ATI Fundamentals Practice Exam (A+B)
a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer SQ. determine the correct order of steps
-inject 10 units of air into the bottle of NPH insulin -inject 5 unites of air into the bottle of regular insulin -withdraw the correct dose of regular insulin from the bottle -withdraw the correct dose of NPH insulin from the bottle
a nurse is reviewing a clients fluid and electrolytes status. which of the following findings should the nurse report to the provider?
1) BUN 15 mg/dL 2) Creatinine 0.8 mg/dL 3) sodium 143 mEq/L 4) potassium 5.4 mEq/L CORRECT: 4) potassium 5.4 mEq/L 1) In expected range of 10 to 20 mg/dL 2) in expected range of 0.5 to 1.1 mg/dL 3) in expected range of 136 to 145 mEq/L 4) above expected of 3.5 to 5 mEq/L. client is at risk for dysrhythmias
a nurse is administering IV fluids to a client. when monitoring for adverse effects which of the following assessments should the nurse identify as the priority?
1) auscultate lung sounds 2) measure urine output 3) monitor blood pressure readings 4) monitor electrolyte levels CORRECT: 1) auscultate lung sounds 1) priority assessment the nurse should make when using the airway, breathing, circulation (ABC) approach is to listen for fluid volume excess, a complication of IV therapy. 2) should be done to monitor renal function 3) should be done to evaluate hemodynamic stability 4) should monitor electrolyte levels, especially sodium, to guide the planning of interventions to correct any imbalances
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?
1) encourage the client to relax and take deep breaths during the dressing change 2) educate the client about the importance of the dressing change to prevent infection 3) assist the client to a comfortable position for the dressing change 4) administer pain medication 45 mins before changing the clients dressing CORRECT: 4) administer pain medication 45 mins before changing the clients dressing 4) Maslow's hierarchy of needs is to meet clients physiological need for comfort and pain relief
a nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
1) increase in hematocrit 2) increase in resp. rate 3) decrease in heart rate 4) decrease in capillary refill time CORRECT: 3) decrease in heart rate 1) fluid volume deficit causes an increase in hematocrit due to depletion of extracellular fluid 2) fluid volume deficit causes an increase in resp. rate. with correction of the imbalance the resp. rate will return to normal range 3) fluid volume deficit causes tachycardia. with correction of the imbalance the HR should return to expected range 4) fluid volume deficit slows capillary refill
a nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter. which of the following actions should the nurse take?
1) place the client in a side-lying position 2) instill 15 mL of irrigation fluid into the catheter with each flush 3) subtract the amount of irrigant used from the clients urine output 4) perform the irrigation using a 20 mL syringe CORRECT: 3) subtract the amount of irrigant used from the clients urine output 1) for a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter 2) open irrigation technique requires instilling 30 to 40 mL or irrigation fluid 3) nurse should calculate the fluid used for irrigation and subtract it from the clients total urinary output 4) nurse should use a 30-50 mL syringe to perform open irrigation
A nurse is caring for a client who reports pain. when documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following client statements?
1) "im having mild pain" 2) "the pain is like a dull ache in my stomach" 3) "i notice that the pain gets worse after i eat" 4) "the pain makes me feel nauseous" CORRECT: 2) "the pain is like a dull ache in my stomach" 1) this describes the severity of he pain 2) this describe the quality of the pain which is how the pain feels in the clients words 3) describes what aggravates the pain 4) describes a manifestation that accompanies the pain
a nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump?
8 mL/hr dose to administer: desired 800 units/hr dose available: 25,000 units quantity of dose available: 250 mL X = desired * quantity/ have --> X mL/hr = 800 * 250/25,000
a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol?
1) the client uses a wool blanket on their bed 2) the client uses nonacetone nail polish remover 3) the client stores an extra oxygen tank on its side under their bed 4) the client has a weekly inspection checklist for oxygen equipment CORRECT: 2) the client uses nonacetone nail polish remover 1) client should use a cotton blanket. Wool blanket should be avoided. it can generate static electricity that could ignite the oxygen 2) client should use noninflammable materials, such as nonacetone nail polish remover 3) extra oxygen should be in an upright position to maintain safety 4) client or caregiver should inspect oxygen equipment daily
a nurse is talking with the partner of a client who has dementia. the clients partner expresses frustration about finding time to manage household responsibilities while caring for their partner. the nurse should identify that the partner is experiencing which of the following types of role performance stress?
