ATI FUNDAMENTALS

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Use a stiff toothbrush to clean the client's teeth B. Use the thumb and index finger to keep the client's mouth open. C. Turn the client on his side before starting oral care. D. Apply petroleum jelly to the client's lips after oral care.

A. Use a stiff toothbrush to clean the client's teeth. Rationale: The nurse should use a soft toothbrush, not a stiff one, to avoid injury to the gingivae. B. Use the thumb and index finger to keep the client's mouth open. Rationale: The nurse should use a bite block or an oral airway, not a thumb or index finger, to keep the client's mouth open. C. Turn the client on his side before starting oral care. Rationale:Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking. D. Apply petroleum jelly to the client's lips after oral care. Rationale: The nurse should apply a water-soluble lubricant to the client's lips after oral care.

.A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. "I will try to anticipate and avoid stressful situations when possible." C. "I will complete the smoking cessation program I started." D. "I will take my medications at the first sign of an attack."

A. "I will wear gloves when removing food from the freezer." Rationale: The client should wear gloves when removing food from the freezer to avoid cold and prevent the onset of vasoconstriction. B. "I will try to anticipate and avoid stressful situations when possible." Rationale: The client should anticipate stressful situations to manage stress and prevent the onset of vasoconstriction. C. "I will complete the smoking cessation program I started." Rationale: The client should cease, not just reduce, smoking to prevent the onset of vasoconstriction. D. "I will take my medications at the first sign of an attack." Rationale: Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

.A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A. Pernicious anemia B. Dehydration C. Prostate enlargement D. Bladder infection

A. Pernicious anemia Rationale:Pernicious anemia is caused by a lack of intrinsic factor, a substance needed to absorb vitamin B12 from the gastrointestinal tract. Vitamin B12 is needed for the formation of red blood cells. Hematuria, or blood present in the urine, is not a manifestation of pernicious anemia. B. Dehydration Rationale: Dehydration is a manifestation of oliguria or a diminished urinary output. C. Prostate enlargement Rationale:Prostate enlargement is a manifestation of urinary hesitancy of difficulty initiating a stream of urine. D. Bladder infection Rationale: The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

.A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction two to three times with a 60-second pause between passes. B. Perform chest physiotherapy prior to suctioning. C. Lubricate the suction catheter tip with sterile saline. D. Hyperventilate the client on 100% oxygen prior to suctioning

A. Suction two to three times with a 60-second pause between passes. Rationale:Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia. B. Perform chest physiotherapy prior to suctioning. Rationale: This intervention mobilizes secretions but does not remove them. C. Lubricate the suction catheter tip with sterile saline. Rationale: This intervention has no effect on the removal of secretions. D. Hyperventilate the client on 100% oxygen prior to suctioning. Rationale: This intervention has no effect on the removal of secretions.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Information about a client can be disclosed to family members at any time." B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." C. "A client's address would be an example of personally identifiable information." D. "HIPAA is a federal law, not a state law."

A. "Information about a client can be disclosed to family members at any time."Rationale:This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information. B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form."Rationale:This statement reflects an understanding of HIPAA. All health care organizations that use electronic transactions and code sets, such as health care claims and claim payments, mustcomply with HIPAA standards. C. "A client's address would be an example of personally identifiable information."Rationale:This statement reflects an understanding of HIPAA. Identifiers for the information include a client's name, address, phone number, driver's license number, and so forth. D. "HIPAA is a federal law, not a state law."Rationale:This statement reflects an understanding of HIPAA, which is a federal law that was passed in1996.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust the water temperature to feel hot. B. Apply 4 to 5 mL of liquid soap to the hands C. Hold the hands higher than the elbows. D. Rub hands and arms to dry.

