ATI Fundamentals DECEMBER 2021
A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take?
Advise the client to tuck his chin downward
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 providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?
Gelatin
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Identify the client using 2 identifiers
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?
Metabolic acidosis
A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?
Physical examination
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 which of the following abnormalities?
Scoliosis
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?
lower the client to the floor
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first?
perform hand hygiene
a nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. which of the following actions should the nurse plan to take?
place the client in the Trendelenburg position
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 cannot take oral fluids
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? (select all that apply)
stabilizing the position of the tube preventing aspirations of secretions preventing air leaks
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
tachycardia
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
While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?
tell me more about how you feel about dying
a nurse is assisting a client who has a right-sided weakness which ambulating using a cane. which of the following client actions should indicate to the nurse that the client understands the procedure of a cane walking?
the client keeps 2 points of support on the ground
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information's must the nurse verify with another nurse prior to the administration? (select all that apply)
the clients ID number The client name ABO compatibility Rh compatibility
A nurse is providing teaching to a client with 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 the planning the change
A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?
the signature on the preoperative consent form is the clients
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 an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?
God is punishing me for something
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
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 in a providers office is teaching a client about foods that are high in fiber. Which of the following choices made by the client indicate an understanding of the teaching? (select all that apply)
black beans whole-grain bread
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 reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
when lifting an object, spread your feet apart to provide a wide base of support
A nurse is caring for a client who is scheduled to receive a transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how the TENS unit helps relive pain. Which of the following responses should the nurse make?
It modulates the transmission of the pain impulse
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?
check the clients vital signs
