ATI FUNDAMENTALS (dynamic quizzes)

A nurse is preparing discharge teaching for a client who is recovering from lung cancer. The provider stated that the client can perform low-intensity ADL's. What activities should the recommend?

washing dishes

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

wiping the labia minora in an anteroposterior direction

A nurse is evaluating the development of a group of adults. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the stages of development?

young adulthood

A nurse is administering medication to a client that asks the nurse to leave the medication at the bedside to be taken at a later time. How should the nurse respond?

"Call me when you are ready, and I will return with the medication."

A nurse is planning an in-service training session about nutrition. What statement should the nurse include in the teaching?

"Fats provide energy"

A nurse is caring for an adult client who has an unmet spiritual need. Which of the following statements should indicate to the nurse that the client is in spiritual distress?

"God is punishing me for something."

The nurse is reviewing the correct use of a fire extinguisher with a client. What action should the nurse direct the client to take first?

remove the safety pin form the extinguisher

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which action should the nurse take first?

remove the sleeve of the gown without the IV line

A nurse is assessing a client's incision and notes the color to be blood-tinged. Which term should the nurse use to document this drainage?

sanguineous

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 what disorder?

scoliosis

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which type of data?

secondary-source data

A nurse is preparing to administer an intramuscular injection to a client who is overweight. What site should the nurse choose for this injection?

side hip between iliac crest and anterior iliac spine

a nurse is examining a client for costovertebral angle tenderness. What position should the nurse out the client in?

sitting

A nurse is caring for a client who has peripheral edema. The nurse should identify that which nutrient regulates extracellular volume?

sodium

A nurse is assessing a client. What is a sign protein-calorie malnourishment?

spoon-shaped nails, poor wound healing, dry and brittle hair

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers that the patient is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. What action should the nurse take first?

start chest compressions

A nurse is performing an abdominal assessments of a client. What position should the client assume for the examination?

supine

A nurse is planning care for a client who reports abdominal pain. An assessment reveals he has a temp of 102.5 degrees, a heart rate of 105 bpm, a soft nontender abdomen, and menses overdue by 2 days. What finding should be the nurse's priority?

temp of 102.5

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 pre-operative consent form is the client's

A nurse is teaching an assistive personnel about proper hand hygiene. What statement from the assistive personnel indicates an understanding of proper hand hygiene?

there are times when I should use soap and water to wash my hands instead of hand sanitizer

A nurse is assessing a client's thyroid gland. What instruction should the nurse give before assessing and palpating this gland?

tilt your head back and swallow

A nurse is preparing to perform tracheostomy care for a client. What action should the nurse perform first?

perform hand hygiene

A nurse is providing nutritional teaching to a group of clients. What definition for the recommended dietary allowance should the nurse include in this teaching?

the RDA defines the level of nutrient intake that meets the needs of healthy people in various groups

A nurse is explaining Piaget's theory for cognitive development to a group of daycare providers at an acute care facility. What activity should the nurse include as an example of concrete operational thinking?

collecting and trading game cards

A nurse is preparing to assess the function of the client's trigeminal nerve. What items should the nurse collect for the test?

cotton wisps

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. What action should the nurse take?

count the apical pulse for one full minute and describe the rythm in the chart

A nurse is caring for a client who is post-operative following an abdominal surgery. What action should the nurse take first after observing that the client's wound has eviscerated?

cover the incision with a moist sterile dressing

A nurse is assessing a patient with fluid volume excess. What is a manifestation to expect?

crackles in the lung fields

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which concept should the nurse and client discuss in the termination phase of the relationship?

loss

A nurse is caring for a client who starts to have a seizure while sitting in a chair. What action should the nurse take?

lower the client to the floor and place a pad under the client's head

A nurse is preparing to administer a medication to a client that has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. What intervention is the nurse's priority?

measure the client's apical pule

A nurse is caring for a client with a stroke that has a risk for falls. What action should the nurse take?

monitor the client at least once every hour

A nurse is assessing a client's nutritional status. The nurse notes that the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg?

