ATI Fundamentals B

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of 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 fire.

C. Evacuate the client.

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 she 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 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 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 stairs, I will first shift my weight to my right leg."

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as an indication of infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

C. Skin blanching

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 bedrail onto the floor. Which of the following statements should the nurse document about this incident? A. "Incident report completed." B. "Client climbed over the bedrails." C. "Client found lying on floor." D. "Client was trying to get out of bed."

C. "Client found lying on floor."

A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. B. A nurse asks a nurse from another unit to assist with her documentation. C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care. D. A nurse discusses a client's status with the physical therapies that is caring for the client's bedside.

B. A nurse asks a nurse from another unit to assist with her documentation.

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 30º 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 30º

A nurse is reviewing protocol in prep for suctioning secretions from a client who has a new tracheostomy. What action should the nurse plan to take? A. Use a 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 a pressure of 170 mm Hg.

B. Select a suction catheter that is half the size of the lumen.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. What assessment finding 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 Neck vein distention is an indication of fluid volume excess. A urine specific gravity of greater than 1.030 would indicate fluid volume loss. Tachycardia indicates fluid volume loss. Hypotension is an expected finding for fluid volume loss.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? A. The medication B. The route C. The dose D. The frequency

C. The dose

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?

0.3 mg

A nurse is preparing a heparin infusion for a client who was hospitalized with DVT. The order reads 25,000 unit of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round to nearest whole number)

8 mL/hr

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the 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 providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give 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 4 feet away from a heat source C. Consider purchasing a generator for power backup D. Monitor for signs of hypoxia E. Select clothing and bedding made of synthetic materials

A. Check the cord routinely for frays and tearing C. Consider purchasing a generator for power backup D. Monitor for signs of hypoxia

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 caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take? A. Instruct the family to refrain from pushing the button for a client while she is asleep. B. Inform the client that because she is on a 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 a client while she is asleep.

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 four 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 four sides of the bed.

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 what? A. "I am having mild pain." B. "The pain is like a dull ache in my stomach." C. "I notice it get worse after i eat." D. "The pain makes me nauseous"

B. "The pain is like a dull ache in my stomach."

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 member will assist with the procedure.

B. Witness the client's signature on the consent form.

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 C 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 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 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 5 years." D. "You should receive a pneumococcal immunization every 10 years."

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

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 hospital medications 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 during hospitalization.

D. Compare prescriptions with medications the client received during hospitalization.

A charge nurse is discussing the responsibility of nurses caring for clients who have a 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 air-flow system B. Use alcohol-based hand sanitizer when leaving he client's room. C. Clean contaminated surfaces in the client's room with a phenol solution. D. Have family members wear gown and gloves when visiting.

D. Have family members wear gown and gloves when visiting.