ATI Fundamentals Practice A 2019

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while i'm lying in bed."

a nurse is talking with an older adult client who is contemplating retirement. the client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' which of the following responses should the nurse make?

'let's talk about how the change in your job status will affect you

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

. Assist the client with a partial bed bath2. Measure the client's BP after the nurse administers an antihypertensive medication3. use a communication board to ask what the client wants for lunch

750ml over 7 hours

107 ml/h

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

Check the IV tubing for obstruction

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have client take sips of water while inserting

Discharge instructions patient with a walker

Hire tree trimmer

nurse is assessing a client's readiness to learn about insulin self-administration. which of the following statements should the nurse identify as an indication that the client is ready to learn?

I can concentrate best in the morning

What to include for self-administering heparin

Inject in abdomen

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the patient's pain?

Is your pain constant or intermittent? Pain on a scale of 1 to 10 Does the pain radiate? Is your pain sharp or dull***

Pattelar reflex

Just below the knee

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area?

Auscultating breath sounds

Normal Breath sounds

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of a sequential compression device (SCD). What action should the nurse take?

Place an SCD sleeve under each leg with the opening at the knee.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 meq/L

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

Which type of role performance stress?

Role overload

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

SBAR

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

Home safety assessment for client receiving supplemental oxygen

The client uses nonacetone nail polish remover.

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

The family member washed out the feeding bag with warm water once every 24 hours.

Minimize risk for client with dementia

Use bed exit alarm

Manage time effectively

Use planning step

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?

antiemetic

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

ask another nurse to observe the wastage

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

calf swelling

Fluid volume deficit correction shows

decrease in heart rate

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

determine reason client is refusing

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process

A nurse is providing care to four clients. Which of the following for physical assessment

ensure bp cuff bladder covers 8 percent of clients arm

a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which type of dressing should the nurse use?

hydrocolloid-- (bc this type of dressing promotes healing in stage 2 pressure injuries by creating a moist wound bed

Which of the following actions should the nurse take for a client with wrist restraints

pad the clients wrists before apply restraints

Actions nurse should take to prevent spread of infection

place a client who has tuberculosis in a room with negative-pressure airflow.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

place arm in dependent position

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

""They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind."

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

Obtain the pronouncement of death from the provider Remove tubes and indwelling lines Wash the client's body Ask the client's family members if they would like to view the body Place a name tag on the body

A nurse is admitting a new client. Which of the following should the nurse take when performing medication reconciliation?

Verify name on id band with MAR Call pharmacy to determine if patients med are available Compare home medications with provider prescriptions*** Place clients medications in a secure place

A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?

abd cramping

A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

Client's partner indicates effective coping

relying on help from family at this time

advocacy

support of clients' health, safety, and personal rights

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

Notify nurse manager

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Pressing gently on the tragus of the client's ear.

nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

Pupil clarity Visual fields Visual acuity

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of the body

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?

We will apply oxygen through a tube in your nose"

a nurse is caring for a client who has herpes zoster and asks the runs about the use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies?

acupuncture

a nurse is caring for a client who is postoperative. when the nurse prepares to change her dressing, she says, 'every time you change my bandage, it hurts so much.' which of the following interventions is the nurse's priority action?

administer pain mediation 45 min before changing the client's dressing

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

administer the medication with the needle at a 45 degree angle

a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

gown

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

regulate oxygen via nasal cannula at a flow rate no more than 6 L/min

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter.

A nurse is performing a skin assessment for a client who expresses concern for about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy?

A lesion with uniform pigmentation. New appearance of petechiae A mole with asymmetrical appearance *** The presence of papule

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

examine personal values about the issue