ATI: Fundamentals Practice Exam

What are some clinical manifestations of fluid volume excess?

-Sunken eyeballs, hypotension and poor skin turgor

What is the functional classification for the medication dextran? When is it commonly administered?

-a plasma volume expander -in emergency situations involving hypovolemia it is administered for hemorrhage or burns.

1 tsp = ? mL 1 oz = ? mL

- 5mL - 30mL

Needle gauge and degree of insertion for a tuberculin skin test;

-25 to 27 gauge needle -inserted at a 10 to 15 degree angle

Use of incentive spirometer

-Exhale normally, Put the mouthpiece in your mouth and close your lips tightly around it. -Inhale slowly and deeply through the mouthpiece to raise the indicator. Try to make the indicator rise up to the level of the goal marker. -When you cannot inhale any longer, remove the mouthpiece and hold your breath for 3 to 5 seconds. -exhale normally. Take normal breathes between cycles to avoid hyperventilation or fatigue. -Repeat these steps 10 to 12 times every hour when you are awake, or as often as directed.

When preparing to irrigate a patients wound what size syringe, catheter and other indications should the nurse follow to maximize patient comfort during procedure?

-use a 30ml syringe (at least) -18 to 19 gauge catheter -administer an analgesic 30 min prior -warm the solution before irrigation

The nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (select all that apply) A. Coat the tip of the tube with water soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

A. , B. , D. ,

A nurse is caring for a client who is post operative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the clients wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the clients surgeon D. Reassure the client

A. Cover the incision with a moist sterile dressing

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status? A. Daily Weight B. Blood pressure C. Specific Gravity D. Intake and Output

A. Daily Weight

A nurse is assessing a patients incision and observes the drainage to be blood tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia

A. Sangineous

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. With your palm facing down , move your wrist side ways towards your thumb B. Move your palm toward the inner part of your forearm C. With your palm facing down, move your wrist sideways towards your little finger D. bring the back of your hand as far back towards the wrist that you can

A. palm facing down, move your wrist sideways towards your thumb

A nurse is caring for a semi-conscious patient who had a small-bore NG tube placed yesterday for the administration of enteral feedings. Which of the following methods should the nurse take to verify correct tube placement? (select all that apply) A. Auscultate injected air B. Verify the initial x-ray examination C. Measure the length of exposed tube D. Determine the pH of aspirated fluid E. Check aspirated fluid for glucose

B. , C. , D.

A nurse is caring for a client with a cuffed endotracheal tube in place. The nurse should identify that the purpose for inflating the cuff includes which of the following? (select all that apply) A. Allows the client to speak B. Stabilizes the position of the tube C. Prevents aspiration on secretions D. Prevents air leaks E. Prevents tracheal injury

B. , C. , D. ,

The nurse is caring for a patient who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The patient asks the nurse how the TENS unit helps relieve pain. Which of the following responses should the nurse make? A. It provides a distraction from the pain B. It modulates the transmission of the pain impulse C. Promotes increased circulation to the painful area D. Elicits a relaxation response

B. Modulates the transmission of the pain impulse

A nurse is responding to a parents question about their infants physical development during the first year of life. Which of the following pieces of information should the nurse include? A. a 2 month old infant can turn from his abdomen to his back B. a 10 month old infant can pull up into a standing position C. a 4 month old infant can sit up without support D. a 6 month old infant can crawl on their hands and knees

B. a 10 month old can pull themselves up into a standing position

A nurse is collecting a specimen for culture from a clients infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves while collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. allow the collection swab to absorb old exudate D. rotate the collection swab over the edges of the wound

B. cleanse the wound with sodium chloride solution

A nurse is assessing a client who reports nausea and vomiting for two days. Which of the following findings should indicate to the nurse that the client experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor What are some additional findings of fluid volume deficit?

B. increased heart rate -Increased BUN levels, dry mucous membranes, dark urine,

A nurse is providing discharge teaching for a client and providing instructions about performing at home dressing changes. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. I'll warp the old dressing in a paper bag and put it in the trash B. I'll wash my hands before I remove the old dressing and again before putting on the new one C. I'll need to take a pain pill 30 min before I change the dressing D. I'll wear sterile gloves when I apply the new dressing

B. wash hands before and after dressing changes.

The nurse is assessing a client who has a total calcium level of 12.7mg/dL. Which of the following findings should the nurse expect? A. Muscle Tremors B. Positive Chovsteks sign C. Depressed deep tendon reflexes D. Numbness around the mouth

C. Depressed deep tendon reflexes

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect for this client? A. BUN 18mg/dL B. Cap Refill 1.5 sec C. HCT 55% D. Urine specific gravity 1.001 What are some other indications of hypovolemia?

C. HCT 55% -weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased specific gravity, decreased urine output

A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings are another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse

D. Bounding Pulse

A nurse is assessing a clients peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60 bpm B. Radial, brachial, and pedal pulses bilaterally weak C. peripheral pulses bilaterally symmetric, equal, strong, in all four extremities D. brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

C. peripheral pulses bilaterally symmetric, equal, and strong in all four extremities

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood

D. Young adulthood

Ethical Principle of Nonmaleficence:

Do no harm

Ethical Principle of Fidelity:

Keeping ones promises

As part of a neurological examination, a nurse instructs a client to keep his eyes closed and places an object in his hand, asking him to identify it. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia

Stereognosis

Ethical Principle of Autonomy:

The clients right to make their own decisions concerning their body

Ethical Principle of Justice:

Treating everyone fairly and equally.