ATI Fundamentals practice questions

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible?

A. Stat prescription Rationale: A stat medication prescription is carried out immediately or as soon as possible and for one time only.

A nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

B. 2 Rationale: a pH of 2 is within the expected range of 0 to 4 for gastric secretions.

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

C. Brainstem

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

C. Pinch the NG tub while removing the tube

A nurse is teaching a middle-aged female clien about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this clients routine health screening?

Eye examination every 2 years

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What a sequence of actions should the nurse plan to take?

- Turn off the vacuum on the NPWT device and administer the prescribed analgesics - Remove the soiled dressing and perform hand hygiene - Apply sterile or clean gloves and irrigate the wound - Apply a skin protectant or a barrier film to the skin around the wound - Place prepared foam Into the wound bed and cover with a transparent dressing

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching?

A. "I need to place a towel between the heating pad and my skin" Rationale: The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns.

A nurse is assessing a client for conductive hearing loss. When using Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the ear?

A. Air conduction is less than bone conduction in the left ear. Rationale: The finding indicates conductive hearing loss of the left ear.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following craniak nerves is the nurse testing?

A. Cranial nerve XII Rationale: The nurse is checking the function of cranial nerve XII (Hypoglossal), which innervates the tongue, by observing a range of tongue movements.

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

A. Use a gait belt during ambulation Rationale: The nurse should use a gait belt to keep the clients center of gravity midline and decrease the risk of a fall.

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 Rationale: According to the evidence-based priority setting framework, daily weight provides important info about the clients fluid status. A gain or loss of 1kg indicates a gain or loss of 1L of fluid. Therefore weighing the client daily will provide the most accurate fluid status measurment.

A nurse is removing PPE after performing a procedure for a client who requires isolation procautions. Which of the following items of PPE should the nurse remove first?

A. Gloves Rationale: According to evidence based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally the nurse should remove mask.

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following PPE items should the nurse don prior to providing client care?

A. Gown B. Gloves Rationale: The nurse should follow standard precaution when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown. Because the nurse's hands will come into contact with the soiled linens, the nurse should don clean gloves in addition to other necessary PPE.

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

A. Hold the dropper 1cm (0.5in) above the ear canal during administration Rationale: The nurse should administer the otic medication by holding the dropper 1cm above the ear canal.

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

A. Hyperglycemia Rationale: Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

A. Provide oral care to a client who cannot take oral fluids Rationale: Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

A. Renew the prescription for the use of restraints within 24hrs. Rationale: The nurse should plan to renew the prescription for the restaints within 24hrs, only after the provieder has evaluated the client.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

A. Repeat each joint motion 5 times during each session Rationale: To maintain the clients joint mobility, the nurse should repeat each motion 3 to 5 times.

A nurse is teaching range of motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an undersating on supination of the hand?

A. The client holds the hand with the palm up Rationale: The nurse should identify the client holding the hand with the palm up as a demonstrationof supination of the hand.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of info must the nurse prior to the administration?

A. The clients ID # C. The clients name D. ABO compatibility E. RH compatibility Rationale: Two nurses must verify this info, including the clients facility ID #, name, ABO compatibility, and RH compatibility, to prevent transfusion reactions due to human error.

A nurse is responding to a parents question about his infants expected physical development during the first year of life. Which of the following pieces of info should the nurse include?

B. A 10 month old infant can pull up to a standing position. Rationale: An 8 to 10 month old infant can pull up to a standing position

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of info should the nurse include in the teaching?

B. Hold the breath for 5 sec after goal volume is reached. Rationale: The nurse should instruct the client to hold the breath for 3 to 5 secs after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia.

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

B. Keep the rubber crutch tips securely in place Rationale: The client should never use crutches without the rubber tips. The client should inspect the tips regularly, replace them when they show signs of wear and tear, and remove and dry them thoroughly with paper towels if they become wet.

A nurse is performinh a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the clients body?

B. Lungs Rationale: Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance or dullness. The nurse also uses ausculation and palpation when evaluating the lungs.

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the clients wound has eviscerated. Which of the following actions should the nurse take?

B. Place the client in a supine position with the hips and knees flexed. D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following?

B. Stabilizes the position of the tube. C. Preventing aspiration of secretions D. Preventing air leaks. Rationale: An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, and keeps air from leaking around the outer portion of the endotracheal tube.

A nurse is caring for a semiconscious client who had a small bore NG tube places yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement?

B. Verify the initial X-Ray examination C. Measure the length of the exposed tube D. Determine the PH of aspirated fluid. Rationale: The nurse should confirm the NG tube placement by checking the XRay results following the insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the clients nose to verify tube placement. Finally the nurse should check the pH of aspirated fluid to verify the tube placement.

