL

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin (Anything clear at room temp)

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish brown urine in the client's urinary catheter bag. The nurse recongnizes these manifestations as which of the following types of transfusion reactions?

Hemolytic (blood is incompatible with the donor's blood - chills, LBP, hypotension, tachycardia = indications of hemolytic transfusion reaction)

A nurse is planning to document care provided for a client. which of the following abbreviations should the nurse use?

PC for after meals

A nurse is reviewing the correct use of a few extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher (PULL, AIM, SQUEEZE, SWEEP)

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion five times during each session.

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway (ABCs)

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

Assessment

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which instructions should the nurse include in the teaching?

Bear weight on both of your legs (3 points on the ground at all times - must be able to bear weight on both legs)

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

Cold extremities Rationale: Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent.

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. which of the following instructions should the nurse include?

Cough deeply after each use

A nurse is caring for a client who is postoperative following abdominal surgery. which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?

Edema at the infusion site

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

Position the client on his left side.

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you." (Open-ended questions)

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. (Suction should be set at 80-100 mm Hg, water soluble lube/NOT petroleum jelly should be used)

A nurse is responding to a parent's question about his infant's expected physical development during the first year of lie. Which of the following information should the nurse include?

A 10-month old infant can pull himself to a standing position

A nurse is explaining the use of written consent forms to a newly hired nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed RBCs (it is a procedure that carries risk)

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults (Primary = health education)

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

A nurse in a long term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following response should the nurse make?

It must be difficult to are for someone who is confined to bed

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver Damage (< 3-4 g/day limit or 2.4 g/day for older adults/hx of liver impairment)

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss Rationale: At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position. Rationale:The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure. (Reduce aspiration risk)

A nurse is planning care for a client who is post op and has a history of poor nutritional intake. Which of the following actions 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 performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test

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

Tie the restraint with a quick-release knot

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3 (above normal range = infection)

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity (O2 is combustable - spark from static could ignite)

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown (Contact precautions: gown & gloves, wash hands with SOAP AND WATER for C. diff)

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Bounding pulse

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning?

Have the client demonstrates the procedure

A nurse is planning to insert a NG tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

I can see that this is upsetting you

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

"All of this equipment can be frightening." Rationale: This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag two-thirds full with ice. Rationale: The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium Rationale: Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

A nurse is caring for a client who is 48 hours postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complaint?

Impaired peristalsis of the intestines

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client.

A nurse in 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

An assistive personnel is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder