ATI Funds Practice Test 4

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? Place them in order Apply a skin protectant or a barrier film to the skin around the wound Turn off the vacuum on the NPWT device and administer the prescribed analgesic Connect the tubing to the transparent film and turn on the NPWT unit Place prepared foam into the wound bed and cover with a transparent dressing Apply sterile or clean gloves and irrigate the wound Remove the soiled dressing and perform hand hygiene

1) Turn off the vacuum on the NPWT device and administer the prescribed analgesic 2)Remove the soiled dressing and perform hand hygiene 3)Apply sterile or clean gloves and irrigate the wound 4)Apply a skin protectant or a barrier film to the skin around the wound 5)Place prepared foam into the wound bed and cover with a transparent dressing 6)Connect the tubing to the transparent film and turn on the NPWT unit

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? Fat Protein Starch Fiber

Starch (Salivary amylase begins digests the initial breakdown of starches--> the majority of starch breakdown occurs in the small intestine with pancreatic amylase INCORRECT: Lipase breaks down fats Pepsin breaks down proteins Fiber is not digestible

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? "Bear down" "Perform Kegel exercises" "Hold your breath" "Raise your head off the pillow"

"Bear down"

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Support the majority of your weight on the axillae" "Keep your elbows extended" "Bear weight on both on both of your legs" "Move both crutches forward at the same time"

"Bear weight on both on both of your legs" (client should keep 3 points on the ground at all times--> must be able to bear weight on both legs)

A nurse is performing a physical exam for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? Percussion Auscultation Inspection Palpation

Palpation

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states, "clear liquids; advance diet as tolerated". Which of the following responses should the nurse make? "Lunch trays should be here within the hour" "I am going to listen to your abdomen" "Ill get you some water to drink" "Let's wait a bit so you don't feel sick"

"I am going to listen to your abdomen" (to determine the presence of bowel signs before clear liquids can be administered)

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? "I am in no hurry to get married. I think ill enjoy being single for a while" "I go on the weekends to be with my family because I do not have any good friends here on campus" "I am interested in politics and may consider becoming an elected official" "I am looking forward to finishing school and going to work for my family's business"

"I go on the weekends to be with my family because I do not have any good friends here on campus"

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching "Ill wear nonsterile gloves" "Ill use adhesive remover each time" "Ill take my pain pill after I change the dressing" 'Ill fold the dressing with the soiled surface facing outward"

"Ill wear nonsterile gloves"

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include? A 2 month old infant can turn from his abdomen to his back A 10 month old infant can pull up to a standing position A 4 month old infant can sit up without support A 6 month old infant can crawl on his hands and knees

A 10 month old infant can pull up to a standing position

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 see first? 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 A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage 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

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage (ostomy bag full of blood means the clients bowel is hemorrhaging and to report it ASAP)

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? Clean the incision from bottom to top Apply sterile gloves prior to opening dressing packages Remove the tape by pulling away from the wound Clean the drain site from the center outward

Clean the drain site from the center outward (to avoid introducing microorganisms from the periphery of the wound into the center of the wound)

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following 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 Air conduction is greater than bone conduction in the left ear Sound is lateralizing to the right ear Sound is lateralizing to the left ear

Air conduction is less than bone conduction in the left ear (indicates hearing loss in the LEFT ear) INCORRECT: C,D results of the Weber test

A nurse is admitting a client who has TB. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? Protective Airborne Droplet Contact

Airborne (ex. measles/varicella)

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation Keep detailed records of each client's progress Test client learning after each teaching session Avoid discussing topics that might increase client's anxiety

Attempt to increase the client's self-motivation

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? Swallow water Prepare for a painful sensation Hold her breath Bear down gently

Bear down gently

A nurse is caring for a client who has stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? Obtain the prescribed irrigation solution Don personal protective equipment Check the client's pain level Place a waterproof pad under the client's extremity

Check the client's pain level

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? Select a 23-gauge needle Insert the needle into the skin at a 25 degree angle Massage the area of injection following removal of the needle Circle the injection area with a pen

