ATI Fundamentals A

A nurse is caring for a client who has COPD. Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Vital Signs 1000: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/min Respirations 32/min Oxygen saturation 85% on room air Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia Select the 3 findings that require follow-up. A. Breath sounds B. Blood pressure C. Oxygen saturation D. Temperature E. Heart rate

A. Breath sounds C. Oxygen saturation E. Heart rate

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? A. Examine personal values about the issue. B. Tell the parents that this is a necessary procedure. C. Inform the parents that the staff does not require their consent. D. Contact a spiritual support person to explain the importance of the procedure.

A. Examine personal values about the issue.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. Pad the client's wrist before applying the restraints. B. Evaluate the client's circulation every 3 hr after application. C. Remove the restraints every 4 hr to evaluate the client's status, D. Secure the restraint ties to the bed's side rails.

A. Pad the client's wrist before applying the restraints.

A nurse is talking with the partner of a client who has dementia. The client's 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. A. Role ambiguity B. Sick role C. Role overload D. Role conflict

C. role overload

A nurse is using an open irrigation technique to irrigate a client's indexing urinary catheter . Which of the following actions should the nurse take ? a . Place the client in a side - lying position b . Instill 15 mL of irrigation fluid into the catheter with each flush c . Subtract the amount of irrigate used from the client's urine output d . Perform the irrigation using a 20 - mL syringe

c . Subtract the amount of irrigate used from the client's urine output

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Obtain the pronouncement of death from the provider 2. Removes tubes and indwelling lines 3. Wash the client's body 4. Place a name tag on the body 5. Ask the client's family if they would like to view the body

1, 2, 3, 5, 4

A nurse is caring for a client who has pneumonia. Vital Signs 0800: Heart rate 109/min Respirations 26/min BP 125/65 mm Hg Temperature 39.2° C (102.6° F) Oxygen saturation 95% 1200: Heart rate 94/min Respirations 18/min BP 115/65 mm Hg Temperature 37.8° C, (100° F) Oxygen saturation 96% Medication Administration Record • 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) • Codeine 20 mg PO every 4 hr PRN cough Nurses' Notes Select... Select 0800: • Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. • Tachycardia. All pulses palpable. Reports chest discomfort with coughing. • Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on 02 2 L via nasal cannula. • Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. • Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. • IV infusing to right arm, no noted redness or irritation at site. • Acetaminophen administered for temperature. 1200: • States feeling better following administration of acetaminoonen. • Vancomycin infusion started. • Client voices no discomfort at this time 1300 Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified. Complete the following sentence by using the list of options. The nurse should identify that the client might be experiencing __1__ as evidence by the client's __2__ 1- A. UTI B. seizures C. Extravasation 2- A. urine appearance B. IV catheter site C. Temperature

1- C. Extravasation 2- A. Urine Appearance

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

107 mL / hr

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 ml of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication. C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

A. Ask another nurse to observe the medication wastage

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 me/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEg/L D. Potassium 5.4 mEg/L

A. BUN 15 me/dL

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. Advocacy ensures clients' safety, health, and rights. B. Advocacy ensures that nurses are able to explain their own actions. C. Advocacy ensures that nurses follow through on their promises to clients. D. Advocacy ensures fairness in client care delivery and use of resources.

A. advocacy ensures clients' safety, health and rights

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. D. Palpate the client's abdomen before auscultating bowel sounds.

B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm

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? A. Insert the catheter at a 45º angle B. Place the client's arm in a dependent position C. Shave excess hair from the insertion site D. Initiate IV therapy in the veins of the hand

B. Place the clients arm in a dependent position

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer. B. Focus teaching on what the client will need to do in the future to manage his illness. C. Provide the client with written information about the phases of loss and grief. D. Reassure the client that this is an expected response to grief.

D) Reassure the client that this is an expected response to grief.

A nurse is caring for a client who has herpes zoster 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? A. Biofeedback B. Aloe C. Feverfew D. Acupuncture

D. Acupuncture

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Bend at the waist. B. Keep his feet close together. C. Use his back muscles for lifting. D. Stand close to the cabinet when lifting it.