A. Adjust the water temperature to feel hot.Rationale:Using warm, instead of hot, water will help protect the skin by minimizing loss of the protective oil on the skin. This will help maintain the integrity of the skin B. Apply 4 to 5 mL of liquid soap to the hands.Rationale:The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms. C. Hold the hands higher than the elbows.Rationale:The nurse should hold the hand lower than the elbows when washing the hands under running water so that the water flows from the more contaminated area (the arms) to the cleaner area(hands and fingers.) D. Rub hands and arms to dry.Rationale:The nurse should use a paper towel to pat the hand and arm dry without rubbing vigorously.Repeated rubbing of moist skin can lead to chapping and skin breakdown.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying

A. An upper respiratory infection Rationale:Although the spleen plays a role in immunity against bacterial infections, the nurse would be more concerned about the risk of an upper respiratory infection in a client who has undergone splenectomy, or removal of the spleen. B. Pulmonary edema Rationale:Pulmonary edema may develop in a client who is on bedrest following trauma, but this is not the most likely cause of decreased breath sounds in this client. C. Atelectasis Rationale:Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis. D. Delayed gastric emptying Rationale:Although delayed gastric emptying may result in ineffective coughing, this is not the most likely cause of decreased breath sounds in this client.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.

A. Close the fire doors on the unit. Rationale: Clients are at risk for injury because the smoke and fire could spread through open doors; however, another action is the priority. B. Activate the fire alarm. Rationale: Clients are at risk for injury because the smoke and fire could spread without emergency services intervention; however, another action is the priority. C. Move any clients in the immediate vicinity. Rationale:The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire. D. Use a fire extinguisher to put out the fire. Rationale: Clients are at risk for injury unless someone extinguishes the fire; however, another action is the priority

.A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Dorsal metacarpal vein B. Radial vein in the wrist C. Antecubital vein D. Median vein in the forearm

A. Dorsal metacarpal vein Rationale: The nurse should avoid using veins in the back of an older adult's hands, because it can limit mobility. Also, the client could easily bump the hand into objects, and older adults have less support for the area due to minimal subcutaneous tissue. B. Radial vein in the wrist Rationale: The nurse should avoid the cephalic vein in the wrist because veins on the palmar side of the wrist lie close to the median nerve, and the venipuncture is likely to be painful and could cause nerve damage. C. Antecubital vein Rationale:An IV site in the antecubital fossa requires immobilization of the client's elbow. An area of joint flexion is not a good choice when other sites are available. D. Median vein in the forearm Rationale: The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? A. Excessive thirst and urination B. Shakiness and diaphoresis C. Fever and chills D. Hypertension and crackles

A. Excessive thirst and urination Rationale:Excessive thirst and urination are manifestations of hyperglycemia, which can be a complication of TPN related to the high proportion of glucose in the infusion. B. Shakiness and diaphoresis Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia. C. Fever and chills Rationale: Fever and chills are manifestations of infection. D. Hypertension and crackles Rationale: Hypertension and crackles are manifestations of fluid overload, which can be a complication of TPN related to the fluid infusion rate.

. The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? A. He is hard of hearing. B. Pain C. Confusion D. Language barrier

A. He is hard of hearing. Rationale:If the client cannot hear the nurse, he would most likely communicate that. B. Pain Rationale: Clients who have pain can usually still provide assessment data. C. Confusion Rationale:Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion. D. Language barrier Rationale:Even if the client speaks a different language as the nurse, the family accompanied him. Although the nurse should use a medical interpreter, the family should be able to provide some initial explanations of the facts leading to the visit.

.A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse? A. Invasion of privacy B. Assault C. Battery D. False imprisonment

A. Invasion of privacy Rationale:Invasion of privacy is defined as failure to respect a client's right to manage their own affairs. This situation does not describe invasion of privacy. B. Assault Rationale:Assault is defined as threatening to inflict injury on a client or an attempt to do harm. This situation does not describe assault. C. Battery Rationale:Battery is defined as intentionally touching a client without her consent. This situation does not describe battery. D. False imprisonment Rationale: False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering B. Dilute each medication with 10 mL of tap water. C. Maintain the head of the bed in a flat position for 30 min following medication administration D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