10 weeks

A nurse is caring for a client who is receiving mechanical ventilation via tracheostomy tube and has a gastrostomy tube for enteral feedings. What pieces of information are critical to communicate to the next nurse who will be caring for this client?

new prescriptions, arterial blood gas results, tracheal secretion characteristics

A nurse is using a Braden scale to predict the risk of a pressure ulcer forming on a client in a long-term care facility. Using this scale, what parameters should the nurse evaluate?

nutrition

A nurse on a med-surg unit is caring for a client. What actions should the nurse prioritize when using the nursing process?

obtain client information

A nurse is preparing to remove an NG tube from a client who had a partial colectomy. What action should the nurse take?

pinch the NG tube while removing the tube

A nurse is preparing to perform mouth care for a client who is unresponsive. What action should the nurse take?

raise the level of the bed

A nurse is caring for a client who is receiving fluid infusion through a peripheral IV catheter. The nurse notes that the area immediately surrounding the site is red and feels warm. What action should the nurse take?

remove the IV catheter

A nurse is measuring a client's vital signs. The client's heart rate is 105 bpm. How should the nurse document this finding?

tachycardic

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. What factors should the nurse consider?

the client's basal metabolic rate could decrease

A nurse is reviewing methods to reduce the risk of back injury. What instruction should the nurse include?

when lifting an object, spread your feet widely apart to provide a wide base of support

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. What finding should the nurse expect?

increased blood pressure

A nurse is assessing a client who is experiencing stress following a near-fall of out bed. What physiological response indicates indicated the patient is in the fight-or-flight response?

increased blood pressure

A nurse is assessing a client who reports nausea and vomiting for 2 days. What finding would indicate that the client is in fluid volume deficit?

increased heart rate

A nurse manager is providing training to a group of newly licensed nurses about ways that clients acquire healthcare-related infections. Which route of infection should the nurse as iatrogenic?

infection acquired from a diagnostic procedure

A nurse is preparing a sterile field for a procedure the physician will perform at bedside. What action should the nurse take?

Hold the sterile drape above the waist and way from the body

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. What statement indicates an understanding of the teaching?

I will clip each suture close to the skin and pull it from the other side

A nurse in a long-term care facility is admitting a client who is incontinent and strongly smells of urine. His partner is embarrassed and apologizes for the smell. What response should the nurse make?

It must be difficult to care for someone who is confined to bed.

a 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 each meal. The nurse should recommend which team member to assess for dysphagia?

Speech-language pathologist

A nurse is cleaning a client's wound by swabbing from areas of greatest contamination to areas of least contamination. What rationale should the nurse use for completing this task?

keeping microorganisms from entering the wound

A nurse is measuring a client's vital signs. The client's resting radial pulse is 55 bpm. What action should the nurse take next?

measure the client's apical pulse

A nurse is caring for a group of clients in a long-term care facility. The nurse should admit that which client is eligible for hospice services?

A client who has end-stage cirrhosis

A nurse is planning care for a group of clients receiving oxygen therapy. What client should the nurse see first?

A client with heart failure who is receiving 100% oxygen via partial rebreather mask

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. What response should the nurse provide?

What worries you about being without your teeth?

A nurse is admitting a client who has measles. What type of transmission-based precautions should be taken?

Airborne

A nurse on a medical unit is caring for a client who has difficulty sleeping. What action should the nurse take to improve the client's ability to sleep?

Allow the client to maintain the same night-time routine as he did at home

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

explain that it is against policy to share access codes and refer him to speak with his supervisor

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. What diagnostic tests should the nurse recommend screening for?

eye examination every two years

A nurse is beginning her shift and reviewing the medication administration records for her clients. She notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage

A nurse is assessing a client who has an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which eye disorder?

glaucoma

A nurse is teaching a client who is recovering from gallbladder surgery about how to use an incentive spirometer. What should the nurse include in the teaching?

hold the breath for 5 seconds after goal volume is reached

A nurse is caring for a client who has a gastric ulcer. The nurse should remind the client that prolonged exposure to stress can also cause what?

hyperglycemia

A nurse is caring for a client who has an NG tube with intermittent enteral feedings. What action should the nurse take before feedings?

