pt 2 Fundamental PN ATI 2023

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

"Bear down"

A nurse is caring for a client who has injuries from a motor-vehicle crash. Which of the following client statements should the nurse address first?

"I can't sleep well because whenever I move in my sleep, the pain wakes me up."

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates a potential problem with achieving Erikson's developmental task for this age group?

"I go home on the weekends to be with my family because I don't have any good friends here on campus."

nurse is reinforcing teaching about heat therapy with a client who has low back pain. 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 is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will make sure to replace my pouch around 4 hours after I eat."

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?

"I will shake the inhaler well right before I use it."

A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?

"I'll make sure to keep the collection bottle in the container of ice they gave me."

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?t

"It modulates the transmission of the pain impulse."

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.)

-Coat the tip of the tube with a water-soluble lubricant -Ask the client to swallow water while the tube enters her Tell the client to tilt her head backward as insertion begins

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse caring for this client? (Select all that apply.)

-New prescriptions .-Arterial blood gas results -Tracheal secretion characteristic

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 is which of the following? (Select all that apply.)

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

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2 A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions.

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

Absent bowel sounds with distention

By asking a client to explain the statement, "A bird in the hand is worth 2 in the bush," the nurse is evaluating the client's ability in which of the following intellectual functions

Abstract reasoning

A nurse in a long-term care facility is attending to a group of clients. One of the clients is walking in the hallway, bumping into walls, and not responding to his name. Which of the following actions should the nurse perform first?

Accompany the client back to his room

A nurse is evaluating a client for conductive hearing loss. Using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis?

Albumin

A nurse is collecting data from a client who has mixed aphasia. Which of the following strategies should the nurse use to help facilitate communication with this client?

Ask simple, short questions

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 is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority?

Assist the client to an upright position

A nurse is reinforcing teaching with 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?

Assist the client to identify ways that these changes will result in positive personal outcomes

A nurse is collecting data about a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse have the client perform just before inserting the catheter?

Bear down gently

A nurse is collecting baseline data of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus

A nurse in a provider's office is collecting data from a 3-year-old client during a routine physical examination. Which of the following findings should the nurse report to the provider?

Cannot walk-up stairs independently

While drawing blood for laboratory testing from a client, a nurse observes a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with those of others

A nurse is assisting with the care of a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect an injury to which of the following areas of the brain?

Cerebellum

A nurse is caring for a client who has a stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take?

Check the medication dose and the client's identification

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

Clean the drain site from the center outward

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water

A nurse finds a client sitting on the floor by the toilet in the bathroom adjacent to his room. He states that he is fine after slipping on the tile floor but is having difficulty getting up. Which of the following actions should the nurse take first?

Collect data from the client about any health alterations before, during, or after the fall

A nurse is caring for a client who has a prescription for the collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen?

Collect the specimen once the client rises in the morning

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?

Confirm unresponsiveness

A nurse is measuring vital signs for a client and notices a pulse irregularity. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is collecting data from a client whose potassium level is 2.8 mEq/L. Which of the following findings should the nurse expect?

Decreased bowel sounds

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

Decreased estrogen and testosterone production

A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

Depressed deep-tendon reflexes

A nurse is caring for a client with a BMI of 29 who expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe

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 performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding

A nurse is assisting with the admission of a client to the medical unit and asks if he has advance directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the client's head of bed 45° before the feeding

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse take to reduce the client's risk for aspiration?

Elevate the head of the bed by 30° to 45°

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying.

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief

Encourage the client to listen to soft music

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 new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's computer orientation class until next week. Which of the following actions should the nurse take?

Explain that sharing access codes is against policy and refer the resident to the supervisor

A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age?

Eye examination every 2 years

A nurse is administering 3 liquid medications through a client's nasogastric tube. Which of the following actions should the nurse take?

Flush the tube with water before and after instilling each medication

A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowler's

A nurse is administering a controlled substance to a client who is postoperative. The IM dosage requires the nurse to use only part of the amount of medication in the vial. Which of the following actions should the nurse take?