Circle the injection area with a pen (ensures the nurse will examine the correct site when reading the test 48-72 hours later)

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? Select all that apply Coat the tip of the tube with a water-soluble lubricant Ask the client to swallow water while the tube enters her throat Place the coiled tube in ice chips prior to insertion Tell the client to tilt her head backwards as insertion begins Instruct the client to bear down during insertion

Coat the tip of the tube with a water-soluble lubricant Ask the client to swallow water while the tube enters her throat Tell the client to tilt her head backwards as insertion begins

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following disorders? Retinopathy Glaucoma Cataracts Macular degeneration

Glaucoma

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? Diarrhea Pupillary constriction Flushing Grimacing

Grimacing

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? Increased intestinal motility Respiratory alkalosis Decreased cardiac output Hypocalcemia

Decreased cardiac output (During immobility, the client's heart rate increases to compensate for increased venous pooling. The reduction in circulating volume increases the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output)

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse in take in response to this finding? Obtain an audiology referral Document this as an expected finding Irrigate the ear with warm water Document mild inflammation

Document this as an expected finding (the light reflects off the tympanic membrane--> right ear= right lower quadrant of the eardrum left ear= left lower quadrant of the eardrum

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? Tenderness when touched Pink, shiny tissue with a granular appearance Seosanguineous drainage Halo of erythema on the surrounding skin

Halo of erythema on the surrounding skin (should report to the provider when there is a ring of erythema (redness) on the surround skin)

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? Place the soiled linens on the chair while making the bed Hold the linens away from the body and clothing Place the linens on the floor until a linen bag is available Shake the clean linens to unfold

Hold the linens away from the body and clothing

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food". Which of the following findings indicates the toddler has an airway obstruction? Flushing of the skin Inability to cry or speak Presence of nausea and mild emesis Capillary refill time of 1.5 sec

Inability to cry or speak

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? Lubricate up to 3.2 cm(1.25 in) of the tip of the rectal tube Position the client on the right side Insert the tip of the tubing 8cm (3.1in) Hold the enema container 61cm (24in) above the rectum

Insert the tip of the tubing 8cm (3.1in) (7-10 cm or 3-4 in)

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? Maintain suction while removing the NG tube Instill 100mL of air into the NG tube before removal Pinch the NG tube while removing the tube Instruct the client to breathe in and out during the removal of the NG tube

Pinch the NG tube while removing the tube (to decrease the rick of aspiration of any gastric contents) INCORRECT: Maintain suction while removing the NG tube (the nurse should disconnect the NG tube from the suction apparatus before removal) Instill 100mL of air into the NG tube before removal (50 ml) Instruct the client to breathe in and out during the removal of the NG tube (hold their breathe during removal)

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? Gustation Stereognosis Proprioception Kinesthesia

Stereognosis (ability to identify objects via tactile sensation) INCORRECT: Gustation= ability to taste Proprioception= awareness of the position of the body Kinesthesia= ability to sense the position w/o visualizing them

A nurse on. a med-surg unit is caring for a client who is a risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?\ Suction equipment Clean gloves Blankets Oxygen

Suction equipment (to reduce the risk of aspiration)

A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? Discourage the use of unregulated medications and supplements Verify the herbal supplements do not interact with medications the provider has prescribed Tell the client to limit the number of herbal supplements to no more than 2 Describe the dangers of taking plant-derived medications and supplements

Verify the herbal supplements do not interact with medications the provider has prescribed

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? Smear the small amount of blood onto the testing strip Hold the finger above heart level Massage the client's fingertip Wrap the client's finger in a warm washcloth

Wrap the client's finger in a warm washcloth

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? Close the fire doors on the unit Use a fire extinguisher on the fire Pull the nearest fire alarm Evacuate clients from the unit

Evacuate clients from the unit (apply the safety and risk-reduction-priority setting framework)

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making whistling sounds. The nurse should identify which of the following factors as the source for this sound? Low battery power Excessive wax in the ear canal A volume setting that is too low A crack in the ear tube