Elevate the head of the bed to 45 degrees before feedings

A nurse is discussion fire safety with newly hired nurses. What action is the priority if fire occurs in a health care facility?

Evacuate clients from unit

A nurse in an emergency department who reports diarrhea and decreased urination for four days. What action 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 teaching a client how to self-administer insulin. What action should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning?

Have the client demonstrate the procedure

A nurse is leading an education session on disposing of biohazardous materials. What instructions should the nurse include?

Place soiled linens in a single linen bag

A nurse is monitoring a client's labs. What is an example of an abnormal lab value?

Potassium level of 3.0

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which action should the nurse take?

Provide more water with feedings

A nurse is teaching a client about the use of a straight-legged cane. What client action indicates an understanding of the teaching?

The client holds the cane on the unaffected side

A nurse is preparing to administer a unit of packed RBC's to a client. What information must the nurse verify?

The client's ID number, the client's name, ABO compatibility, Rh compatibility

A nurse is planning care for a client who has a wound following abdominal surgery. To promote healing and fight infection, which vitamins and minerals should the nurse plan to include in the client's diet?

Vitamin C and Zinc

A nurse is reviewing the labs of a client who reports chills and aching joints. What finding indicates an infection?

WBC 15,000

A nurse is collecting a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger but does not collect enough blood for the sample. Which action should the nurse take?

Wash the client's finger in a warm washcloth

A nurse is caring for a client who has MRSA. What precautions should the nurse implement?

Wear a gown when in the client's room?

A nurse is caring for a client who has a C-diff infection and is in contact isolation. What action should the nurse take?

Wear gloved when changing the client's gown

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

absent bowel sounds with distention

A nurse is caring for a child following a tonsillectomy. What action should the nurse take?

administer analgesics to the child on a routine schedule throughout day and night

A nurse on a surgical unit is caring for a client who has abdominal surgery from the post-anesthesia care unit. What assessment should the nurse make first?

airway

A nurse is caring for a client who has injuries from a motor-vehicle crash. What statement should the nurse address first?

"I can't sleep well because whenever I fall asleep, the pain wakes me back up."

A nurse is reviewing the use of side rails with an assistive personnel. What statement from the AP indicates that she needs more teaching.

"If the client seems confused I should raise all 4 side rails to prevent a fall."

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly lost interest in certain foods." What statement should the nurse make?

"Keep a diary of the foods your child eats every day"

A nurse is caring for a client who has Type 1 Diabetes Mellites and is resistant to learning how to self-inject insulin. Which statement should the nurse make?

"Tell me how I can help you overcome your fear of self-injections"

A nurse is discussing with a client who has a sudden onset of severe back pain from unknown origin. What question should the nurse ask to encourage discussion with the client?

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

A middle-aged adult client is discussing future plans with the nurse. Which statement by the client should indicate that he is having difficulty achieving Erikson's developmental task for his age group?

"we miss our daughter so much that we are going to move closer to her"

A nurse is caring for a client who is set to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks how the TENS unit helps relieve pain. How should the nurse respond?

it modulates the transmission of the pain impulse

A nurse is providing teaching about crutches for a client with a fracture of the right foot. What instruction should the nurse include?

keep the rubber crutch tips securely in place

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume.

apply light pressure to the scanner head once in position

A nurse is preparing to administer eye drops to a patient with glaucoma. While instilling the medication, what action should the nurse take?

apply pressure to the puncta after instillation

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are swollen. Which of the findings is another manifestation of fluid volume excess.

bounding pulse

A nurse documents the presence of clubbing on fingernails for a client who has emphysema. What is the underlying cause of this finding?

chronic hypoxemia

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health nurse. What statement from the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound"

A nurse is preparing a client for discharge and providing instructions about dressing changes at home. What statement is an indication that the client understands medical asepsis procedure?

