ATI Fundamentals
C
A nurse is assessing a client who has total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A. Muscle tremors B. Positive Chvostek's sign C. Depressed deep-tendon reflexes D. Numbness around the mouth
B
A client is wearing a Venturi mask. The meal tray arrives. What action should the nurse perform next? A. Assess oxygen saturation and if normal turn off the oxygen. B. Assess oxygen saturation for the patient's ability to switch to a nasal cannula for meals. C. Instruct the patient to lift the mask away from the face while taking bites. D. Turn the oxygen off while the client eats and resume later.
D
A nurse 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? A. "You look just fine to me." B. "nobody expects you to look beautiful in the hospital." C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"
D
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders
C
A nurse in a community clinic is assessing a 50-year- old client as part of a routine physical examination. The client's BP is 146/90 mm Hg, his body mass index (BMI) is 34, and he has smoked for 14 years. The nurse identifies that this client has multiple risk factors for which of the following disorders? a. Depression b. Thyroid disease c. Cardiovascular disease d. Bladder cancer
A
A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. establish client outcomes B. collect information about past health problems C. determine whether the client has met specific goals D. Identify the client's specific health problems
A
A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. postural hypotension D. Dark yellow urine
A
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood glucose C. Decreased oxygen use D. Increased gastrointestinal motility
A
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves
B
A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following should the nurse include in the teaching? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young adults B. Clients who are age 65 or older are reluctant to report pain C. Clients who are age 65 or older should not receive opioid narcotics D. Clients who are age 65 or older experience a shorter duration of action with medications than young adult clients
A
Define: HAI A. Infection acquired in a hospital or other healthcare setting. B. A disease of the human immune system. C. Bacteria which causes severe, watery diarrhea. D. A bacterial infection that affects the lungs.
C
During assessment of the cardiovascular system, where does the nurse palpate to determine whether the patient has pulsations in the area of the mitral valve? a. Right 2nd intercostal space b. Left 5th intercostal space c. Left 5th intercostal space at the mid-clavicular line d. Left 2nd intercostal space
D
Nasal Cannulas have a flow rate of: a. 6-11 L/min b. 10-15 L/min c. 4-10 L/min d. 1-6 L/min
A
Normal sodium lab values: a. 135-145 b. 100-200 c. 150-200 d. 3.5-5.0
B
Nursing interventions for a patient with fluid volume excess and hyponatremia most likely include: a. Encouraging clear liquids as tolerated throughout the day b. Educating the patient about fluid restriction of less than 1000 mL/day c. Administration of hypotonic IV fluids as ordered d. Administration of 0.45% NaCl as ordered
C
The Venturi mask delivers: a. Low-flow oxygen b. High-concentration oxygen c. Precise amounts of oxygen d. High concentration oxygen & water
C
The implementation step of the nursing process involves: A. Setting goals and creating a care plan B. Deciding if goals were met C. Putting the care plan into action D. Identifying the health problems and resident needs
D
The nurse assesses the patient's radial pulse as irregular. What should the nurse do next? a. Call the physician and request an order for an EKG b. Wait 2 minutes, then assess again c. Use a Doppler to assess the radial pulse d. Assess the apical pulse for one minute
C
The nurse cannot understand a handwritten physician's order for a medication. The nurse should a. Call the pharmacy to clarify the physician's order for the medication. b. Clarify with the client and family what the physician told them about the medication. c. Call the provider to clarify and have a second nurse verify the order with the physician on the phone. d. Look at the client's medication history for previous orders for the medication.
A
The nurse suspects the patient has developed a DVT in the left lower extremity. She should do all of the following except: a. Apply SCDs b. Assess peripheral pulses c. Assess for warmth and tenderness in the lower extremities d. Measure the circumference of the lower extremities
A, D
Which of these are unintentional torts? (select all that apply) A. Negligence (ex: forgetting to set bed alarm for a patient at risk of falls) B. Assault (ex: nurse threatens patient) C. Battery (ex: nurse hits patient, or administers medication against patient's will) D. Malpractice (ex: medication error that harms patient) E. False Imprisonment (ex: nurse inappropriately restrains a patient or administers a chemical restraint such as a sedative)
D
A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the same range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage B. Give the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage
C
A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. Protein C. Starch D. Fiber
C
A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to told his head backward
B
A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L
A
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via tracheostomy collar C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula
C
The nurse is administering an enema, and the patient complains of abdominal cramping. The nurse should first a. Stop the enema and call the physician. b. Check to see if the patient has an order for pain medication. c. Slow the rate of the enema by lowering the bag or using the clamp. d. Turn the patient on her other side to see if that relieves the cramping.