1) role ambiguity 2) sick role 3) role overload 4) role conflict CORREECT: 3) role overload 1) role ambiguity occurs when people are unclear about the expectations of their role in given situation 2) sick role refers to the expectations placed on the individual who has the alteration of health, rather than the caregiver 3) the partners expression of frustration is an example of role overload which refers to having more responsibilities within a role than one person can manage 4) role conflict develops when a person must assume multiple roles that have opposing expectations
a nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions assess the quality of the clients pain?
1) "is your pain constant or intermittent?" 2) "what would you rate your pain on a scale of 0 to 10?" 3) "does the pain radiate?" 4) "is your pain sharp or dull?" CORRECT: 4) "Is your pain sharp or dull? 1) determines the onset, duration and pattern of the pain 2) determines the intensity of the pain 3) determines the pains location 4) determines the quality of the pain (sharp, dull, crushing, throbbing, aching, burning, shooting)
a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which of the following types of dressing should the nurse use?
1) alginate 2) gauze 3) transparent 4) hydrocolloid CORRECT: 4) hydrocolloid 1) alginate dressings are used to treat stage III and IV pressure injuries to absorb drainage. alginate forms a soft gel when it comes in contact with drainage 2) moistened gauze promotes healing in stage IV or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed 3) transparent dressings promote healing in stage I pressure injuries by preventing further friction and shearing 4) hydrocolloid dressings promote healing in stage II pressure injuries by creating a moist wound bed
a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following clients statements indicate an understanding of herbal supplement use?
1) "i can take echinacea to improve my immune system" 2) "i can take feverfew to reduce my level of anxiety" 3) "i can take ginger to improve my memory" 4) "i can take gingko niloba to relieve nausea" CORRECT: 1) "i can take echinacea to improve my immune system" 1) echinacea is taken to promote immunity and reduce the risk of infection 2) feverfew is take to promote wound healing and decrease inflammation associaed with arthritis 3) ginger is taken to relieve nausea and vomiting and aid in digestion 4) gingko niloba is taken to improve memory and reduce stress
a nurse is caring for a client who is receiving fluid through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration?
1) purulent exudate 2) warmth 3) skin blanching 4) bleeding CORRECT: 3) skin blanching 1) exudate indicates infection 2) warmth indicates phlebitis 3) skin blanching edema and coolness at the IV site indicates infiltration 4) can have a mechanical cause or occur as result of anticoagulation
a nurse in a clinic is caring for a middle adult client who states "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does that involve?" which of the following responses should the nurse make?
1) "ill get a blood sample from you and send it for a screening test" 2) "beginning at age 60, you should have a colonoscopy" 3) "you should have a fecal occult blood test every year" 4) "the recommendation is to have a sigmoidoscopy every 10 years" CORRECT: 3) "you should have a fecal occult blood test every year" 1) blood tests do not detect colorectal cancer. one option for screening is a double-contrast barium enema every 5yrs 2) colorectal cancer screening for clients who are at average risk begins at age 50. one option for screening is a colonoscopy every 10 yrs. 3) one option for screening is a fecal occult blood test annually 4) one option for screening is a flexible sigmoidoscopy every 5yrs
a nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks "what would happen if I arrived at the emergency department and I had difficulty breathing?" which of the following responses should the nurse make?
1) "we would consult the person appointed by your health care proxy to make decisions" 2) "we would give you oxygen through a tube in your nose" 3) "you would be unable to change your previous wishes about your care" 4) "we would insert a breathing tube while we evaluate your condition" CORRECT: 2) "we would give you oxygen through a tube in your nose" 1) staff must honor the clients wishes as stated in their living will 2) oxygen can provide comfort and is not considered a resuscitative measure when nurse delivers it via nasal cannula 3) clients determine advance directives ahead of time to guide decision making at the time of emergency. if the client initiates a change the staff must honor it 4) intubation is a resuscitative measure
a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include?