D. Stand close to the cabinet when lifting it.

A nurse is preparing to administer enoxaparin subcutaneously to a client . Which of the following actions should the nurse take ? a . Administer the medication with the needle at a 45 ° angle b . Administer the medication into the client's non dominant arm c . Pull the client's skin laterally downward prior to administration d . Massage the injection site after administration

a . Administer the medication with the needle at a 45 ° angle

A nurse is providing discharge instructions to a client who will be using a walker . Which of the following client statements indicates an understanding of the teaching ? a . " I can place an extension cord across my living room to plug in my television " b . " I will hire someone to trim the tree that hangs low over the stairs of my front porch c . " I will place my alarm clock on my bedroom dresser across the room " d . " I will replace the old throne rug in the kitchen with a new one "

b . " I will hire someone to trim the tree that hangs low over the stairs of my front porch

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery . Which of the following actions is the nurse's priority ? a . Request that a respiratory therapist discuss the technique for incentive spirometry with the client b . Determine the reasons why the client is refusing to use the incentive spirometer c . Document the client's refusal to participate in health restorative activities d . Administer a pain medication to the client

b . Determine the reasons why the client is refusing to use the incentive spirometer .

activities A nurse is preparing a change - of - shift report . Which of the following tools or documents should the nurse use to communicate continuity of care ? a . Critical pathway b . Situation , background , assessment , and recommendation ( SBAR ) c . Transfer report d . Medication administration record ( MAR )

b . Situation , background , assessment , and recommendation ( SBAR )

A nurse is caring for a client who has an aggressive form of prostate cancer . The provider briefly discusses treatment options and leaves the client's room . When the nurse asks if the client would like to discuss any concerns , the client declines . Which of the following statements should the nurse make ? a . " I will return shortly after I document this in your record " b . " Most men live a long time with prostate cancer c . " I am available to talk if you change your mind " d . I will make a referral to a cancer support group for you "

c . " I am available to talk if you change your mind "

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family

A. During the admission process

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. I dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply A. Stop the infusion B. Elevate the client's left arm C. Apply heat to the client's left hand D. Place a dressing over the IV site E. Start a new IV in the client's left hand

A. Stop the IV infusion B. Elevate the client's left arm C. Apply heat to the client's left hand

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. Turn the client every 2 hr. B. Administer an antiemetic every 6 hr. C. Hold oral care. D. increase the room's temperature.

A. Turn the client every 2 hr

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. "They allow the court to overrule an adult client's refusal of medical treatment. B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness. C. "They permit a client to withhold medical information from health care personnel! D. "They allow health care personnel in the emergency department to stabilize a client's condition.

B. " They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse in an emergency department is caring for a client. Physical Examination 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria Plan: Admit for IV fluids. Vital Signs 1200: Temperature 38.4° C (101.1° F) Pulse rate 126/min Respirations 28/min BP 92/54 mm Hg Oxygen saturation 93% Nurses' Notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation. Medication Administration Record Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr Promethazine 25 mg IV bolus every 4 to 6 hr PRN nausea and vomiting Diphenoxylate 5 mg PO four times daily Acetaminophen 625 mg PO every 6 hr PRN temperature greater than 38.6° C (101.5° F) Complete the following sentence by using the list of options The nurse should first ____1____ followed by ____2____ 1 A. Review medications that might be causing confusion B. Obtain a prescription from the provider for restraints C. Assess where the restraints will be placed on the client 2 A. Padding bony prominences under the restraints B. Monitoring the client in restraints every 2 hr C. Using other methods to keep the client safe

1- A. Review medications that might be causing confusion 2- C. Using other methods to keep client safe

A nurse is caring for a client who has a new diagnosis of seizure disorder Nurses Notes 0800: Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900: On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Medication Administration Record Carbamazepine ER 200 mg PO twice per day Lorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min Complete the following sentence by using the list of options The nurse should first address the client's __1__ followed by the client's __2__ 1- A. Blood pressure B. Physical safety C. Privacy 2- A. PRN medication B. Positioning C. Incontinence

1- C. Privacy 2- B. Positioning

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? A. "We would consult the person appointed by your health care proxy to make decisions. B. "We would give you oxygen through a tube in your nose." C. "You would be unable to change your previous wishes about your care." D. "We would insert a breathing tube while we evaluate your condition.

B. "we would give you oxygen through a tube in your nose"

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B. Droplet

A nurse in a provider's clinic is caring for a client who has diarrhea. Vital Signs Temperature 36.2° C (97.2° F) Pulse rate 116/min Respiratory rate 24/min BP 102/68 mm Hg Oxygen saturation 95% Weight 52.2 kg (115 Ib)Nurses' Notes 1000: • Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." • Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. • Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea. Physical Examination 1015: Oriented to person, place, and time; lethargic, reports neadache • Tachycardia, hypotension, thready pulse, dry mucous membranes. tenting present Respirations slightly labored, chest clear. • Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. A. Increase intake of high-calcium foods. B. Eat probiotic foods, such as yogurt. C. Avoid alcohol while experiencing diarrhea. D. Eat raw vegetables. E. Eat three large meals a day. F. Avoid caffeine while experiencing diarthea G. Drink hot liquids several times a day. H. Drink carbonated beverages to replace lost fluids. I. Follow a low-fiber diet.

