ATI Fundamentals Assessment

An RN is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin. Which of the following actions should the RN take 1st when mixing the insulin? A: Withdraw the regular insulin from the vial B: Inject 15 units of air into the regular vial of insulin. C: Withdraw the NPH insulin from the vial. D: Infect 25 units of air into the NPH vial of insulin

D Rationale: According to EBP the RN should 1st inject 25 units of air into the NP vial of insulin to prevent contamination of the rapid-acting regular insulin with the intermediate-acting NPH insulin & to equalize the pressure in the vial when insulin is later removed.

An RN is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following finding s should the RN report to the provider? A: Gastric residual of 50 mL B: Weight gain of 0.23 kg(0.5lbs) in 24 hr. C: Blood glucose of 105 mg/dL D: Gastric aspirate of pH of 7

D Rationale: The RN should identify that a gastric pH of 7 is an indication the nasogastric tube is not in the stomach. Gastric pH is usually between 1 and 4 but can be up to 6, if the client receives a mediation that alters gastric pH. The client is at risk for aspiration and the RN should report this finding to the PCP.

A home health RN is visiting an older adult client who has anemia. Which of the following foods should the RN recommend to increase the client's iron intake? A: Greek yogurt B: Bran muffin C: Peanut butter sandwich D: Dried fruit

D Rationale: The RN should recommend the client eat more dried fruit to increase iron in the diet.

An RN is assessing an older adulty client. Which of the following findings should the nurse report to the provider? A: Decreased cough reflex B: Decreased urinary bladder capacity C: Decreased sebum production D: Decrease spinal column movement

D Rationale: The RN should report an onset of lower back tenderness and restricted spinal column movement, which can indicate a compression fracture due to osteoporosis.

A charge RN is delegating tasks for 4 clients. Which of the following tasks should the RN delegate to the assistive personnel (AP)? A: Prepare the room for a client who requires seizure precautions. B: Check a client's deep tendon reflexes. C: Develop a plan of care for a client who is at risk for falling. D: Obtain a wound culture on a client who has a small pressure injury.

A Rationale: AN AP can set up a room with the equipment a client requires for seizure precautions because the necessary equipment is the same for each client.

An RN in a provider's office is reviewing the laboratory reports for a client who is at risk for heart disease. Which of the following results should the RN report to the provider? A: LDL 170mg/dL B: HDL 60 mg/dL C: Triglycerides 60 mg/dL D: Total cholesterol 197 mg/dL

A Rationale: AN LDL level of 170 mg/dL is above the expected reference range and places the client at increase risk for heart disease; therefore, the RN should report this result to PCP. (>160mg/dL is HIGH)

An RN is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A: Daily weight B: BP C: Specific gravity D: Intake and output

A Rationale: According to EBP priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1kg(2.2lbs) indicates a gain or loss of 1L of fluid; therefore, weighing the client daily will provide the most accurate fluid status measurement.

An RN on a mental health unit is preparing to terminate the RN-client relationship with a client who no longer requires care. Which of the following concepts should the RN and client discuss in the termination phase of the relationship? A: Loss B: Trust C: Self-disclosure D: Risk-taking

A Rationale: At the close of a relationship, even when planned, loss is an expected feeling for both the client and the RN It is important for both the RN and the client to terminate the relationship w/o feelings of guilt or anxiety.

An RN observes assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A: Assault B: Battery C: False imprisonment D: Invasion of privacy

A Rationale: By threatening the client, the AP is committing assault. The AP's threats could make the

A RN is conducting an admission interview with a client. Which of the following pieces of assessment information should the RN collect during the introductory phase of the interview? A: A client's level of comfort and ability to participate in the interview. B: Previous illnesses and surgeries. C: Events surrounding the client's recent illness. D: Sociocultural history.

A Rationale: The RN should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The RN should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the RN in gaining the necessary data to formulate appropriate nursing diagnosis and outcomes.

