Fundamentals ATI review

A nurse is preparing to insert an NG tube for a client. Which of the following actions would help facilitate the insertion of the tube? Select all that apply. a. coat the tip of the tube in a water soluble lubricant b. ask the client to swallow sips of water during insertion c. place the tip of the tube in ice chips before isnertion d. tell client to tilt head back during beginning of insertion e. instruct client to bear down

a, b, d

A nurse is preparing to administer a unit of packed rbcs to a client. Which of the following pieces of information should the nurse verify with another nurse prior to administration? select all that apply. a. client ID number b. client room number c. clients name d. ABO compatabilty e. rH compatability

a, c, d, e

A nurse is planning care for a client who is confused and requires a prescripton for restraints. which of the following interventions shoudl the nurse include in the plan of care? a. renew the prescription for the use of restrains within 24 hours b. secure the restraint with a buckle side next to the cleints skin c. ensure four fingers can fit under the secured restraint d. remove every 3 hours

a.

A nurse is reviewing a clients laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg and HCO3 24 mEq/ L. The client has which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic acidosis d. metabolic alkalosis

a.

A nurse is caring for a client with chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? a. regulation of acid-base balance b. reabsorption of nutrients for cellular growth c. regulation of body temp. d. secretion of hormones for growth

a. is the answer

A nurse is instructing a client about a 24 hour urine collection for creatinine clearance. whoch of the following statements shoudl the nurse identify as the clients understanding of the procedure? a. "the next time i urinate will be the first urine of the collection" b. "ill make sure to keep the collection bottle in the bucket of ice they gave me" c. "once the container is half full, i no longer have to add any more urine" d. "its okay if a piece of toilet paper gets in the bottle. the lab people will remove it when they do the test"

b.

A nurse is planning to adminster an IM injection to a client who is overweight. which of the following sites should the nurse select for injection? a. lower medial quadrant of the buttock near coccyx b. side hip between ililac crest and anterior iliac spine c. tissue of the posterior upper arm d. lower inner thigh 4 finger widths above patella

b.

A nurse is assessing a clients pH of gastric fluid to confirm the placement of an NG tube in the stomach. which of the following pH values shoudl the nurse expect? a. 6 b. 2 c. 10 d. 8

b. a pH of 0 to 4 is expected for gastric secretions

A nurse is caring for a client with a fever of 101.7 degrees F, Which of the following actions should the nurse take? a. apply ice packs to the groin b. keep bed linens dry c. apply an alcohol-water solution to the clients skin d. limit fluid intake to 1183 mL per day

b. is the answer

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? a. "now that we talked about your medications, lets talk about your pain" b. " are you having other symptoms" c. "it sounds like your pain is intermittent" d. "it seems as though you really have had a rough time these past weeks"

c

A nurse is caring for a client with an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? a. auscultate bowel sounds after each feeding b. ensure formula is cold before administration c. elevate head of bed to 45 degrees before the feeding d. flush the tubing with 15 mL of water after the enteral feeding

c.

A nurse is evaluating the devlopment of a group of clients. According to erikson, the devlopmental task of intimacy vs. isolation occurs during which of the follwing stages of devlopment? a. middle adulthood b. adolescence c. young adulthood d. childhood

c.

A nurse is planning to document care for a client. Which of the following abbreviations shoudl the nurse use? a. BT for bedtime b. SC for subcutaneous c. PC for after meals d. HS for half strength

c.

A nurse is caring for a client with fecal impaction. Before the digital removal of the mass, whoch of the following types of enemas shoudl the nurse expect to adminster to soften the stool first? a. carminative b. hypertonic c. oil retention d. sodium polystyrene sulfate

c. oil retention enemas make the digital removal less painful for the client

A client is being discharged home with oxygen therapy delivered via nasal cannula. Which of the following instructions shoudl the nurse provide to the client and family members? a. use battery operated equipment b. apply mineral oil to protect facial skin from irritation c. remove tv from client room d. wear cotton clothing to avoid static electricity

d.

A client who has glaucoma of the right eye self administers timolol eye drops by lookign at the ceiling, instilling a drop onto the center of the conjunctival sac and applying pressure onto the lower lid with a facial tissue. After observing this process, which of the following actions shoudl the nurse take? a. confirm the client performed the procedure correctly b. instruct the client to look down during instillation c. remind the client to avoid using a facial tissue after instillation d. instruct client to apply pressure to inside corner of eye after instillation

d.

A nurse in an emergency department is caring for a client who reports having severe right eye pain with a gritty sensation during sawing wood. Which of the following actions should the nurse take first ? a. instill proparacaine hydrochloride eye drops b. perform ocular irrigation of the right eye c. place client in a supine position with the head turned toward the affected side d. ask the client about first aid performed at the scene

d.

A nurse is caring for a client who requires a chest X ray. Prior to the cliet being transported to the x ray which of the following actions should the nurse take first? a. explain x-ray procedure to the client b. ask if the client has any qyestions c. help the client into a wheelchair before the transporter arrives d. identify the client with 2 identifiers

d.

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? a. hypothalumus b. cerebral cortex c. cerebellum d. brainstem

d.

A nurse is performing a mental status examination on a client who has manifestations of dementia. Which of the followign directions should the nurse give the client when evaluating the clients ability to think abstractly? a. subtract serially by 7s from 100 b. deescribe a previous illness c. explain what to do in the event of a fire in the clients bedroom d. discuss the meaning of a proverb

d.

Which of the following statements indicates an understanding of the education on sutures? a. i will use a staple remover and remove each staple individually b. bandage scissors are used to cut the sutures c. tweezers are necessary only for removing retention sutures d. i will clip each suture close to the skin and pull it through the other side

d.