Excessive wax in the ear canal

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP) Provide oral care to a client who cannot take oral fluids Check a client's IV insertion site for manifestations of infiltration Assess a client's ability to ambulate Demonstrate the use of a glucometer to a client who has diabetes mellitus

Provide oral care to a client who cannot take oral fluids (within the range of function)

A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? The client holds the hand with the palm up The client holds the hand with the palm down The client points the fingers toward the floor The client points the fingers toward the ceiling

The client holds the hand with the palm up

A nurse is caring for a client who just received a diagnosis of cancer. The client states, 'I just dont know what i am going to do now". Which of the following responses should the nurse make? "In time you will now the right thing to do" "I am sorry. Would you like me to call someone for you?" "There are multiple treatment options for you to consider" "Can you explain the concerns you're having right now?"

"Can you explain the concerns you're having right now?"

A nurse is instructing a client about collecting a 24 hour urine specimen for creatine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? "The next time I urinate will be the first specimen of the collection" "Ill make sure to keep the collection bottle in the container of ice they gave me" "Once the container is half full, I no longer have to add any more urine" "Its ok if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test"

"Ill make sure to keep the collection bottle in the container of ice they gave me" (must be remained chilled to prevent change in the composition)

A nurse in an urgent-care center is caring for a 15 year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? Explain that the treatment can wait until the parent is available Inform the grandmother that she may give consent for the treatment Invoke the principle of implied consent and prepare the client for treatment Ask the adolescent to sign the consent form

Ask the adolescent to sign the consent form

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? Change the colostomy bag following breakfast Cleanse the skin around the stoma with warm water Change the pouch every day Place an aspirin in the ostomy pouch to decrease odor

Cleanse the skin around the stoma with warm water (no soap) INCORRECT: Change the colostomy bag following breakfast --> change BEFORE a meal Change the pouch every day--> change every 3-7 days

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? Renew the prescription for the use of restraints within 24 hours Secure the restraint with the buckle side next to the client's skin Ensure 4 fingers can be inserted under the secured restraint Remove the restraint every 3 hours

Renew the prescription for the use of restraints within 24 hours

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Place the client supine Keep both side rails up Raise the level of the bed Inspect the client's mouth using a finger sweep

Raise the level of the bed

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? Allow minimal treatment Benefits the client's family Offers hope for a cure Supports self-determination

Supports self-determination (honor client autonomy)

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temp of 39.2C (102.6F), a heart rate of 105/min, a soft nontender abdomen, menses overdue by 2 days. Which of the following findings should be the nurse's priority? Heart rate of 105/min Soft nontender abdomen Temperature Overdue menses

Temperature (Maslow's Hierarchy of Needs)

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? "When you go up a flight of stairs, place your right foot on the first step" "Keep the rubber crutch tips securely in place" "When standing, keep the crutches 12in in front of you and 12in to the side" "Place your weight on the crutch pads at your armpits"

"Keep the rubber crutch tips securely in place"

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child?

2 tsp 5mL/1 tsp= 10 mL/Xtsp 5X=10 X=2

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many millimeters of water should the nurse document as intake for the 3 separate medications the client receives during 12 hr shift?

90 1oz/30ml= 3oz/X ml x=90

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? Hypothalamus Cerebral cortex Brainstem Cerebellum

Brainstem (difficulty breathing= injury to the medulla and pons of the brainstem) INCORRECT: Hypothalamus= sleeping Cerebral cortex= expression Cerebellum= balance

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure? Make eye contact with the interpreter Break sentences into shorter segment to allow time for interpretation Ensure the interpreter and the client speak the same dialect Speak in a loud tone of voice

Ensure the interpreter and the client speak the same dialect

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure Use the thumb and index finger to keep the client's mouth open Rinse the client's mouth with an alcohol-based mouthwash following the procedure Cleanse the client's mucous membranes with lemon-glycerin sponges

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 has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? Suggest the client talk with someone who has survived breast cancer Encourage the client to not give up Support the client's decision Refer the client to a counselor

Support the client's decision