B, D, E
The nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (select all that apply) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock
B
The patient weighs 110 lb. How many kilograms does she weigh? a. 36 kg b. 50 kg c. 250 kg d. 150 kg
B
The planning step of the nursing process involves: A. Identifying health problems and client needs B. Setting goals and creating a care plan C. Getting information about the client and reviewing it D. Putting the care plan into action
C
The pre-op nurse is reviewing a patient's lab work. Which range represents a platelet count within normal limits? a. 10-20 b. 12-18 c. 150,000-400,000 d. 3.5-5.0
C
We have an order to give a patient: Insulin regular 10 units subcutaneously now and Insulin NPH 10 units subcutaneously now. Which is the correct way to prepare the insulin for injection? a. Inject air into the regular insulin and withdraw regular insulin. Inject air into NPH insulin and withdraw NPH insulin. b. Use 2 separate syringes to prepare and administer the regular and NPH insulin. c. Inject air into NPH insulin, then into regular insulin. Withdraw regular insulin, then withdraw NPH insulin. d. Inject air into regular insulin, then into NPH. Withdraw NPH, then withdraw regular insulin.
D, E
Your patient has been admitted for wound care and IV antibiotics. The provider has ordered an IV saline lock for administration of the antibiotics. Which of the following are correct actions when inserting the saline lock? Select all that apply a. The first place you look for a vein is the antecubital space. b. Your first choice for the correct size catheter is an 18-gauge. c. You avoid veins that have a soft, bouncy sensation. d. You insert the needle at an angle of 30 degrees or less. e. You loosen the tourniquet before you connect the saline lock to the catheter.
440 mL
Your patient has had an intake of 1000 mL of tube feeding, 200 mL of water, and an 8-ounce cup of coffee today. They have had 1000 mL of urine output. What is their net intake in mL?
B
A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive
C
Which of the following preoperative lab values should be reported immediately to the provider? a. Potassium Level - 3.9 mEq/L b. Sodium Level - 145 mEq/L c. Blood Glucose Level - 235 mg/dL d. White Blood Cell Count - 8,000 cells/mm
B, C, F
Which of these are RN responsibilities? (select all that apply) A. Explain risks vs. benefits B. Ensure patient is competent to give informed consent and have patient sign consent document C. Notify provider if patient has more questions or doesn't understand any information provided D. Describe other options to treat the condition E. Communicate purpose of procedure, and complete description of procedure in the patient's primary language F. Make sure the patient has been provided information about their procedure
C
The surgery schedule for tomorrow includes a patient with a latex allergy. What is included in the preparations for surgery? a. Move the patient's surgery to a day when no other patients will have surgery. b. Place a malignant hyperthermia cart in the operating room. c. Schedule the patient as the first surgery of the day. d. Inform the surgeon that the patient will not be able to have IV fluids or an indwelling urinary catheter.
B
To prevent a CAUTI, the nurse should a. Insert a Foley catheter for all incontinent patients b. Ensure an indwelling catheter drainage bag remains below the level of the bladder c. Change the central line dressing every 72 hours d. Use medical asepsis when inserting an indwelling catheter
C, D, E
When does a nurse complete the process of medication reconciliation? Select all that apply. a. When he completes the three checks before administering a medication. b. At the end of his shift. c. When a patient is admitted. d. When a patient is transferred from a different hospital. e. When a patient is discharged home.