"I will wash my hands before removing the old dressing and again before putting on the new one"

A nurse is performing an admission assessment for a client. What response by the nurse is an example of the communication technique of clarifying?

"It sounds like your pain is intermittent"

A nurse is caring for a client who is receiving total parenteral nutrition. What action should the nurse take?

check the client's capillary blood glucose level every four hours

A nurse is caring for a client who was transferred to the surgical unit on a stretcher from PACU. What action should the nurse perform immediately following the transfer?

check the client's vital signs

A nurse is teaching a client who has low back pain about heat therapy. What statement 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 assessing a client who has deep, rapid respirations. Arterial blood gas values: ph- 7.25, PaCO2- 40, HCO3- 18. Which acid-base imbalance should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is preparing to administer a packed unit of RBC's to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come place a new line in 30 minutes. What should the nurse do?

Return the blood to the laboratory

A nurse is preparing to administer a tuberculin skin test. After performing hand hygiene, what action should the nurse take?

circle the injection area with a pen

A nurse is caring for a client who requires a dressing change. What action should the nurse take?

clean the drain site from the center outward

A nurse is performing a neurological assessment on a client. To promote safety, the nurse will stand nearby the client as they perform which test?

Romberg

A nurse is conducting an admission interview with a client. What pieces of 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 caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. What action should the nurse take to ensure proper operation of the device?

collapse the device to remove air after emptying

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should include that a written consent from be signed by which patient?

a client who has a prescription for a unit of packed red blood cells

A nurse on an oncology unit received report about four patients who are post-operative. What client should the nurse see first?

a client who is 2 days post-op and has an ostomy bag full of bright red, bloody drainage

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

advise the client to perform range-of-motion exercises while in bed

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, what 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 signs of nutritional deficiencies. A lab result within the expected range for which substance indicates adequate protein uptake and synthesis?

albumin

A provider is planning to open an immunization clinic for older adults. AT what time should the older adults receive the influenza vaccine?

annually in the fall

During a client care staff meeting, the nurse manager discusses potential problems with data security that affect confidential information. What environment should the nurse identify as an acceptable place for discussing client information?

areas with no public access

A nurse is preparing to insert an indwelling urinary catheter. What should the nurse tell the client directly before inserting the catheter?

bear down gently

a nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should expect injury to which part of the brain?

brainstem

A nurse is providing teaching about nutritious diets to a group of older females. What statement should the nurse include?

include 2.5 cups of vegetables in your diet every day

A nurse is performing a breast examination on a female client. What technique should the nurse use first?

inspect both breasts simultaneously

A nurse is planning to perform an abdominal assessment on a client who reports being bloated for several weeks. What method of assessment should the nurse use first?

inspection

A nurse is teaching a group of unit nurses about about the experiences of clients who are having surgery. In what phase of care is the client transferred to the surgical suite before being transferred to the PACU?

intraoperative

A nurse is providing teaching to a client about protein intake. What food should the nurse include as an incomplete protein?

lentils

A nurse in a provider's office is measuring a client and notes a loss in height from the last year. The nurse should identify this finding as a manifestation of what musculoskeletal disorder?

osteoprosis

A nurse is initiating seizure precautions for a client who has a seizure disorder. What piece of equipment should the nurse have readily available at the bedside?

oxygen equipment

A nurse is performing a physical assessment of a client. What actions should the nurse take to assess the client's tissue perfusion?

perform a blanch test

A nurse is providing oral care for a client who is unconscious. What action should the nurse take?

place the client in a lateral position with the head turned to the side before beginning the procedure

A nurse is caring for a client who is immobile. The nurse should recognize that immobility puts the client at risk for what health alteration?

decreased cardiac output

A nurse is caring for a client with terminal pancreatic cancer. When the client states "It is so sad that I will not be here to see my child graduate," the nurse should identify that the client is in which stage of grief as defined by Kubbler-Ross?