An RN is preparing to insert a new IV catheter for a client. Which of the following actions should the RN plan to take? A: Choose a vein that is palpable B: Use the client's dominant air to start the IV. C: Select an insertion site at an area of flexion. D: Elevate the extremity prior to insertion.

A Rationale: The RN should choose a vein that is palpable and straight to limit the risk of infiltration.

An RN is completing dietary teaching with a client who has heart failure and has a Rx for a 2g sodium diet. Which of the following statements made by the client indicates an understanding of the teaching? A: "I can have a nonfat yogurt as a dessert." B: "I can eat processed foods as long as it has less than 500 mg of sodium per serving." C: "I can use baking soda when I bake."

A Rationale: The RN should identify that yogurt is a recommended dessert for a client on a 2g sodium diet who has heart failure because it is low in sodium and fat.

An RN is planning care for a client who is postoperative. Which of the following interventions should the RN include in the plan to decrease the client's risk for venous stasis? A: Instruct the client to elevate her legs when sitting in a chair. B: Assist the client to ambulate after IV infusions are discontinued. C: Place a pillow under the client's knees while she is in bed. D: Encourage the client to exercise the legs q4hrs while awake.

A Rationale: The RN should instruct the client to elevate her legs when sitting in a chair to prevent pooling and clotting of the blood in the lower extremities.

An RN is reviewing a client's ABG laboratory results. Which of the following ABG results should the RN report to the provider? A: pH 7.42 B: PaCO2- 33 mmHg C: PaO2- 84 mmHg D: HCO3- 25 mEq/L

B Rationale: A PaCO2 of 32 mmHg is below the expected reference range of 35 to 45 mmHg and should be reported to PCP.

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (SATA) A: Home health care B: Rehabilitation facilities C: Diagnostic centers D: Skilled nursing facilities

Answer: A, B, D C Rationale: Secondary health care includes the diagnosis and treatment of acute injury or illness. Diagnostic centers are a type of secondary health care.

An RN is teaching a client who has a new hearing aid. Which of the following statements by the client indicates to the RN an understanding of the teaching? A: "I will turn the volume up on my hearing aid to full volume after insertion." B: "I will reinsert the hearing aid if I hear a whistling sound." C: "Initially, I will wear my hearing aid for 2 hrs each day." D: "I will soak my hearing aid in warm water to clean it."

B Rationale: A whistling sound can indicate the incorrect insertion of the hearing aid, improper fit, or ear wax buildup.

An RN is performing guaiac testing for a client to screen for colon cancer. The RN should identify that ingestion of which of the following foods can cause a false negative result? A: Dairy products B: Citrus fruits C: Soy products D: fish w/omega-3 fats

B Rationale: Clients should not consume citrus fruits or juices for 3 days prior to guaiac stool testing because vit. C can produce a false negative results.

An RN is completing an informed consent document for a 16-yo adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the RN take? A: Locate the adolescent's partner to sign the form prior to the appendectomy. B: Document that consent is implied due to the urgency of the procedure. C: Tell the client that a general consent to tx covers the surgical procedure. D: Ask the client if they understand the provider's plan for the appendectomy.

B Rationale: The RN should identify that implied consent is used for noninvasive procedures, such as obtaining vital signs, in which the client implies consent by allowing the action to take place.

A charge nurse is teaching a newly hired RN about the facility's computerized documentation system. Which of the following actions should the RN take? A: Direct the newly hired RN to wait until the end of the shift to document client care. B: Instruct the newly hired RN to use direct quotes when recording client statements. C: Perform documentation for the newly hired nurse until the orientation period is complete.

B Rationale: The newly hired RN should include both subjective data (what the client says), and objective data (what the RN observes) when entering computer documentation. It's important to directly quote what the client says rather than summarizing to provide factual information.

