Fundamentals ATI practice

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 in the client's medical record?

0.3 mg

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 is planning care for a pt 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 caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine.

A nurse is an acute care facility is preparing a discharge summary for a pt who is transferring to a long term care facility. Which of the following should the nurse include?

Current medications

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 planning 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 psychomotor approach to learning?

Practice sessions

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°.

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

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."

A nurse is discussing the use of herbal supplements for health promotion with A client. Which of the following client statements indicate and 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 7:00 a.m. 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 caring for a pt who has terminal liver cancer. Which of the following statements should the nurse id as an indication that the pt is experiencing spiritual distress?

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

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 stairs, I will first shift my weight to my right leg."

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 vaccine when you are 65 years old"

A nurse is caring for a pt who reports difficulty falling asleep. Which of the following recommendations should the nurse take?

"Maintain a consistent time to wake up each day."

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

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 contractors?

Apply an ankle-foot orthotic device to the client's feet.

A nurse is preparing to transfer a client who can bear weight on one 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 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 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 at the facility.

A nurse is assessing a pt who received an IV fluid bolus for dehydration. Which of the following findings should the nurse id as an indication of fluid volume excess?

Distended neck veins

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?

Droplet

A nurse is performing a Romberg test during the phys assessment of a pt. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together.

A nurse is reviewing a pts med prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify w the provider?

Medication dose

A nurse is reviewing protocol in preparation for suctioning secretions from a pt 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 caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insuoin to mix together and admin subq. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

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.

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 clients plan of care?

Wrap blankets around all four sides of the bed.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with a deep vein thrombosis. The prescription reads 25,000 units of heparin in 0.9 sodium chloride 250 mL to infuse at 800 units per hour. At what rate should the nurse said the infusion pump? Round the answer to the nearest whole number

X mL/hr = 8 mL/hr

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (SATA) a. Place the client in a room with negative-pressure airflow. b. Wear gloves when assisting the client with oral care. c. Limit each visitor to 2-hr increments. d. Wear a surgical mask when providing client care. e. Use antimicrobial sanitizer for hand hygiene.

a. Place the client in a room with negative-pressure airflow. b. Wear gloves when assisting the client with oral care. e. Use antimicrobial sanitizer for hand hygiene.

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.

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 that involve?" Which one of the following responses should the nurse make?

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

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which fo the following findings should the nurse intervene?

· Erythema on pressure points

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."

A nurse is administering IV fluids to a client. The nurse should perform which priority assessment to monitor for adverse effect?

Auscultate lung sounds

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? (SATA)

Check the cord routinely for frays or tearing. Consider purchasing a generator for power backup. Observe for signs of hypoxia.

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 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.

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 with obtaining the blood pressure?

To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff. = 122 mm Hg

A nurse is caring for a pt who reports pain. When documenting the quality of the pt's pain on an initial pain assessment, the nurse should record which of the following pt statements?

"The pain is like a dull ache in my stomach."

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests 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 group of clients on a med surg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

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 calculating a client's fluid intake over the past 8 hr. which of the following items 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 teaching a group of staff nurses about the use of the essential oils for aroma therapy. The nurse should include it in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

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 HIPPA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client

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

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms presence of the fire, which of the following actions should the nurse take nest?

Evacuate the client.

A nurse is preparing to administer multiple medications to a pt 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 preparing to admin 0.5 mL of oral single dose liquid med 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 information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse is caring for a pt 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.

A nurse is planning care for a pt who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the pt?

N95 respirator

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. This sound indicates which of the following?

Narrowed arterial lumen

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

A nurse is caring for a pt who is receiving fluid through ta peripheral iv catheter. Which of the following findings at the IV site should the nurse id as indicating infiltration?

Skin blanching

A nurse is caring for a pt who req an informed 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 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.