depression

A nurse is caring for a client who is unstable and has vital signs taken every 15 minutes by an electronic machine. The nurse notes that the machine starts to take bp at random intervals and has become unreliable. What action should the nurse take?

disconnect the machine and take the blood pressure manually every 15 minutes

A nurse is caring for a client who has MRSA. An assistant asks the nurse what precautions are required for entering the client's room with a lunch tray. What instruction should the nurse give to the assistant?

don gloves when entering the room and use hand sanitizer when exiting

A nurse is preparing to administer eye drops to a client following surgery. What action should the nurse take during application?

drop the eye drops into the lower conjunctival sac

A nurse is caring foe a client who has an NG tube in place and a prescription for continuous enteral feedings. What actions should the nurse perform to reduce the client's risk for aspiration?

elevate the head of the bed to 30 or 45 degrees

A nurse is auscultating a client's lung sounds and hears rhonchi over the trachea and bronchi. What action should the nurse take?

encourage the client to cough

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

encourage the client to express her thoughts about death and dying

A nurse is admitting a client who has decreased circulation in his leg. What action should the nurse take for.

evaluate pedal pulses

A nurse is caring for an older adult client who has an in-canal hearing aide. The client states that it is making a whistling sound. The nurse should identify that what factor is the source for this sound?

excessive wax in the ear canal

A nurse is providing teaching about food choices for a client who is on a clear liquid diet. What selections by the client indicates an understanding of the teaching?

gelatin

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. The nurse notes that the client's wound has eviscerated. What actions should the nurse take?

place the client in supine position with hips and knees flexed, cover the wound and intestines with a sterile and moist dressing, monitor the client for manifestations of shock

a home health nurse enters a client's home and notices a used insulin syringe without a cap on the table, What action should the nurse take?

place the syringe in a puncture-proof sealed container

A nurse is caring for a client who is post-op and has a history of poor nutrition. What action should the nurse include to promote wound healing?

provide a protein intake of 1.5 mg/kg per day

A nurse is caring for a group of clients. What task should the nurse assign to an assistive personnel?

provide oral care to a client who cannot take oral fluids

A nurse is performing suctioning for a client who has a tracheostomy. What action should the nurse take?

pull suction catheter back 1 cm if client starts coughing

A nurse is inserting an NG tube to a client who begins to cough and gag. What action should the nurse take?

pull the NG tube back slightly

A nurse is changing the dressings for a client who is 3 days post-op following a cholecystectomy. The nurse observes yellow, thick drainage from the dressing. The nurse should document what type of drainage?

purulent

A nurse is caring for a client who is violent and attempting to pull out her IV lines. The provider prescribes soft wrist restraints. What action should the nurse take while the client is on restraints?

remove the restraints one at a time

A home health nurse is visiting an older adult client with dementia. The client's son and primary caregiver states "I am exhausted from working and taking care of my mother when I get home." What should the nurse suggest to the caregiver?

respite care

A community health nurse is preparing a campaign about seasonal influenza. What plan should the nurse include as a from of secondary prevention?

screening groups of adults in nursing care facilities for early influenza manifestations

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel. The nurse later observes the assistive personnel emptying the bag without wearing gloves. What action should the nurse take?

talk with the assistive personnel about the technique used

A nurse on a med-surg unit is washing her hands prior to assisting with a surgical procedure. What actions by the nurse demonstrates proper surgical handwashing technique?

the nurse holds her hands higher than elbows while washing

A nurse is teaching a client who has incontinence about urinary retention. What instruction should the nurse include?

try to block the urge to urinate until the next scheduled time

A nurse is preparing to change the dressing on a client who is receiving negative pressure wound therapy. In order, what actions should the nurse take?

turn off the vacuum, remove the soiled dressing and perform hand hygiene, apply gloves and irrigate the wound, place prepared foam in wound bed, connect tubing and turn machine on

A nurse is applying anti-embolism stockings for a client who has a history of deep vein thrombosis. What action should the nurse take when applying the stockings?

turn the stocking inside out up to the heel before applying

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which action should the nurse take during this procedure?

use the index finger to insert the suppository