A. Mix the three medications together prior to administering. Rationale: The nurse should administer each medication separately and flush the tube with 15 to 30 mL of sterile water to ensure the client receives the entire dose. B. Dilute each medication with 10 mL of tap water. Rationale:If the nurse needs to further dilute the medication because it is viscous, the nurse should only use sterile water because tap water can contain contaminants that can adversely interact with the medication. C. Maintain the head of the bed in a flat position for 30 min following medication administration. Rationale: The nurse should ensure the head of the bed is elevated to at least 30° when a client is receiving enteral feedings and also following medication administration through an enteral tube. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration Rationale: The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device D. Administer a local anesthetic.

A. Remove the catheter and insert another into a different site. Rationale:It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere. B. Administer an analgesic PO. Rationale:Before administering any medication for the client's discomfort, the nurse should assess the pain and try to identify and eliminate its cause. C. Request a prescription for placement of a central venous access device. Rationale:A central venous access device is for long-term administration of various medications and IV preparations. Outpatient surgery is not an indication for this type of IV access. D. Administer a local anesthetic. Rationale:Before administering any medication for the client's discomfort, the nurse should assess the pain and try to identify and eliminate its cause.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick-release tie. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints to the lowest bar of the side rail. D. Anticipate removing the restraints every 4 hr.

A. Secure the restraints using a quick-release tie. Rationale: The nurse should secure the restraints using a quick-release tie for easy removal in an emergency. B. Ensure four fingers fit under the restraints to prevent constriction. Rationale: The nurse should prevent constriction by inserting two fingers under the restraints. The restraint might be ineffective if the nurse can insert four fingers under it. C. Secure the restraints to the lowest bar of the side rail. Rationale: The nurse should secure the restraints to an area of the bed frame that moves with the client when repositioning, such as raising and lowering the head of the bed. The nurse should not secure the restraints to the side rail. D. Anticipate removing the restraints every 4 hr. Rationale: The nurse should remove the restraints at least every 2 hr or more frequently according to facility policy.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? A. Steatorrhea B. Blood C. Bacteria D. Parasites

A. Steatorrhea Rationale:A guaiac test does not test for steatorrhea. The nurse would need to send the total quantity of stool expelled at one time to the laboratory for testing. B. Blood Rationale:A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers. C. Bacteria Rationale:A guaiac test does not test for bacteria in the stool. This type of specimen is collected in a culture tube with sterile and aseptic technique. D. Parasites Rationale:A guaiac test does not test for parasites in the stool. This requires warm stool samples over a period of days for evaluation.

.A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before the instillation. B. Assist the client to a side-lying position. C. Hold the dropper 2 cm (1 in) above the naris D. Instruct the client to stay in the same position for 2 min.

A. Tell the client to blow her nose gently before the instillation. Rationale:Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication. B. Assist the client to a side-lying position. Rationale: The nurse should assist the client to lie supine for a nasal instillation. C. Hold the dropper 2 cm (1 in) above the naris. Rationale: The nurse should hold the dropper 1 cm (1/2 in) above each naris before instilling the drops. D. Instruct the client to stay in the same position for 2 min. Rationale: The client should stay in the same position for 5 min to make sure the drops do not run out when the she sits or stands up

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? A. The client who has a tracheostomy tube attached to humidified oxygen B. The client who has an indwelling urinary catheter to gravity drainage C. The client who has a chest tube to water sea D. The client who has a nasogastric (NG) tube to suction

A. The client who has a tracheostomy tube attached to humidified oxygen Rationale: This client is not at risk for hypokalemia. B. The client who has an indwelling urinary catheter to gravity drainage Rationale: This client is not at risk for hypokalemia. C. The client who has a chest tube to water seal Rationale: The serous or serosanguineous fluids lost via a chest tube are not any higher in electrolytes than circulating blood; therefore, this is not the client at risk for hypokalemia. D. The client who has a nasogastric (NG) tube to suction Rationale: Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.