B, C, E
Which of these are intentional torts? (select all that apply) A. Negligence (ex: forgetting to set bed alarm for a patient at risk of falls) B. Assault (ex: nurse threatens patient) C. Battery (ex: nurse hits patient, or administers medication against patient's will) D. Malpractice (ex: medication error that harms patient) E. False Imprisonment (ex: nurse inappropriately restrains a patient or administers a chemical restraint such as a sedative)
E
Which nursing ethical principle is this? Do no harm. A. Autonomy B. Beneficence C. Fidelity D. Justice E. Nonmaleficence F. Veracity
A, B, C
Which pieces of equipment can be used to transfer a patient from a bed to a chair (Select all that apply)? A. Gait Belt B. Transfer Board C. Hydraulic Lift D. Incentive spirometer E. Obturator
D
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record? A. The client refused to take medication today. B. The client stated, "I would not take this pill." C. The client seemed angry and hostile D. The client threw the medication on the floor
A
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? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea
B, D, E
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastroscope tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (select all that apply) A. Room temperature B. New prescriptions C. Number of visitors D. Arterial blood gas results E. Tracheal secretion characteristics
D
A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A. "In time you'll know the right thing to do." B. "I am sorry. Would you like me to call someone for you?" C. There are multiple treatment options for you to consider." D. "Can you explain the concerns you're having right now?"
A
A nurse is caring for a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C. Heightened immune response D. Bleeding tendencies
A
A nurse is caring for a postoperative client who has an in dwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 ht. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids
B
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound
C
A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A. Sims' B. Supine C. Sitting D. Standing
A
A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown
D
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? A. "Let's get the process over with because you won't get better without this tube." B."You should talk to your provider about your fears." C. "Why don't you want the tube inserted?" D. "I can see that this is upsetting you."
30
A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
B
A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the osteomy pouch to decrease odor
A
A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? A. Assessment B. background C. Situation D. Recommendation
B
A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse use first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an osteomyelitis bag full of bright red, bloody drainage C. A client who is 2 days postoperative following an excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine
B
A patient has researched complimentary therapies for wound healing. Which therapies are the patient most likely to express interest in using for this purpose? a. Ginseng and valerian b. Chamomile and aloe c. Ginger and ginseng d. Gingko biloba and aloe
A
A post-operative client has not urinated since the Foley catheter was removed 8 hours ago. What is the best action for the nurse to take first? A. Assess the volume of urine in the bladder with a bladder scanner B. Use a straight catheter to assess the volume of urine in the bladder C. Encourage the patient to increase po fluid intake D. Assess CVA tenderness
B
Acute pain: a. Can only be relieved with opioids. b. Is protective and temporary c. Cannot lead to chronic pain d. Is experienced by all hospitalized patients.
C
An assistive personnel (AP) is helping a nurse care for a female client who has an in dwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area B. The AP tapes the catheter to the client's inner thigh C. The AP hangs the collection bag at the level of the bladder D. The AP ensures there are no kinks in the drainage bag
A
The nurse is caring for an elderly patient who is confused at times. The patient refuses her oral medications. What is the first action the nurse should take? a. Identify the patient's concerns about taking the medication. b. Hold the medication dose and document the patient's refusal. c. Explain to the patient that if she does not take her medications by mouth, an enteral tube can be placed. d. Call the physician to report the patient's refusal and ask to give it by a different dosage route.
B
The nurse is preparing to give discharge instructions, including step-by-step instructions about wound care, to a patient who does not speak the same language as the nurse. His wife has been able to translate some conversations between the nurse and patient. Which of the following is the best action for the nurse to take to provide the instructions? a. Give the patient a handout with instructions in the patient's primary language. b. Call a translation service to assist with providing the instructions. c. Give the instructions to the wife and ask her to translate as you teach. d. Consult social work to set up a home health nurse to provide wound care.
B
Which action promotes safety in a patient at risk for falls: A. Medicate with a sleep medication for a good night sleep B. Hourly rounds to check on patient needs C. Using physical restraints to make sure patient stays in bed D. Place patient far away from nursing station to ensure quiet
C
Which methods should be used to verify feeding tube placement when administering intermittent feedings every 4 hours? a. Obtain an x-ray every time you use the tube for a tube feeding. b. Auscultate for bowel sounds and check the pH of the gastric contents. c. Check the pH of the gastric contents and observe placement of the tube. d. Flush the tube with water and observe for any signs of distress.
