Ati Fundamentals test

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I need to place a towel between the heating pad and my skin"

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties?

"I often have a cup of coffee with my dessert before going to bed"

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following?

-Stabilizing the position of the tube -preventing aspiration of secretions -preventing air leaks

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client's actions indicated an understanding of the teaching?

A client holds the cane on the unaffected side

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the clients indicates an understanding of the teaching?

A nurse will show me how to care for my wound

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include?

A. Sit with your back supported B. Keep your knees at hip level C. Use an ergonomically designed computer keyboard

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?

Advise the client to perform range of motion exercises while in bed.

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment

A nurse is implementing old therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check capillary refill before applying an ice pack to the affected area

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

Feedback is provided

A nurse is caring for a client who has the head of his bed elevated at 45 angles with his knees slightly flexed. Which of the following positions should the nurse document for the client?

Flowers

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves Then Apron or Gown, Eye Protection, and Surgical Mask.

A nurse is changing then bed linens for a client who is on bed rest. Which of the following actions should the nurse perform?

Hold the linens away from the body and clothing

A nurse is preforming a breast examination for a female client. which of the following techniques should the nurse use first?

Inspect both breast simultaneously

A nurse is performing an admission for a client. which of the following responses by the nurse reflects the communication technique of clarifying?

It sounds like your pain is intermittent

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

Keep the rubber crutch tips securely in place"

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the clients head

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision.

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations.

A nurse is planning to document the care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A. nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates high-pitched scratching sounds during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Place the client in a left sim's position

A nurse is caring for a client who has a bilateral cast on her hands. which of the following actions should the nurse take when assisting the clients with feeding?

Sit at the bedside while feeling the client

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden. -Complicated grief can occur when the death of a loved one is sudden and unexpected.

A nurse is preparing to assist an older adult with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

What do you think caused the onset of your pain?"

A nurse is caring for a cleint who has cancer and refuses visitors because of his debiliated physical appearance. Which of the following comments should the nurse made?

Would you like to talk about how you feel?

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch hair. Which of the following instructions should the nurse include in the teaching?

bear weight on both of your legs

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following foods choices made by the client indicate an understanding of the teaching?

black beans whole grain bread

A nurse is caring for an older client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

offer the client tart or sour foods first.

A nurse is caring for a client who has fecal impaction. before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

oil retention

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside?

oxygen equipment

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.

A nurse is planning care for a client who has a single-lumen nasogastric NG tube for gastric decompression. Which of the following actions should the nurse include in the plan of care?

provide oral hygiene frequently measure the amount of drainage from the NG tube every shift secure the nG tube to the clients gown

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

pull the NG tube back slightly

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the clients before beginning the procedure?

raise your index finger if you need to pause during the insertion

A nurse is screening a client who has an s-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of with of the following abnormalities?

scoliosis

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

sit and olf the clients hand

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

starch

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

suction equipment

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination?

supine

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

supports self determination

A nurse is caring for a client who has methicillin- resistant staphylococcus aureus (MRSA). which of the following precautions should the nurse implement?

wear a gown when in the clients room

A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take?

wear gloves when changing the clients gown

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet?

whole milk

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?

ASSESSMENT

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallways and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?

Accompany the client back to his room.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decrease estrogen and testosterone production.

A nurse is reviewing the laboratory values of a client who has a positive Chvosek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis

A nurse is caring for a client who is receiving blood transfusions. he client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catherer bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body.

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic internal nutrition formula

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

client's level of comfort and ability to participate in the interview

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

help the patient identify ways that these changes will result in positive personal outcomes

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document as the client's reflexes?

Average AverageRationale: 0 to 4+ Diminished: 1+ or less Brisk: 3+ more Hyperactive: 4+

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked.

A nurse is teaching an assistive personnel how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger about the heat level.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day.

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

Sodium 150 mEq/L sodium level of 150 mEq/L is greater than the expected range of 135-145. The client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration.

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include?

Try to block the urge to urinate until the next scheduled time.

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following is the location of the most distal pulse.

dorsalis pedis

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

limit drinking liquids with foods

A nurse is preparing an insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

lower abdomen

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in the biohazard bag

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expressed concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with this client?

Donate autologous blood before surgery

A nurse is working with the facility language interpreter to explain a wound care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

Ensure the interpreter and the client speak the same dialect

A nurse is admitting a client who has decreased circulation in his left leg. Which action of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids" advance diet as tolerated. Which of the following responses should the nurse make?

I am going to listen to your abdomen

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

The dietitian will help you choose foods you are used to that also meets your heal needs.

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of a disease can vary widely across cultures.

A nurse is witnessing a client sign an informed consent form for surgery. What are the nurses affirming by the action?

The signature on the preoperative consent form is the clients.

An RN is assessing a pt. Which of the following should indicate protein calorie malnourishment?

dry, brittle hair Edema Poor wound healing

A nurse is teaching a newly licensed nurse about pain management in clients aged 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are 65 or older are reluctant to report pain

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel(AP)?

Provide oral care to a client who can not take oral fluids

A nurse is cleaning a client's wound by swabbing from an area of lease contamination to an area of greater contamination. which of the following rationales should the nurse identify for using this technique?

Keeping microorganisms from entering the wound. starting at the lest contamination and working toward the area of greatest contamination spreads the microorganism within the wound.

A nurse in a rehabilitation facility is observing an assistive personnel help a client transfer from a bed to a wheelchair. Which of the following actions indicated to the nurse that the AP understands how to perform this task?

Locking the brakes on the bed and the wheelchair before moving the client

A nurse is changing the dressing for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps- priority-setting framework.

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

fats provide energy

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

it modulates the transmission of the pain impulse