ATI Fundamentals test A

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen. (admin 2 in from umbilicus as SUB Q injection)

Crackles breath sounds

heard during inhalation when air bubbles though fluid in airways

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

" Let's talk about how the change in your job status will affect you." (this helps verbalize feelings about the transition to retirement)

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

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

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid (creates a moist wound bed to promote healing)

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area. (bc of compromised immune system-> infection risk)

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min (flow rate of 1-6L/min, anything above causes drying of airway and excess of air needed)

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors (protect against foreign particles or cold air)

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind."

A nurse is assessing a client's readiness to learn about insulin self-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." (verbalizes best way for him to learn)

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel?

Assisting a client with a bed bath Measure pt's BP (like after a nurse administers meds) Use a communication board to ask what the client wants for lunch Assistive personnel assist pt with things that pose 100% no risk of injury

A nurse is caring for a client who is postoperative and refuses to sue an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer. (bc. nurses always assess first) (assessing the reason behind their actions)

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet (rubella, meningococcal pneumonia, streptococcal pharyngitis = stay 3 feet away)

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue (nurse's bias check)

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) (used for transfers)

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

Wear a gown when caring for the client. (contact precaution from bacteria transmission via fluids and contaminated surfaces)

Friction Rub breath sounds

scratching or squeaking sound that persists throughout the respiratory cycle

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitits?

swelling, redness, tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility

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

Acupuncture (contraindicated for skin infections bc of holes in skin)

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing. (30-60min beforehand) (Maslow's hierarchy of needs)

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while I'm lying in bed." (like guided imagery)

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

The client's caregiver washes out the feeding bad with warm water once every 24 hrs. (prevent contamination)

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 a serious illness" (includes living will-care in the hands of trustee)

A nurse is preparing to administer an injection of an opioid medication to a client. 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 ("I need a witness!")

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in Hear Rate (Tx tachycardia related to imbalance)

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process (begin to assess the client's needs and plan for care both during and after time in the facility)

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position. (bc. veins will dilate due to gravity)

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L (3.5-5 normal range, over 5 = dysrhythmias)

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

Pupil Clarity (cloudy = cataracts = foggy halos seen) Visual Fields (cardinal vision test = test fall risk) Visual Acuity (Snellen chart/Jaeger chart) Lacrimal apparatus or Bulbar conjunctivae don't affect fall risk from bad sight

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief. (During the anger stage the nurse should support and explain this expected reaction to a cancer diagnosis)

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary 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 evaluating a client's use of a cane which of the following actions should the nurse identify as an indication of correct use?

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

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher

A nurse is responding to a call light and finds a client lying on the bathroom floor. 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 terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hr.

A nurse is caring for a client who has terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time." (having a family to depend on is effective coping)

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull" (throbbing, aching, burning, shocking, shooting describes pain)

A nurse manager is preparing to review mediation documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

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

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficultly breathing?" Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." (O2 is not resuscitative if delivered via nasal cannula, it is a comfort measure)

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45* angle. (45-90* angle)

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures client's safety, health, and rights

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping (hyponatremia-> s/s: cramping, weakness, confusion, headache, nausea, lethargy)

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter. (prevent injury to mucosa but if done longer than 10 sec it causes cardiopulmonary compromise.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 ml/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 ml over the last 2 hr. Which of the following actions should the nurse take first?

Check the IV tubing for obstruction (re-establishes the infusion rate the provider prescribed as 1st action)

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact Precautions (admit client to private room)

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves (if less then it can cut off circulaiton)

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager. (the greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore the next action is to use the chain of command)

A nurse in a long-term caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the steps.

Obtain the pronouncement of death from the provider. Next, remove tubes and indwelling lines prior to cleaning the body. After cleansing, ask the family if they want to view the body. Finally, the nurse should place a name tag on the body before transfer

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Place a client who has tuberculosis in a room with negative-pressure airflow. (airborne precautions)

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in 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 in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. (bc. they forget everything)

Ronchi breath sounds

are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction like secretions