ATI fundamentals questions

A nurse is administering 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round to the nearest whole number.

29 gtt/min

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing. B. Loosen the dressing by pulling the tape away from the wound. C. Remove the entire old dressing at once. D. Open sterile supplies after applying sterile gloves.

A. Rationale: The nurse should use standard precautions by applying clean gloves when faced with the possibility of coming into contact with secretions.

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.? A. Inspection B. Auscultation C. Percussion D. Palpation

A. Rationale: According to evidence based practice, the nurse should inspect abdomen first by observing contour, condition of skin, and position of umbilicus.

A nurse is planning weight-loss strategies for a group of clients who are obese. What action by the nurse would improve the client's commitment to a long-term weight loss goal? A. Attempt to increase the client's self motivation B. Keep detailed records of each client's progress C. Test client learning after each teaching session D. Avoid discussing topics that might increase client's anxiety.

A. Rationale: Motivation to learn is a key of improving a client's commitment to achieving a health goal, as well as, increasing the amount and speed of learning.

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for BP? A. 142/85 mmHg B. 116/70 mmHg C. 130/76 mmHg D. 124/82 mmHg

B. Rationale: The blood pressure is within the expected reference range, which is any value less than 120 systolic and less than 80 diastolic.

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Chest the clients vital signs C. Instruct the client to use the incentive spirometer every hour. D. Provide ice chips as per provider prescription.

B. The greatest risk to this client is injury from unstable vital signs (hypotension and respiratory depression) after receiving anesthesia and medication.

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

B. Tuberculosis requires airborne precautions, which are protocols that prevent the spread of infections via small droplets.

A nurse is caring for a client who is receiving intermittent eternal feedings through an NG tube. The specific gravity of urine is 1.035. What action should the nurse take? A. Deliver the formula at a slower rate. B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

C. Rationale: The elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids or request a formula that contains less protein.

A nurse is reviewing a client's laboratory results and notes a WBC count of 3600 mm3. The nurse should identify this result as which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia

D. Rationale: Leukopenia occurs when there is a decrease in the production of WBCs. This alteration places the client at a risk for infection.

A nurse is caring for an older client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide? A. "It's for your safety. Dentures can slip and block your airway during surgery" B "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures." D. "What worries you about being without your teeth"

D. Rationale: This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks reason.

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. I'll wrap the old dressing in a paper bag and put it in the trash B. I'll wash my hands before I remove the old dressing and again before putting on a new one. C. I'll need to take a pain pill 30 mins before I change the dressing D. I'll wear sterile gloves when I apply new dressing.

B. Rationale: It is essential that the client understand the importance of hand hygiene before, during, and after handling wounds or dressings.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

B. Rationale: The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions.

A nurse in an ER is assessing a client who reports diarrhea and decreased urination for 4 days. What action should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers.

B. Rationale: This is the proper technique to assess skin turgor. If the client has good turgor and is properly hydrated the skin will immediately return to normal.

A nurse is preparing to administer eye drops to a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the puncta after instilling the medication. D. Place each drop of the medication directly onto the client's cornea.

C. Rationale: The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 or 2 minutes afterward to prevent systemic absorption of the medication.