An RN is caring for a client who has a cuffed endotracheal tube in place. The RN should identify that the purpose of inflating the cuff includes which of the following? (SATA) A: Allowing the client to speak B: Stabilizing the position of the tube C: Preventing aspiration of secretions D: Preventing air leaks E: Preventing tracheal injury

B, C, D

An RN is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plans of care? (SATA) A: Set the suction machine at 120 mmHg. B: Provide oral hygiene frequently. C: Measure the amount of drainage from the NG tube every shift. D: Apply petroleum jelly to the client's nares.

B, C, D

An RN is assessing a client. which of the following findings should the RN identify as an indication of protein-calorie malnourishment? (SATA) A: Gingivitis B: Dry, brittle hair C: Edema D: Spoon-shaped nails E: Poor wound healing

B, C, E

An RN is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the RN take 1st? A: Flush the client's tubing with 30 mL of water. B: Draw up 30 mL of air and instill into the tubing. C: Check the pH of the client's stomach contents. D: Check the gastric residual volume.

C Rationale: According to EBP, the RN should 1st check the pH of the aspirate by drawing up 5 mL of gastric fluid. The pH should be <5 to confirm gastric placement.

An RN is admitting a client to an acute care facility. Which of the following actions by the RN promotes client self-determination? A: Reviewing the policy on safeguarding personal valuables with the client. B: Informing the client's family about the regulations for visiting hours. C: Providing the client with information about end-of-life decision-making. D: Comparing the client's home medications to the admission prescriptions.

C Rationale: By promoting the client's autonomy, the RN ensures the client's ability to self-determine care. Under the Patient Self-Determination Act, facilities must ensure a client is aware of their rights to make choices about their care, including completing advance directives to predetermine end-of-life tx options.

An RN is planning care for 4 clients. Which of the following clients should the RN see 1st? A: A client who has diabetes mellitus and a fasting blood glucose of 68 mg/dL. B: A client who has moderate serosanguineous drainage on a surgical dressing. C: A client who has pneumonia and expiratory wheezing. D: A client who has a PCA pump and reports pain as 7 on a scale of 0 to 10.

C Rationale: The 1st action the RN should take when using the ABC approach to client care is to assess the client's airway and breathing, which could be impaired as a results of the pneumonia.

An RN is caring for a client who is recovering from a stroke and tells the RN he is concerned about paying his medical bills. The RN should refer the client to which of the following members of the interprofessional health care team? A: Physical therapist B: Occupational therapist C: Social worker D:Speech pathologist

C Rationale: The RN should refer the client to a social worker to assist the client with finding available financial resources.

An RN is planning to perform postmortem care for a client. Which of the following actions should the RN plan to take? A: Request the family members leave the client's room. B: Remove dentures from the client's mouth. C: Verify whether the client requires an autopsy. D: Lower the head of the client's bed.

C Rationale: The RN should verify whether the client requires an autopsy before completing postmortem care or removing any indwelling lines, tubes, or catheters.

An RN is assessing a client's thyroid gland. Which of the following instructions should the RN give the client before inspecting and palpating this gland? A: "Tilt your head 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 Rationale: To examine the thyroid gland, the RN should instruct the client to extend her head backward and to swallow. The RN should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland.

An RN is performing a mental-status exam on a client who has manifestations of dementia. Which of the following directions should the RN give the client when evaluating the client's ability to think abstractly? A: Subtract by 7 serially, starting at 100. B: Describe a previous illness. C: Explain what to do if a fire happened in his bedroom. D: Discuss the meaning of a common proverb.

D Rationale: This part of the mental-status exam evaluates the client's ability to think abstractly.

An RN is performing medication reconciliation with a client. Which of the following actions should the RN take 1st? A: Contact the PCP about discrepancies in medication dosages. B: Provide the client with a new list of prescribed medications. C: Compare the provider's admission prescriptions to the client's list of home medications. D: As the client if she takes any OTC medications.

D Rationale: the 1st action the RN should take when using the nursing process is to assess the client's current us of prescription and nonprescription medications, vitamins, and herbal supplements to obtain a complete list for comparison to the provider's admission prescriptions.