ATI Fundamentals of Nursing

A nurse is reinforcing teaching about crutch use with a client who has had knee surgery. Which of the following instructions should the nurse include? A. "Hold both crutches with a hand when you sit down in a chair." B. "Stand with the crutches about 9 inches in front and 9 inches to the side of your feet." C. "Lean your weight on the crutch pads at your armpits." D. "Wear leather-soled shoes when you use your crutches."

A. "Hold both crutches with a hand when you sit down in a chair."

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 6.6 pounds each month would be acceptable."

A. "Losing 2.2 pounds each month would be acceptable."

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A. Assertive community treatment B. Support group C. Private counseling D. Vocational rehabilitation services

A. Assertive community treatment

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration B. Apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner ear canal for 30 minutes following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration

A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. Which of the following findings should the nurse report to the provider? (Select all that apply.) x A. Tachycardia and hypertension B. Respiratory rate 16/min C. Negative Chvostek's sign D. Laryngeal stridor and hoarseness E. Positive Trousseau's sign

A. Tachycardia and hypertension D. Laryngeal stridor and hoarseness E. Positive Trousseau's sign

A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following statements should the nurse include in the preparation for this procedure? A. "Your father is going to be outside the room while I give you the shot." B. "I am going to give you some medication that will go under your skin." C. "This medication doesn't hurt that much." D. "This will feel like a bee sting."

B. "I am going to give you some medication that will go under your skin."

A nurse is teaching a client who has a new prescription for amitriptyline to treat depression. Which of the following client statements indicates an understanding of the teaching? A. "I should take this medication when I experience active symptoms." B. "I should take this medication before bedtime." C. "This medication may cause excess salivation." D. "I might experience weight loss while taking this medication."

B. "I should take this medication before bedtime."

A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue your IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."

B. "The bleeding is minimal until I discontinue your IV medication."

A nurse is assisting with preparing a client who is scheduled for an arthroscopy on the following day. Which of the following statements indicates that the client understands the pre-procedure instructions? A. "I have to be able to keep my leg straight for the whole procedure." B. "The doctor will be able to see if I have signs of rheumatoid arthritis." C. "I should expect to stay overnight until I can walk around." D. "I'll have a scar that will be about an inch long."

B. "The doctor will be able to see if I have signs of rheumatoid arthritis."

A nurse is assisting with the care of a client who is in labor. She received meperidine for pain 1 hour prior to entering the second stage of labor. Which of the following actions should the nurse take? A. Assess the client's reflexes B. Assess the newborn for respiratory depression C. Assess the client for bradycardia D. Assess the newborn for signs of opiate withdrawal

B. Assess the newborn for respiratory depression

A nurse is collecting data from a newborn following a vaginal birth with the assistance of a vacuum extractor device. The newborn has head swelling that crosses the suture line. The nurse should document this finding as which of the following conditions? A. Cephalohematoma B. Caput succedaneum C. Nevus flammeus D. Erythema toxicum

B. Caput succedaneum

A nurse is reinforcing teaching with a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? A. "Impetigo is caused by a virus." B. "Impetigo is contagious for 48 hours after vesicles rupture." C. "I will wash my child's clothes in hot water." D. "My child now has immunity against impetigo."

C. "I will wash my child's clothes in hot water."

A nurse is reinforcing teaching with a client who has been taking an NSAID to treat rheumatoid arthritis. During the client's first month checkup, the provider prescribed methotrexate to be added to the medication regimen. Which of the following statements should the nurse include in the teaching about the purpose of this change in the client's medication? A. "Your current medication was not strong enough to manage this condition." B. "Once your blood levels of methotrexate are within the therapeutic range, the NSAID will be discontinued." C. "This medication was added to delay the disease progression." D. "Treating this disease with 2 medications will help protect you from becoming treatment-resistant."

C. "This medication was added to delay the disease progression."

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hours after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

C. Amylase

A nurse assisting with monitoring a client who ingested an overdose of pentobarbital sodium. For which of the following adverse effects of toxicity should the nurse assess the client? A. Cerebrovascular accident B. Dysrhythmias C. Liver failure D. Respiratory depression

D. Respiratory depression

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. The client's temperature measures 101.9°F (38.8°C) 3 hours following delivery. B. Lochia is red with small clots and mucus 2 days after delivery. C. Client reports abdominal pain 48 hours after delivery when the newborn is breastfeeding. D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.

D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.

A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates clang associations? A. "I am the king, and everyone should bow to me." B. "I'm feeling schmoolizious today." C. "Option, contrary, moose, allergic." D. "Basketball in the hall very tall."

