ATI fundamentals practice test B
a nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next?
assess the client for orthostatic hypotension
a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess?
distended neck veins: Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
evacuate the client
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: The nurse should gently shake the liquid medication to ensure that the medication is mixed.
a nurse is caring for a client who reports pain. when documenting the quality of 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 is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend?
walking briskly： Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.
a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family?
1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia
a nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump?
8 mL/hr
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
8 oz of ice chips
a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client?
N95 respirator
a nurse is caring for a group of medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?
a client is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively
a nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
a client who has asthma
a nurse is preparing to delegate client care tasks to an assistive personnel. which of the following tasks should the nurse delegate?
ambulating a client who is postoperative
a nurse is caring for a client who has an indwelling catheter. which of the following findings indicates that the catheter requires irrigation?
bladder scan shows 525 mL of urine
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: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.
a nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident?
client found lying on floor: The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
compare prescriptions with medications the client received while are the facility
a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include?
current medications: The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.
a nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene?
erythema on pressure points: Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting
have family members wear a gown and gloves when visiting
a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use?
have the client stand with their arms at their sides and their feet together: A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.
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 prevent skin breakdown?
have the client use a trapeze bar when changing position: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.
a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use?
i can take echinacea to improve my immune system
a nurse is caring for a client who requires a 24 hr urine collection. which of the following statements by the client indicates an understanding of the teaching?
i flushed what i urinated at 7 am and have saved all urine since
a nurse is caring for a client who has recently started using a behind the ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?
i will be sure to remove my hearing aid before taking a shower
a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice?
initiate an enteral feeding through a gastrostomy tube
a nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take?
instruct the family to refrain from pushing the button for the client while she is asleep: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.
a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?
maintain a consistent time to wake up each day: The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.
a middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?
people in middle adulthood often find satisfaction in nurturing and guiding young people: According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.
a nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning?
practice sessions: Practice sessions require psychomotor skills when learning.
a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?
rapid heart rate: Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.
a nurse is caring for a client who is receiving fluids through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration?
skin blanching: Skin blanching变白, edema, and coolness at the IV site indicate infiltration侵润.
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 actions should the nurse take first?
tell the client to keep the head of the bed elevated at least 30 degrees
a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse?
the caregiver insists on remaining in the room: A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.
a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?
the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field: Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.
a nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining blood pressure?
the one close to 120 mm Hg
a nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advance directives. which of the following responses should the nurse make?
we can talk about advance directives, and i can also give you some brochures about them
a nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
what could i have done to deserve this illness?： The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.
a nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching?
when descending the stairs, i will first shift my weight to my right leg
a nurse is caring for a client who is refusing a blood transfusion for religious reasons. 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: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.
a nurse is caring for a client who requires consent for a surgical procedure. which of the following actions is the nurse's responsibility?
witness the client's signature on the consent form
a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care?
wrap blankets around all four sides of the bed: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.
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 of the following precautions should the nurse take?
wrap monitoring cords with stockinette and tape them in place: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.
a nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does this involve?" which of the following responses should the nurse make?
you should have a fecal occult blood test every year： Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.
a nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has a myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3 mg: The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.
a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure
1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle
a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? select all that apply
1)place the client in a room with negative-pressure airflow 2) wear gloves when assisting the client with oral care 3) use antimicrobial sanitizer for hand hygiene
a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension?
a client who smokes one pack of cigarettes each day
a nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
a nurse asks a nurse from another unit to assist with documentation for a client
a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement?
an x-ray shows the end of the tube above the pylorus
a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
apply an ankle-foot orthotic device to the client's feet
a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
arrange food in a consistent pattern on the client's plate
a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
auscultate lung sounds: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.
a nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide?
breath sounds： When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.
a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate?
droplet: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies.
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 plan to take?
flush the tube with 15 mL of sterile water
a nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider?
medication dose
a nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following?
narrowed arterial lumen: Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.
a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take?
select a suction catheter that is half the size of the lumen
a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include?
you should receive a pneumococcal immunization every 10 years: 1. Older adults should have an eye examination every year. Older adults should receive a tetanus booster every 10 years. Older adult clients will receive a shingles vaccine when they are 60 years old. Older adult clients will receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.