B
Which nursing ethical principle is this? Do what is best for the patient (do good). A. Autonomy B. Beneficence C. Fidelity D. Justice E. Nonmaleficence F. Veracity
C
Which nursing ethical principle is this? Keep your promises. A. Autonomy B. Beneficence C. Fidelity D. Justice E. Nonmaleficence F. Veracity
A
Which nursing ethical principle is this? Patient has right t make their own decision, even if it is not their best interest. A. Autonomy B. Beneficence C. Fidelity D. Justice E. Nonmaleficence F. Veracity
D
Which nursing ethical principle is this? Provide fairness in care and allocation of resources. A. Autonomy B. Beneficence C. Fidelity D. Justice E. Nonmaleficence F. Veracity
F
Which nursing ethical principle is this? Tell the truth. A. Autonomy B. Beneficence C. Fidelity D. Justice E. Nonmaleficence F. Veracity
C
Which of the following DOES NOT influence bowel elimination? A. Patient's age B. Patient's medications C. Patient's height D. Positioning of the patient
A, C, D
Which of the following apply when caring for a patient with enteric precautions? (Select all that apply): A. Washing hands with soap and water when leaving the patient's room. B. Wearing a mask in the patient's room. C. Wearing a gown and gloves in the patient's room. D. Educating the patient's visitors to wear a gown and gloves when in the patient's room. E. Using hand sanitizer when leaving the patient's room.
A, B, E
Which of the following can be used as part of two patient identifiers? (select all that apply) a. Name b. Date of birth c. Room number d. Address e. Medical record number
B
Which of the following statements best describes the effects of medications? a. Toxic effects and adverse effects are always predictable. b. Therapeutic effects and side effects are predictable effects of a medication. c. Allergies and side effects are the same thing. d. Side effects are never predictable.
C
Which statement most accurately describes discharge planning? a. Discharge planning should begin 48 hours before discharge. b. Discharge planning should begin when the discharge order is written. c. Discharge planning should begin upon admission. d. Discharge planning should begin when the health insurance company approves it.
C, E
Which statements most accurately describe urinary incontinence? Select all that apply. a. Urinary tract infections do not contribute to any type of incontinence. b. Kegel exercises will decrease the risk for all types of urinary incontinence. c. Urinary incontinence significantly increases the risks for falls, pressure injuries, and depression. d. Inserting an indwelling urinary catheter is one of the first strategies the nurse should use to manage incontinence. e. Females are at higher risk of urinary incontinence than males.
A
Which team member is this? Assesses, diagnoses and treats illnesses. Includes: doctors, advance practice nurses, physicians assistants. A. Provider B. Occupational Therapist C. Social Worker D. Speech Language Pathologist
D
Which team member is this? Assists with patient issues related to speech, language, and swallowing. A. Provider B. Occupational Therapist C. Social Worker D. Speech Language Pathologist
B
Which team member is this? Helps patients regain their ability to perform ADLs. A. Provider B. Occupational Therapist C. Social Worker D. Speech Language Pathologist
C
Which team member is this? Identifies and coordinates community resources and other patient needs necessary for discharge and recovery. A. Provider B. Occupational Therapist C. Social Worker D. Speech Language Pathologist
A
While performing an abdominal assessment, which is the correct order? A. Inspect, auscultate, percuss, palpate B. Palpate, percuss, inspect, auscultate C. Percuss, auscultate, palpate, inspect D. Auscultate, palpate, inspect, percuss
D
You are helping a client transfer from the bed to the chair. Which is correct? a. The client wears any type of socks or slippers. b. The client is helped out of bed on his weak side. c. The bed is in the highest horizontal position. d. Help the client to dangle first, making sure his feet touch the floor.
B
Your patient has been admitted for wound care and IV antibiotics. The provider has ordered an IV saline lock for administration of the antibiotics. Which of the following are correct actions when inserting the saline lock? Select all that apply a. The first place you look for a vein is the antecubital space. b. Your first choice for the correct size catheter is an 18-gauge. c. You avoid veins that have a soft, bouncy sensation. d. You insert the needle at an angle of 30 degrees or less. e. You loosen the tourniquet before you connect the saline lock to the catheter.
B, E
Your patient has been admitted for wound care and IV antibiotics. The provider has ordered an IV saline lock for administration of the antibiotics. Which of the following are correct actions when inserting the saline lock? Select all that apply a. The first place you look for a vein is the antecubital space. b. Your first choice for the correct size catheter is an 18-gauge. c. You avoid veins that have a soft, bouncy sensation. d. You insert the needle at an angle of 30 degrees or less. e. You loosen the tourniquet before you connect the saline lock to the catheter.