Have another nurse witness the disposal of the medication

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

Hyperglycemia

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take

Hyperoxygenate the client before suctioning

A nurse is reinforcing teaching with a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I can still use my TENS unit even though I'm pushing the PCA button."

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

I should expect my heart rate to take longer to return to normal after exercise as I get older."

A nurse is reinforcing teaching with a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

I'll wear nonsterile gloves."

A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis

A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following actions should the nurse take?

Keep the client's bed linens dry

A nurse is assisting with the planning of an in-service training session about various dietary practices. Which of the following pieces of information should the nurse recommend including in the teaching?

Kosher diets involve restrictions regarding how food must be prepared.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

Let's set up a meeting time with the doctor to discuss your options for home care."

A nurse is reviewing the laboratory results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as an indication of which of the following conditions?

Leukopenia

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

Limit drinking liquids when eating food

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which of the following actions indicates 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 planning to reinforce teaching for a client who is learning to self-inject a medication subcutaneously. The nurse does not speak the client's language, so arrangements are made for a medical interpreter from the facility to assist. Which of the following actions should the nurse take when working with the interpreter and the client

Make sure the client and the interpreter are culturally compatible

A nurse is caring for a client who requires the insertion of a nasogastric tube. Which of the following actions should the nurse take when preparing to insert the tube?

Measure the distance from the nose to the earlobe to the xiphoid

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Monitor the client's blood glucose level

A nurse is changing the dressings 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

A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?

Moro

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 nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter

A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as a part of an effective conference?

Other health care professionals are in attendance at the conference.

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse perform when working with the interpreter?

Pace speech to allow time for the interpreter to convey the words

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications?

Plasma volume expanders

A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take?

Position the client supine with the knees in flexion

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

Reduced level of consciousness

nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints individually

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

Sodium 123 mEq/L

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? A.Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

Sodium 150 mEq/L

nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of her meals. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

Speech-language pathologist

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis

A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about this procedure before. Which of the following actions should the nurse take?

Stop reinforcing the teaching and check with the surgeon about informed consent

A nurse on a medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priority to keep near the client at all times?

Suction equipment

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations?

Tachycardia

A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide?

Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal

A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side.

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

The death was sudden.

A nurse is reinforcing teaching with a client who has heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse is helping a client perform range-of-motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform?

Touching his chin to his chest

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin assisting with discharge planning?

Upon admission to the care facility

nurse is inserting an indwelling urinary catheter into the penis of a client. Which of the following actions should the nurse take?

Use the nondominant hand to grasp the penile shaft

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

Using a cuff that is too small will result in an inaccurately high reading."

A nurse is caring for a client who reports using several herbal supplements. Which of the following actions should the nurse take?

Verify that the herbal supplements do not interact with medications the provider has prescribed

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings is the nurse's priority to report to the surgeon immediately?

Warm, tender area on the right calf

A nurse is reinforcing teaching for a client about managing her tracheostomy care. Which of the following instructions should the nurse include?

Wear a tracheostomy cover when outdoors

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising in the morning

A nurse is collecting data from a client who has an 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 collecting data about a client's spiritual wellbeing. Which of the following questions should the nurse ask?

What is your source of strength and hope?"

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction

A nurse is reinforcing teaching for a client about performing range-of-motion exercises of the wrist. To have the client demonstrate adduction, which of the following instructions should the nurse give?

With your palm facing down, move your wrist sideways toward your thumb."

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

Would you like to talk about how you feel?"

A nurse is reinforcing teaching with a client who needs to reduce cholesterol levels. Which of the following foods should the nurse suggest that the client add to his diet?

carrot

A nurse is reviewing the laboratory results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse initiate?

contact

nurse on a same-day procedure unit is caring for several clients undergoing different types of procedures. A client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?

hearing aids

A nurse is in the facility's cafeteria when she notices a person grasping at the front of the neck in apparent distress. Which of the following behaviors should the nurse identify as an indication that the person requires an abdominal thrust intervention immediately?

inability to speak

A nurse is performing a physical examination of a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

palpation

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups?

preschoolers

A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?

inspect the eyes for drainage or redness