D. "Basketball in the hall very tall."

A nurse in a mental health facility is assisting with the care of a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit? A. Lack of remorse B. Self-mutilation C. Delusional behavior D. Splitting

A. Lack of remorse

A nurse is caring for a child who has leukemia and is receiving chemotherapy. The child's parent is upset and says, "I just can't believe my child is going to lose her beautiful hair!" Which of the following responses should the nurse offer? A. "You are feeling a sense of loss right now." B. "Sometimes the hair thins, but it will grow back." C. "This hair loss means the chemotherapy is working." D. "Kids love to wear the special baseball caps we have."

A. "You are feeling a sense of loss right now."

A nurse is assisting with preparing IV nitroprusside for a client who had a myocardial infarction. Which of the following actions should the nurse take? A. Obtain an infusion pump for the RN to regulate the rate of infusion B. Plan to have the IV solution bag changed every 48 hours C. Make sure the freshly prepared IV solution has a slight greenish tint D. Locate an amber plastic bag to cover the medication solution

A. Obtain an infusion pump for the RN to regulate the rate of infusion

A nurse at a long-term care facility is assisting with planning care for a group of older adult clients. When planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following? A. Short-term memory B. Creative ability C. Decision-making skills D. Cognitive capacity

A. Short-term memory

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus about self-administration of a new prescription for acarbose. Which of the following pieces of information should the nurse include in the teaching? A. Tell the client to take the medication with food B. Show the client how to perform an intramuscular injection C. Advise the client to avoid taking this medication with insulin D. Warn the client against exercising while taking this medication

A. Tell the client to take the medication with food

A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output

A. Tell the guardian that a repeat dose of medication should not be given

A nurse collecting data from a full-term newborn who is demonstrating the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward

A nurse is reinforcing teaching with a client who is scheduled to start taking hydrochlorothiazide for hypertension. The nurse instructs the client to eat foods that are rich in potassium. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication will not work unless I have enough potassium." B. "This medication can cause a loss of potassium." C. "Potassium will lower my blood pressure." D. "Potassium will increase the therapeutic effect of my blood pressure medication."

B. "This medication can cause a loss of potassium."

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about exercise. Which of the following statements should the nurse include in the teaching? A. "You should exercise during a peak insulin time." B. "Wear a medical alert identification tag when you exercise." C. "Exercise can decrease the effects of insulin and cause the blood glucose levels to increase." D. "You will get the most benefit from exercise when your glucose levels are higher than normal."

B. "Wear a medical alert identification tag when you exercise."

A nurse is assisting with the admission of a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions be added to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne

A nurse is providing immediate postoperative care for a child who had a tonsillectomy. Which of the following actions should the nurse take? A. Offer ice cream or pudding when the child is fully awake B. Eliminate the use of a straw when offering fluids C. Apply a heating pad to the neck area D. Instruct the child to blow his nose to clear bloody secretions

B. Eliminate the use of a straw when offering fluids

A nurse is reinforcing teaching with a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? A. Maternal-fetal B. Fecal-oral contamination C. Genital sexual contact D. Blood-to-blood

B. Fecal-oral contamination

A nurse is caring for a female client who has been taking clomiphene to treat infertility. Which of the following findings should indicate to the nurse that the medication has been effective? A. Decreased serum luteinizing hormone (LH) levels B. Follicular enlargement and conversion to corpus luteum after ovulation C. Increased human chorionic gonadotropin (hCG) levels D. Blocked endogenous release of LH and prevention of premature ovulation

B. Follicular enlargement and conversion to corpus luteum after ovulation

A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take? A. Weigh the client weekly B. Monitor the client for ototoxicity C. Place the client on a 24-hour urine collection analysis D. Monitor for hypoglycemia

B. Monitor the client for ototoxicity

A nurse is assisting with the plan of care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hours B. Position the child on a cooling blanket and cover her with a sheet C. Place the child in a tub filled with water cooled to 26.7° to 29.4°C (80° to 85°F) D. Assess the child's temperature every 2 hours during the cooling process

B. Position the child on a cooling blanket and cover her with a sheet

A nurse is reinforcing education with a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Ability to follow simple directional commands D. Ability to name a color

B. Vocabulary of 10 or more words

A nurse is reinforcing teaching about breastfeeding with a client who is at 32 weeks of gestation. Which of the following responses should the nurse make? A. "You should place plastic-lined breast pads into your bra." B. "You should start pumping your breasts now." C. "You should apply lanolin ointment to your areolas." D. "You should use warm water to wash your nipples."