1) "you should have an eye examination every 2 years" 2) "you should receive a tetanus booster every 5 years" 3) "you should receive a shingles vaccine when you are 70 years old" 4) "you should receive a pneumococcal vaccine when you are 65 years old" CORRECT: 4) "you should receive a pneumococcal vaccine when you are 65 years old" 1) older adults should have an eye examination every year 2) older adults should receive a tetanus booster every 10 years 3) they should receive a shingles vaccine when they are 60 years old 4) older adults should receive one of the two vaccines when they are 65 years old
a nurse is caring for a group of clients on a medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?
1) a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively 2) a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the clients wishes 3) a client who has do not resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the clients family 4) a client who is about to undergo a painful procedure receives pain medication 30 mins before the procedure that the nurse previously promised to administer CORRECT: 1) a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse respinds affirmatively 1) following the ethical principle of veracity, the nurse must tell the truth at all times and not deceive others 2) ethical principle of autonomy, clients right to refuse treatment 3) follows client end of life wishes under ethical principle of autonomy 4) ethical principle of fidelity, which means keeping promises
a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. which of the following actions should the nurse take?
1) assist the client into a prone position 2) place a sleeve over the top of each leg with the opening at the knee 3) make sure two fingers can fit under the sleeves 4) set the ankle pressure at 65 mm Hg CORRECT: 3) make sure two fingers can fit under the sleeves 1) nurse should place client in a dorsal recumbent or semi-fowlers position to facilitate application of the sleeves 2) nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg to secure it 3) nurse should ensure that there is enough space because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate 4) nurse should set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the clients skin and circulation
a nurse is caring for a client who has herpes zosters and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that this condition is a contraindication for which of the following therapies?
1) biofeedback 2) aloe 3) feverfew 4) acupuncture CORRECT: 4) acupuncture 1) biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many others 2) aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects 3) feverfew is a complementary and alternative therapy that helps promote wound healing. anticoagulant therapy is a contraindication for taking feverfew 4) nurse should inform client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. an open portal on the skins surface can increase the risk for further infection
A nurse is providing discharge teaching for a client who has a new prescription for home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
1) check the cord routinely for frays or tearing 2) keep the unit at least 1.2 m (4 feet) away from a gas stove 3) consider purchasing a generator for backup 4) observe for signs of hypoxia 5) select synthetic clothing and bedding CORRECT: 1) check the cord routinely for frays or tearing, 3) consider purchasing a generator for backup 4) observe for signs of hypoxia 1) oxygen concentrators require electrical power. Safe use of this system requires assessing the electrical function of the device 2) at least 2.4 m (8 feet) away from a gas stove 3) loss of energy prevents the concentrator from functioning and could deprive the client of necessary oxygen 4) signs include anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis 5) using clothing and bedding that does not generate static electricity
a nurse is admitting a client who is having an exacerbation of heart failure. in planning this clients care, when should the nurse initiate discharge planning?
1) during the admission process 2) as soon as the clients condition is stable 3) during the initial team conference 4) after consulting with the clients family CORRECT: 1) during the admission process 1) discharge planning should begin as soon as the client is undergoing the admission process 2) until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the clients physiological stability 3) team conferences facilitate discharge planning, but they are not essential for initiating the planning process 4) the nurse should only consult with the clients family if the client gives the nurse permission to share that information
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?
1) insert the catheter at a 45 degree angle 2) place the clients arm in a dependent position 3) shave excess hair from the insertion site 4) initiate IV therapy in the veins of the hand CORRECT: 2) place the clients arm in a dependent position 1) generally the nurse should insert at a 10 to 30 degree angle but for older adults an angle of 10 to 15 degrees is preferable because veins are closer to the skin surface as aging diminishes SQ tissue 2) nurse should place the clients arm in a dependent position because veins will dilate due to gravity 3) nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection 4) nurse should avoid using the fragile veins of an older adults hands because the loss of SQ tissue can allow those veins to roll away from the needle. also having the IV in the hand can interfere with the clients performance and ADLs
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 this client?
1) insert the suction catheter while the client is swallowing 2) apply intermittent suction when withdrawing the catheter 3) place the catheter in a location that is clean and dry for later use 4) hold the suction catheter with her clean, nondominant hand CORRECT: 2) apply intermittent suction when withdrawing the catheter 1) nurse should insert the suction catheter while the client is inhaling to avoid insertion into the esophagus 2) intermittent suction should be applied during the withdrawal of the catheter to prevent injury to the mucosa. suctioning continuously for more than 10secs can cause cardiopulmonary compromise 3) nurse should discard the catheter after use to eliminate the risk of reintroducing pathogens into the resp. tract 4) nurse should hold the suction catheter with her dominant hand after donning a sterile gloves
a nurse is assessing an older adult clients risk for falls. which of the following assessments should the nurse use to identify the clients safety needs?
