ATI Fundamentals Practice

a nurse is assessing a client's readiness to learn about insulin administration.which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

a nurse is caring for a client who report pain. when documenting the qualityof 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."

a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should thenurse manger plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

a nurse is caring for a client who has terminal live cancer. which of thefollowing statements should the nurse identify as an indication that the client is experiencing spiritual distress?

"What could I have done to deserve this illness?"

a nurse in a clinical is caring for a middle age adult 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 responsesshould the nurse make?

"You should have a fecal occult blood test every year."

a nurse is preparing a herparing infusion for a client who was hospitalizedwith deep- vein thrombosis. the orders read: 25,000 units of heparin in 250mL of 0.9% sodium chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole number)

8mL/hr

a nurse is providing care to four clients. which of the following situationsrequires the nurse to complete an incident report? A. a nurse tied a client's restraints straps to the moveable part of the bedframe B. an assuétude personnel placed a surgical mask on a client who has TBbefore transporting her to radiology C. a nurse administer a medication to a client 30 min before the dose is due D. a client who has an IV infusion pump receives an additional 250 mL of IVfluid

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

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

Acupuncture

a nurse is preparing to administer an injection of an opioid medication to aclient. 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

a nurse is administering IV fluid to an older adult client. the nurse shouldperform which priority assessment to monitor for adverse effects?

Auscultate lung sounds.

a nurse is responding to a call light and finds a client lying on the bathroomfloor. which of the following actions should the nurse take first?

Check the client for injuries.

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.

a nurse is admitting a client who has an abdominal wound with a largeamount of purulent drainage. which of the following types of transitionprecautions hold the nurse initiate?

Contact precautions

a nurse is admitting a client who has influenza. which of the following typesof transmission precautions hold the nurse initiate?

Droplet

a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following assessment findings should the nurse expect?

Rapid heart rate

a nurse is caring for a client who is expressing anger over his diagnosis ofcolorectal cancer. which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

a nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." which of the following components ofthe prescription should the runs question?

The dose

a nurse is planning care to improve self-feeding for a client who has visionloss. which of the following interventions should the nurse include in the plan of care?

Use a clock pattern to describe food on the client's plate.

a nurse is caring for a client who is reporting difficulty falling asleep. whichof the following measures should the nurse recommend?

Use progressive relaxation techniques at bedtime.

a nurse is caring for a client who is refusing a blood transfusion for religiousreasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take?

Withhold the blood transfusion.

a nurse is planning to insert a peripheral IV catheter for an older adultclient. which of the following actions should the nurse plan to take?

place the client's arm in a dependent position

a nurse is caring for a client who has had his diet prescription changed to amechanical soft diet. which of the following food items should the nurse remove from the client's breakfast tray?

sunny side up (fired) eggs

a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a program of regular physical activity. which of the following types of activity should the nurse recommend?

walking briskly

a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identifyas an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good workingorder."

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 aserious illness."

a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity

B. pupil clarity D. visual fields E. visual acuity

a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that iswithin the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube.

a nurse in a long-term care facility is planning to perform hygiene care for anew resident. which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

a nurse is caring for a client who is terminally ill. which of the following statements should the nurse identify as an indication that the client's familymember is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this."

a nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV STAT for a client who has myxedema coma. how should the nurse transcribe the dosage of this medication on the client's medical record?

0.3 mg

a nurse is preparing to transfer a client who has right-sided weakness fromthe bed to a chair. in what order should the nurse take the following actionsto assist the client? 1. ask the client is he can bear weight 2. use the stand-pivot technique to move the client to the chair 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside

1. ask the client is he can bear weight 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 2. use the stand-pivot technique to move the client to the chair

a nurse is caring for a client who has a prescription for 5 units of regularinsulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure. 1. inject 5 units of air into the bottle of regular insulin 2. withdraw the correct dose of NPH insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 4. withdraw the correct dose of regular insulin from the bottle

3. inject 10 units of air into the bottle of NPH insulin 1. inject 5 units of air into the bottle of regular insulin 4. withdraw the correct dose of regular insulin from the bottle 2. withdraw the correct dose of NPH insulin from the bottle

a nurse manager is overseeing the care on a unit. which of the followingshould the nurse manager identify as a violation of HIPAA guidelines? A. a nurse who is caring for a client reviews the client's medical chart withthe nursing student who is working with the nurse B. a nurse asks a nurse from another unit to assist with her documentation C. a nurse who is caring for a client returns a call to the client's durablepower of attorney for health care designee to discuss the client's care D. a nurse discusses a client's status with the physical therapies that iscaring for the client's bedside

A nurse asks a nurse from another unit to assist with her documentation.

a nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene

A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene

a nurse is planning an education session for an older adult client who hasjust learned that she has type 2 diabetes mellitus. which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions.

a nurse is assessing a client who has been on bed rest for the past month.which of the following findings should the nurse identify as an indicationthat the client has developed thrombophlebitis?

Calf swelling

a nurse is caring for a client who is postoperative and refused to use anincentive spirometer following major abdominal surgery. which of the following is the nurse's priority action?

Determine the reasons why the client is refusing to use the incentive spirometer.

a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requiresfurther intervention?

Erythema on pressure points

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse planto take?

Flush the tube with 15 mL of sterile water.

a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following informationshould the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

a nurse is performing a Romberg's test during the physical assessment of aclient. which of the following techniques should the nurse use? A. touch the face with a cotton ball B. apply a vibrating tuning fork to the clients forehead C. have the client stand with her arms at her side and her feet together D. perform direct percussion over the area of the kidneys

Have the client stand with her arms at her side and her feet together.

a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take wheninserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into theesophagus.

a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to preventskin breakdown?

Have the client use a trapeze bar when changing position.

a nurse is caring for a client who requires a 24-hour urine collection. which of the following statement by the client indicates an understanding of the teaching?

I flushed what I urinated at 7:00 a.m. and have saved all urine since."

a nurse is performing a peripheral vascular assessment for a client. whenplacing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent bloodflow. this sound indicates which of the following?

Narrowed arterial lumen

a nurse is reviewing a client's fluid and electrolyte status. which of thefollowing findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL

Potassium 5.4 mEq/L

a nurse is administering an otic medication to an older adult client. which ofthe 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.

a nurse is caring for a client who requires bed rest and has a prescription foranti embolic stocking. which of the following actions should the nurse take?

Remove the stockings at least once per shift.

a nurse is talking with the partner of an older adult male client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role-performing stress?

Role overload

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

Select a suction catheter that is half the size of the lumen.

a nurse is assisting a client who is postoperative with the use of an incentivespirometer. into which of the following positions should the nurse place theclient?

Semi-Fowler's

a nurse is preparing a change-of-shift report. which of the of the following tools or documents should the nurse use to communicate continuity of care? A. critical pathway B. SBAR C. transfer report D. medication administration record (MAR)

Situation, background, assessment, and recommendation (SBAR)

a nurse is caring for a client receiving fluid through a peripheral IV catheter.which of the following filings at the IV site should the nurse identify as infiltration?

Skin blanching

a nurse is lifting a bedside cabinet to move it closer to a client who is sittingin a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

a nurse is using an open irrigation technique to irrigate a client's indwellingurinary catheter. which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actionsshould the nurse take first?

Tell the client to keep the head of the bed elevated at least 30°.

a nurse is evaluating a client's use of a cane. which of the following actionsshould the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which ofthe following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place.

a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the followingintervention should the nurse take first?

assist the client to an upright position