Fundamentals ATI Practice B

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? a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes c. a client who has a DNR order has a cardiac arrest, and the nurse does not perfrom CPR despite requests from the client's family d. a client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer

a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic

a. ambulating a client who is postop

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as priority? a. auscultate lung sounds b. measure urine output c. monitor blood pressure readings d. monitor electrolyte levels

a. auscultate lung sounds

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment

a. droplet

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day

a. erythema on pressure points

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it

a. gently shake the container of medication prior to administration

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bicycle c. performing isometric exercise d. engaging in high-impact aerobics

a. walking briskly

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside

a. wrap blankets around all 4 sides of the bed

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? a."I can take echinacea to improve my immune system" b. "I can take feverfew to reduce my level of anxiety" c. "I can take ginger to improve my memory" d. "I can take ginkgo biloba to relieve nausea"

a."I can take echinacea to improve my immune system"

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. "drink a cup of hot cocoa before bedtime" b. "maintain a consistent time to wake up each day" c. "exercise 1 hour before going to bed" d. "watch a television program in bed before going to sleep"

b. "maintain a consistent time to wake up each day"

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain" b. "the pain is like a dull ache in my stomach" c. "I notice that the pain gets worse after I eat" d. "the pain makes me feel nauseous"

b. "the pain is like a dull ache in my stomach"

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg

b. 0.3 mg

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap

b. N95 respirator

A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week

b. a client who smokes one pack of cigarettes each day

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol

b. tell the client to keep the head of the bed elevated at least 30 degrees

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the client's family to intervene

b. withhold the blood transfusion

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. describe the procedure to the client b. witness the client's signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure

b. witness the client's signature on the consent form

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. ensure sterilization of non-disposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place c. cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. wear hypoallergenic latex gloves that contain powder.

b. wrap monitoring cords with stockinette and tape them in place

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 subcutaneously. Determine the correct order of the steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

c,a,d,b

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 routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "beginning at age 60, you should have a colonoscopy" c. " you should have a fecal occult blood test every year" d. "the recommendation is to have a sigmoidoscopy every 10 years'

c. " you should have a fecal occult blood test every year"

A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly"

c. "I flushed what I urinated at 7 am and have saved all urine since"

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on the floor" d. "client was trying to get out of bed"

c. "client found lying on the floor"

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea

c. 8 oz of ice chips

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 next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply gait belt to the client

c. assess the client for orthostatic hypotension

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? a. urine has an unusual odor b. urine specific gravity is 1.035 c. bladder scan shows 525 mL of urine d. urine is positive for ketones

c. bladder scan shows 525 mL of urine

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound.

c. cleanse the wound from the center outward

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports

c. current medications

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore

c. evacuate the client

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? a. touch the face with a cotton ball b. apply vibrating tuning fork to the client's forehead c. have the client stand with their arms at their sides and their feet together d. perform direct percussion over the area of the kidneys

c. have the client stand with their arms at their sides and their feet together

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? a. medication name b. route of administration c. medication dose d. frequency of administration

c. medication dose

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? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg

c. rapid heart rate

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? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years"

d. "You should receive a pneumococcal immunization every 10 years"

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? a. "most people are happy when their children grow up and leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma

d. a client who has asthma

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. place a pillow under the client's knees b. position a trochanter toll under each of the client's hips c. advise the client to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the client's feet

d. apply an ankle-foot orthotic device to the client's feet

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. assign a staff member to feed the client b. provide small handled utensils for the client c. thicken liquids on the client's tray d. arrange food in a consistent pattern on the client's plate

d. arrange food in a consistent pattern on the client's plate

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins

d. distended neck veins

A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting

d. have family members wear a gown and gloves when visiting

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. insert an implanted port b. close a laceration with sutures c. place an endotracheal tube d. initiate an enteral feeding through a gastrostomy tube

d. initiate an enteral feeding through a gastrostomy tube

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions

d. practice sessions

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a. the caregiver is the client's financial power of attorney b. the client is in a wheelchair with the wheels locked c. the client reports receiving a full bath twice each week d. the caregiver insists on remaining in the room

d. the caregiver insists on remaining in the room

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene

a,b,e

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "what could i have done to deserve this illness?" b. "I blame medical science for not curing me" c. "where is my daughter at a time like this? d. "will i ever begin to feel in charge of my life again?"

a. "what could i have done to deserve this illness?"

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "when descending the stairs, I will first shift my weight to my right leg" b. "I should place my crutches 12 inches in front and to the side of each foot" c. "As I sit down, I will hold one crutch in each hand" d. "I will make sure the shoulder rests are snug against my armpits"

a. "when descending the stairs, I will first shift my weight to my right leg"

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 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number

8 mL/hr

The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? select all that apply. a. check the cord routinely for frays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generator for power backup d. observe for signs of hypoxia d. select synthetic clothing and bedding

a,c,d

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? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this with you?"

a. "we can talk about advance directives, and I can also give you some brochures about them"

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia(PCA) pump. Which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the client while she is asleep b. inform the client that because she is on PCA, vital signs will be taken every 8 hours c. teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 d. increase the basal rate and shorten the lock-out interval time if the client's pain level is too high

a. instruct the family to refrain from pushing the button for the client while she is asleep

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field b. the newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field c. the newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring d. the sterile field is positioned at the level of the newly licensed nurse's waist

a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b. a nurse asks a nurse from another unit to assist with documentation for a client c. a nurse who is caring for a client returns a call to a person appointed in the health care proxy to discuss the client's care d. a nurse discussed a client's status with the physical therapist who is caring for the client.

b. a nurse asks a nurse from another unit to assist with documentation for a client

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the client reports relief of nausea

b. an x-ray shows the end of the tube above the pylorus

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temperature d. diagnostic test results

b. breath sounds

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. use resuscitation bag with 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170 mmHg

b. select a suction catheter that is half the size of the lumen

A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. "this type of hearing aid does not allow for fine tuning of volume" b. "I shouldn't have trouble keeping the hearing aid in place during exercise c. "I expect to hear a whistling sound when I first insert the hearing aid" d. "I will be sure to remove my hearing aid before taking a shower"

d. "I will be sure to remove my hearing aid before taking a shower"

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? a. purulent exudate b. warmth c. skin blanching d. bleeding

c. skin blanching

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the client's ability to self-administer medications c. report an identified discrepancy to The Joint Commission. d. compare prescriptions with medications the client received while at the facility

d. compare prescriptions with medications the client received while at the facility

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15 mL of sterile water

d. flush the tube with 15 mL of sterile water

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. place the client in high-Fowler's position. b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position

d. have the client use a trapeze bar when changing position