D. "You should use warm water to wash your nipples."

A nurse is collecting data from a client who has conduct disorder. Which of the following findings should the nurse expect? A. Fearfulness of authority figures B. Flat affect C. Preoccupation with enforcing rules D. Aggressive behavior toward others

D. Aggressive behavior toward others

A nurse in an employee assistance program is counseling a client who states, "I just feel completely lost at work these days." The nurse replies, "You feel like you are not getting things done." Which of the following therapeutic communication techniques is the nurse using? A. Presenting reality B. Encouraging comparison C. Offering general leads D. Attempting to translate words into feelings

D. Attempting to translate words into feelings

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? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

D. Clamp the tubing below the collection port

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. Metered-dose inhaler B. Continuous passive motion machine C. External defibrillator pads D. Oral-nasal suction equipment

D. Oral-nasal suction equiptment

A nurse is reinforcing teaching with a client who has a prescription for doxycycline for the treatment of a Helicobacter pylori infection. Which of the following instructions should the nurse include in the teaching? A. "Take this medication with meals to decrease gastrointestinal upset." B. "Continue this medication if you become pregnant." C. "Wear protective clothing while in the sun." D. "Expect to have severe diarrhea while taking this medication."

C. "Wear protective clothing in the sun."

A nurse is reinforcing teaching about disease management strategies with a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can reduce your chance of needing a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication will be given on a schedule to help you sleep better."

C. "Your mucus is thick because cystic fibrosis interferes with how your glands work."

A nurse is caring for a client who is experiencing cycloplegia following the administration of atropine eye drops during an eye examination. Which of the following findings should the nurse expect as a result of cycloplegia? A. Inability to tolerate bright lights B. Pinpoint pupils C. Blurred vision D. Inability to perform upward gaze

C. Blurred vision

A nurse is caring for a client who has a stimulant use disorder. Which of the following manifestations should indicate to the nurse that the client is experiencing withdrawal? A. Mental alertness B. Tachycardia C. Depression D. Dilated pupils

C. Depression

A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan? A. Keep the door of the client's room open while the client is awake B. Ensure that the client's meal tray contains no knives C. Observe the client swallow medications D. Have a staff member observe the client once every 30 minutes

C. Observe the client swallow medications

A nurse is contributing to the plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client? A. Explaining that tube feedings are necessary if the client refuses oral intake B. Weighing the client each day prior to any oral intake C. Permitting the client to spend some quiet time alone after each meal D. Refraining from commenting on what the client is eating during mealtime

C. Permitting the client to spen some quiet time alone after each meal

A nurse is caring for a 4-month-old child who is hospitalized. Which of the following playtime objects should the nurse provide for the child? A. Board book with large pictures B. Toy with movable parts C. Plastic mirror D. Push-pull toy

C. Plastic mirror

A nurse at a long-term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? A. Encourage the client to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place a wander alert electronic alarm bracelet on the client's wrist

C. Post a large calendar on the bulletin board

A nurse on an antepartum unit is assisting the charge nurse with an in-service session for newly licensed nurses. Which of the following descriptions should the nurse identify as referring to a pudendal block? A. Using low-voltage electric currents to decrease pain B. Eliminating sensation from the umbilicus to the thighs C. Providing local anesthesia to the perineum during delivery D. Removing sensation from the breasts to the feet

C. Providing local anesthesia to the perineum during delivery

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? A. Return the unused portion of the medication to the pharmacy B. Dispose of the wasted medication into a sharps container C. Record the amount of medication wasted on the controlled substance inventory record D. Ask an assistive personnel (AP) to witness the wasting of the controlled substance

C. Record the amount of medication wasted on the controlled substance inventory record

A nurse on a mental health unit is planning care for a client who has anorexia nervosa with purging behaviors. Which of the following interventions should the nurse include in the plan? A. Set the client's weight gain goal at 2.3 kg (5 lb) per week B. Allow the client to establish his own mealtimes C. Stay with client for 1 hour following meals D. Have the client weigh himself daily

C. Stay with the client for 1 hour following meals

A nurse is reinforcing teaching with a client who has Addison's disease about healthy snacks. Which of the following food choices by the client indicates an understanding of the teaching? A. Sliced bananas B. Baked potato C. Turkey and cheese sandwich D. Plain yogurt with peaches

C. Turkey and cheese sandwich

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse can safely administer which of the following medications while this client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

C. Valproic acid

A nurse is collecting data from an older adult client who has right-sided heart failure. Which of the following findings is the nurse's priority to report? A. Oxygen saturation 92% on room air B. 20% consumption of meals C. Weight increase of 0.91 kg (2 lb) in 24 hours D. 1+ edema in the lower extremities

C. Weight increase of 0.91 kg (2 lb) in 24 hours

A nurse is assisting in the preparation of a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Check the client's identification number with the number on the blood C. Witness the informed consent D. Prepare the blood with a Y-type infusion set

C. Witness the informed consent