1) lacrimal apparatus 2) pupil clarity 3) appearance of bulbar conjunctivae 4) visual fields 5) visual acuity CORRECT: 2) pupil clarity, 4) visual fields, 5) visual acuity 1) if the client has an impairment in the ability to produce tears. should not affect fall risk 2) cloudy pupils mean that the client has cataracts. this makes vision cloudy and creates halos around lights 3) will not impair clients safety 4) nurse should test peripheral field. clients with a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision 5) nurse should use a Snellen chart to assess distance vision. clients who wear eyeglasses should wear them during the assessments. increased risk for falls because they might not see objects
a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?
1) neck vein distention 2) urine specific gravity 1.010 3) rapid heart rate 4) blood pressure 144/82 mm Hg CORRECT: 3) rapid heart rate 1) clinical manifestation of fluid volume excess 2) typically clients urine specific gravity is greater than 1.030 in the presence of fluid volume deficit. reference range is 1.005-1.030 3) tachycardia indicates fluid volume deficit and is also an expected finding for vomiting and diarrhea for 3 days 4) hypotension is an expected finding for fluid volume deficit
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
1) place the client in a room with negative pressure airflow 2) wear gloves when assisting the client with oral care 3) limit each visitor to only 2hr incremental 4) wear a surgical mask when providing client care 5) use antimicrobial sanitizer for hand hygiene CORRECT: 1) place the client in a room with negative pressure airflow, 2) wear gloves when assisting the client with oral care, 5) use antimicrobial sanitizer for hand hygiene 1) airborne precautions 2) standard precautions 3) does not need to limit visitors time only patients time outside of room 4) should wear n95 mask 5) routine hand hygiene
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
1) position the client with head of the bed elevated to 30 degree prior to insertion of the NG tube 2) remove the NG tube if the client begins to gag or choke 3) apply suction to the NG tube prior to insertion 4) have the client take sips of water to promote insertion of the NG tube into the esophagus CORRECT: 4) have the client take sips of water to promote insertion of the NG tube into the esophagus 1) client should be sitting in high-fowlers position with head of bed elevated to 90 degrees to reduce risk for aspiration 2) nurse should withdraw the NG tube slightly, not removing it, if the client gags or chokes to reduce the risk of injury 3) nurse should not apply suction until the NG tube is in place with x-ray verification of its position 4) taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea
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?
1) protective equipment 2) airborne precautions 3) droplet precautions 4) contact precautions CORRECT: 4) contact precautions 1) clients with a compromised immune system require protective equipment 2) airborne precautions are required for clients who have infections via droplet nuclei smaller than 5 microns in diameter, including tuberculosis and measles 3) airborne precautions are required for clients who have infections via droplet nuclei larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis 4) major wound infections require contact precautions which means the client should be in a private room and all caregivers should wear a gown and gloves
a nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take first?
1) rock the client up to a standing position 2) pivot on the foot that is the farthest from the chair 3) assess the client for orthostatic hypotension 4) apply a gait belt to the client CORRECT: 3) assess the client for orthostatic hypotension 1) nurse should rock client to standing position to generate momentum and reduce the nurses workload in lifting the client up off the bed 2) nurse should pivot on foot farthest from the chair to give the client room to move. however something comes first 3) first action the nurse should take when using the nursing process is to assess the client. nurse should determine the clients risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. assess for dizziness and significant drop in BP before assisting to stand 4) nurse should use a gait belt to help maintain the clients stability
a nurse is caring for a client who has an indwelling urinary catheter. which of the following findings indicates that the catheter requires irrigation?
1) urine has unusual odor 2) urine specific gravity is 1.035 3) bladder scan shows 525 mL of urine 4) urine is positive for ketones CORRECT: 3) bladder scan shows mL of urine 1) can be a sign of infection 2) indicates that urine is concentrated 3) client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore the nurse should irrigate the catheter to resolve any existing blockage 4) sign of DM with poor glucose control
