ATI Fundamentals

a nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue which of the following cranial nerves is the nurse testing? a. cranial nerve XII b. cranial nerve X c. cranial nerve VIII d. cranial nerve V

A X by asking the client to vocalize VIII by using the Rinne and Weber tests and asking the client if he can hear a whisper V by asking the client to clench his teeth and palpating the masseter muscles for contraction

a nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are post op. which of the following should the nurse see first? a. one day post op following a lobectomy for small cell carcinoma and has a chest tube with 35 ml/hr of bright red bloody drainage b. a client who is two days post op following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drianage c. a client who is 2 days post op following the excision of an abdominal mass and has a portable wound suction device with 20 ml/hr of serosanguineous drainage d. a client who is one day post op following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 ml/hr reddish pink urine

B

A nurse is determining a client's risk of developing osteoporosis. the nurse should identify which of the following as risk factors for bone loss? a. small body frame b. hypertension c. african american ethnicity d. low vitamin D intake e. smoking

a, d, and e

a nurse is admitting a client who has measles. which of the following types of transmission precautions should the nurse take? a. airborne b. droplet c. contact d. protective environment

a. airborne

A nurse is reviewing the medical record of an older adult client. for which of the following medications should the nurse conduct a hearing assessment of the client? a. omeprazole b. ferrous sulfate c. digoxin d. furosemide

d- can cause ototoxicity, especially in an older adult client, due to a decrease in medication metabolism in the kidneys monitor omeprazole for bone loss ferrous sulfate for GI effects, such as bloating or changes in elimination digoxin for hypokalemia such as muscle weakness

A nurse is assessing a client's thyroid gland, which of the following instructions should the nurse give the client before inspecting and palpating this gland? a. tilt your high slightly forward b. keep your head straight and look ahead of you c. tilt your head back and swallow d. turn your head to the side against my hand

C

A nurse is providing teaching to an older adult client who has constipation. which of the following should the nurse include in the teaching? a. drink a minimum of 1000 ml of fluid daily b. increase your intake of refined fiber foods c. sit on the toilet 30 minutes after eating a meal d. take a laxative everyday to maintain regularity

C consume a minimum of 1500 ml of fluid to prevent constipation increase consumption of course fiber and whole grains, rather than refined fiber foods

a nurse is assessing a client who has guillain barre syndrome. which of the following findings should the nurse expect? a. tonic clonic seizures b. report of a severe headache c. weakness of the lower extremity d. decreased LOC

C- inflammatory disorder of the peripheral nerves

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? a. gustation b. stereognosis c. proprioception d. kinesthesia

B. Gustation is the ability to taste proprioception is the awareness of the position of the body kinesthesia is the ability to sense the position and movement of body parts without visualizing them

A nurse is obtaining the blood pressure in a client's lower extremity. which of the following actions should the nurse take? a. auscultate the BP at the dorsalis pedis artery b. measure the BP when the client is sitting on the side of the bed c. place the cuff 7.6 cm above the popliteal artery d. place the bladder of the cuff over the posterior aspect of the thigh

D the nurse should auscultate the BP at the popliteal artery the nurse should measure the BP when the client is prone the nurse should position the cuff 2.5 cm above the politeal artery

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor of the eye. this manifestation is consistent with which of the following eye disorders? a. retinopathy b. glaucoma c. cataracts d. macular degeneration

b manifestations of retinopathy include changes in the blood vessels of the retina that can leads to blindness manifestations of cataracts include an increase in the opacity of the lens, blocking rays of light from entering the eye manifestations of macular degeneration include changes in sharp and central vision and are often associated with aging

A nurse is developing a plan of care for a client after a recent stroke who has a history of GERD. for which of the following disorders should the nurse plan to monitor to this client? a. duodenal ulcer disease b. aspiration pneumonia c. viral pneumonia d. esophageal varices

b- GERD results in reflux of gastric secretions from the stomach into the lower esophagus. when regurgitation occurs, the client is at high risk for pneumonia. pneumonia occurs due to aspiration of gastric contents into the airway

A nurse is preparing to insert an indwelling urinary catheter for a male client. which of the following locations should the nurse secure the urinary catheter tubing? a. lateral thigh b. lower abdomen c. mid abdominal region d. medial thigh

b- this location will decrease tension and trauma to the urethra

a nurse is caring a client who has xerostomia with a lack of saliva. which of the following nutrients will be affected by the lack of salivary amylase? a. fat b. protein c. starch d. fiber

c

which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. people who practice the islamic faith pray over the deceased for a period of 5 days before burial b. people who practice the hindu faith bury the deceased with their head facing north c. people who practice judaism stay with the body of the deceased until burial d. people who are practicing the buddhist faith have the female family members prepare the body following death

c

A nurse is caring for a client who requires a peripheral IV insertion. when choosing the site, which of the following sites should the nurse select? a. a vein in the clients dominant arm b. the most proximal vein in the exrremitiy c. a vein that is soft on palpation d. a site distal to previous venipuncture attempts

c the nurse should select a vein that is distal to areas where the tip of the catheter will not be at a point of flexion avoid a site that is distal to previous venipuncture attempt or site. these areas often cause infiltration around a newly placed IV site

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. which of the following client statements indicates an understanding of the teaching? a. i should rinse my mouth out right before i use the inhaler b. after this first puff i will wait 10 seconds before taking the second puff c. i will shake the inhaler well right before i use it d. i will tilt my head forward while inhaling the medication

c.