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

C. Determine the clients intention to change current eating habits Rationale: When using the nursing process, the nurse should first assess the client's readiness to commit to a change in behavior.

A nurse is caring for a client who has a MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant?

C. Don gloves when entering the room and use hand sanitizer when exiting. Rationale: Delivering the tray will require contact with the clients environment; therefore, the dietary assistant must wear gloves.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

C. Elevate the head of the client's bed to 45 degrees before the feeding Rationale: The nurse should elevate the clients head of the bed between 30 and 45 to prevent aspiration.

A nurse is working with the facilitys language interpreter to explain a wound care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

C. Ensure the interpreter and the client speak the same dialect Rationale: To encourage effective communication and promote client understanding, the nurse should first ensure the interpreter and the client speak the same dialect.

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

C. Insert the tip of the tubing 8cm (3.1in) Rationale: The nurse should insert the tip of the tubing 7 to 10 cm (3-4in) along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa.

A nurse is administrating a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

C. Insert the tip of the tubing 8cm (3.1in) Rationale: The nurse should insert the tip of the tubing 7 to 10cm (3 to 4in) along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa.

A nurse is teaching a client who has urinary incontinence about bladder training. Which of the following instructions should the nurse include?

C. Try to block the urge to urinate until the next scheduled time Rationale: When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, she should try slow, deep breathing to reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises.

A nurse is preparing to irrigate a clients wound. Which of the following actions should the nurse take?

C. Warm the irrigating solution to 37C (98.6F) Rationale: The nurse should prepare about 200mL of irrigating solution and warm it to body temp to minimize discomfort and vascular constriction

A nurse is reviewing a client's 24hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken. 2 cups of steamed broccoli, and a glass of milk for dinner. This clients diet is deficient in whch of the following food groups?

D. Grains Rationale: This client only consumed 1 serving of grains on the day of the 24hr dietary recall. USDA dietary guidelines recommend 3 or more ounce-equivaents of whole-grain products per day. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half of the grains consumed should be whole grain.

A nurse obtaining the BP in a clients lower extremity. Which of the following actions should the nurse take?

D. Place the bladder of the cufff over the posterior aspect of the thigh Rationale: This is the correct position for the bladder of the cuff when the nurse is measuring a lower- extremity BP.

A nurse is caring for a client who requires an X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

D. Identify the client using 2 identifiers Rationale: The nurse should use Maslows heirarchy of needs, the ABC priority setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Once the identity is determined, the nurse can proceed with the other options. This action is the priority because it provides safety for the patient. Thenurse must be certain that each client receives only what has been prescribed. Hence the nurse must assure that the correct client is being transported for a chest X-ray.

A nurse in a long term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions shoul the nurse take?

D. Observe the client closely

A nurse is supervising a newly licensed nurse who is suctioning a clients tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

D. Adminster high flow oxygen prior to procedure Rationale: The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.

A nurse is using a portable ultrasound bladder scanner to measure a clients post-void residual volume. Which of the following actions should the nurse take?

D. Apply light pressure to the scanner head once it is in position Rationale: The nurse should apply light pressure and hold the scanner steadily while pointing it slightly down toward the clients bladder.

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

D. Cerebellum Rationale: The nurse should suspect an injury to the cerebellum if the clients is experiencing difficulty controlling balance and coordination. A clients movements can become uncoordinated, unsure, and clumsy following an injury to this area of the brain.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

D. Place the stool specimen collection container in a biohazard bag Rationale: The nurse should place the specimen collection container in a biohazard bag with the client label on the container and the bag for easy identification. This will also prevent contamination with microorganisms.

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethescope to auscultate the aortic valve?

D. Second intercostal space to the right of the sternum Rationale: The aortic valve is located on the second intercostal space to the right of the sternum. Aortic stenosisproduces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is planning to obtain the vital signs of a 2 yo child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the childs temperature?

D. Temporal Rationale: The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temp, is noninvasive and can be used to obtain a temp in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic but should avoid placing it over an area covered with hair.

A nurse is evaluating a clients use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

D. The client has slightly flexed elbows when ambulating with the crutches Rationale: The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae.

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

D. The client keeps 2 points of support on the ground Rationale: When ambulating with a cane, the client should keep 2 points of support on the ground at all times, which can be either both feet or a foot and the cane.

A nurse is applying antiemboletic stockings for a client who has a history of deep vein thrpmbosis. Which of the following actions should the nurse take when applying stockings?

D. Turn the stocking inside out up to the heel before applying Rationale: The nurse should turn the stocking inside out up to the clients heel to make the application of the stocking easier and cause fewer constrictive wrinkles.