ATI Fundamentals Practice B

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Limit each visitor to 2-hr increments. Wear a surgical mask when providing client care. Use antimicrobial sanitizer for hand hygiene.

negative-pressure- correct (airborne precautions) wear gloves- correct (standard precautions for all clients). limit visitors- incorrect. surgical mask- incorrect. The nurse should wear an N95 (airborne precautions). antimicrobial sanitizer- correct

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? "Most people are happy when their children grow up and leave home." "You should be proud that your children are becoming independent." "Maybe you should consider why you are feeling useless." "People in middle adulthood often find satisfaction in nurturing and guiding young people."

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

A nurse in a clinic is caring for a middle adult client who states, "The doctor say that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?" "I'll get a blood sample from you and send it for a screening test." "Beginning at age 60, you should have a colonoscopy." "You should have a fecal occult blood test every year." "The recommendation is to have a sigmoidoscopy every 10 years."

Blood tests do not detect colorectal cancer. Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. Another is to have a fecal occult blood test annually. Another is to have a flexible sigmoidoscopy every 5 years.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? "I can take echinacea to improve my immune system." "I can take feverfew to reduce my level of anxiety." "I can take ginger to improve my memory." "I can take ginkgo biloba to relieve nausea."

Echinacea promotes immunity and reduces the risk of infection. Feverfew is taken to promote would healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress.

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? Wrap blankets around all four sides of the bed. Apply restraints during seizure activity. Place the client in a supine position during seizure activity. Have a tongue depressor at the client's bedside.

The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures. Inserting any object into the mouth of a client who is having seizures increases the risk for injury to the mucous membranes in the mouth and damage to the teeth.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration. Transfer the medication to a medicine cup. Place the client in a semi-Fowler's position prior to medication administration. Verify the dosage by measuring the liquid before administering it.

The nurse should: Gently shake the liquid medication to ensure that it is mixed. Not transfer the prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose. Place the client in a high-Fowler's position.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? Use a resuscitation bag with 80% oxygen prior to the procedure. Select a suction catheter that is half the size of the lumen. Place the end of the suction catheter in water-soluble lubricant. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

The nurse should: preoxygenate with 100% oxygen before suctioning. Select a catheter that is half the size of the lumen to Prevent hypoxemia and trauma to the mucosa. Lubricate the end of the suction catheter with sterile water or 0.9% NaCl irrigation solution to decrease trauma to the mucosa. Adjust the suction pressure to approximately 120 mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Urine has an unusual odor. Urine specific gravity is 1.035. Bladder scan shows 525 mL of urine. Urine is positive for ketones.

Urine with an unusual odor can be a sign of infection; however, it is not an indication for irrigation. Urine specific gravity of 1.035 indicates that the urine is concentrated; however, it is not an indication for irrigation. A client who has an indwelling urinary catheter should have a continuous urine flow w/o an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. Ketones are a sign of diabetes mellitus with poor glucose control, not an indication for irrigation.

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? Rinse the feeding bag with water between feedings Tell the client to keep the head of the bed elevated at least 30°. Make sure the enteral formula is at room temperature. Wipe the top of the formula can with alcohol.

All correct but the priority is: When using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated to prevent reflux of the formula into the trachea.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following. Narrowed arterial lumen. Distended jugular veins. Impaired ventricular contraction. Asynchronous closure of the aortic and pulmonary valves.

Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as bruit.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 10 units of air into the bottle of NPH insulin Inject 5 units of air into the bottle of regular insulin. Withdraw the correct dose of NPH insulin from the bottle. Withdraw the correct dose of regular insulin from the bottle.

The nurse should first inject air into the vial of NPH insulin w/o touching the needle. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball. Apply a vibrating tuning fork to the client's forehead. Have the client stand with their arms at their sides and their feet together. Perform direct percussion over the area of the kidneys.

The nurse should touch the client's corneas with a wisp of cotton to measure light touch and pain across the the client's face and test cranial nerve V, the trigeminal nerve. The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to identify sound lateralization when assessing hearing. The Romberg test helps identify alterations in balance. The nurse is looking for swaying and a loss of balance. Direct percussion over the kidneys to evaluate them for inflammation.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? Rock the client up to a standing position. Pivot on the foot that is the farthest from the chair. Assess the client for orthostatic hypotension. Apply a gait belt to the client.

All correct; however, there is one action that is the priority. The nurse should: Rock the client up to a standing position to generate momentum and reduce the nurse's workload in lifting the client up off the bed. Pivot- to give the client room move. Apply a gait belt to help maintain the client's stability. The first action should be to assess the client to determine the risk for falling or fainting during the transfer by assisting client to sit and dangle the feet on the side of the bed. Assess for dizziness and a significant drop in BP.

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.) Check the cord routinely for frays or tearing. Keep the unit at least 1.2 m (4 feet) away from a gas stove. Consider purchasing a generator for power backup. Observe for signs of hypoxia. Select synthetic clothing and bedding.

Check the cord routinely for frays or tearing- correct Keep the unit at least 1.2 m (4 feet) away from a gas stove- incorrect. It should be 3.05 m (10 feet). Consider purchasing a generator for power backup- correct. Observe for signs of hypoxia- correct. Select synthetic clothing and bedding- incorrect.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly Riding a bicycle Performing isometric exercises Engaging in high-impact aerobics

Walking- weight-baring exercises are essential for maintaining bone mass. Cycling and isometric exercises- no weight-bearing advantages High-impact aerobics can injure bones that have lost density.

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? Admitting diagnosis Breath sounds Body temperature Diagnostic test results

When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.