B. Eat probiotic foods, such as yogurt. C. Avoid alcohol while experiencing diarrhea. F. Avoid caffeine while experiencing diarthea I. Follow a low-fiber diet.

A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least six air exchanges per hour. B. Make sure the client wears a mask when outside her room if there is construction in the area C. Place the client in a private room with negative-pressure airfow. D. Wear an N95 respirator when giving the client direct care.

B. Make sure the client wears a mask when outside her room if there is construction in the area

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity

B. Pupil clarity D. Visual fields E. Visual acuity

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? A. The client uses a wool blanket on their bed. B. The client identifies the location of a fire extinguisher. C. The client stores an extra oxygen tank on its side under their bed. D. The client has a weekly inspection checklist for oxygen equipment.

B. The client identifies the location of a fire extinguisher.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning. B. Use tracheostomy covers when outdoors. C. Use sterile technique when performing tracheostomy care at home. D. Cleanse irritated skin with full-strength hydrogen peroxide.

B. Use tracheostomy covers when outdoors.

A nurse in a provider's clinic is caring for a client who has heart failure. Nurses' Notes First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle. changes for heart fallure, Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide. Vital Signs First Clinic Visit: Temperature 36.7° C (98° F) Heart rate 106/min Respirations 26/min BP 162/88 mm Hg Oxygen saturation 93% on room air Weight 83.9 kg (185 lb) Second Clinic Visit: Temperature 36.7° C (98° F) Heart rate 86/min Respirations 22/min BP 142/78 mm Hg Oxygen saturation 94% on room air Weight 81.6 kg (180 Ib) A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? A. 'I have been weighing myself every other morning." B. 'I am trying to decrease my intake of foods with potassium." C. "I am limiting my sodium intake to 2 grams daily.' D. 'I am eating fewer potato chips and more fruit for snacks. E. "I lie down and rest after meals. F. " I know to call my doctor if I gain 3 pounds or more in 2 days."

C. "I am limiting my sodium intake to 2 grams daily." D. "I am eating fewer potato chips and more fruit for snacks." F. " I know to call my doctor if I gain 3 pounds or more in 2 days."

A nurse is talking with an older adult client who is contemplating retirement. The clients states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? A. "You would have so much more time to spend with your family" B. "You should consider getting a part-time job or doing volunteer work" C. "Let's talk about how the change in your job status will affect you" D. "Why wouldn't you want to retire and relax?"

C. "Let's talk about how the change in your job status will affect you"

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. A lesion with uniform pigmentation B. New appearance of petechiae C. A mole with an asymmetrical appearance D. The presence of a papule

C. A mole with an asymmetrical appearance

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. Insert the needle at a 15° angle. B. Aspirate for blood return prior to administration. C. Administer the medication into the abdomen. D. Massage the site following the injection.

C. Administer the medication into the abdomen

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.

C. Compare the client's home medications with the provider's prescriptions.

A nurse is administering 1 L 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 successtul? A. Increase in hematocrit B. Increase in respiratory rate C. Decrease in heart rate D. Decrease in capillary refill time

C. Decrease in heart rate

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? A. Assist the client into a prone position. B. Place a sleeve over the top of each leg with the opening at the knee. C. Make sure two fingers can fit under the sleeves, D. Set the ankle pressure at 65 mm Hg.

C. Make sure two fingers can fit under the sleeves

A nurse is caring for a client who is postoperative following abdominal surgery. Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised × 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200; Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional Urine output since 1200. Repositioned client for comfort. Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN pain Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting Vital Signs 1100: Temperature 36.2° C (97.2° F) Heart rate 76/min Respirations 18/min BP 122/68 mm Hg Oxygen saturation 95% on room air 1200: Temperature 36.8° C (98.2° F) Heart rate 116/min Respirations 20/min BP 112/68 mm Hg Oxygen saturation 93% on room air click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. A. Neurological assessment B. incisional drainage C. Urinary output D. Reported pain level E. Gastrointestinal assessment F. Vital signs

C. Urinary output D. Reported pain level F. Vital signs

A nurse is responding to a call light and finds a client lying on the bathroom floor Which of the following actions should the nurse take first ? a . Check the client for injuries b . Move hazardous objects away from the client c . Notify the provider d . Ask the client to describe how she felt prior to the fall

a . Check the client for injuries

A nurse is planning strategies to manage time effectively for client care . Which of the following strategies should the nurse implement ? a . Combine client care tasks when caring for multiple clients b . Wait until the end of the shift to document client care c . Use the planning step of the nursing process to prioritize client care delivery d . Allow for interruptions in tasks to discuss client care issues with colleagues

c . Use the planning step of the nursing process to prioritize client care delivery