Fundamentals Practice Exam B 2020 - ATI

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30lbs. How many kilograms does the child weigh?

13.6 kg

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Actual Loss. (The nurse should identify that the client's comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear, or know an object, another person, or a part of themselves, such as the loss of a body part.)

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Clean the perineal area at least once a day. (The nurse should clean the perineal area at least once a day to reduce the risk for infection)

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Describe your concerns about sleeping to me. (This statement is open-ended and allows for further communication. This addresses the client's concerns and builds trust.)

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Have you had small liquid stools? (Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Therefore, the first question for the nurse to ask is if the client has had any small liquid stools, which can indicate that there is seepage of liquid feces around the impacted mass.)

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Headache. (The nurse should identify that a headache can be an adverse effect following a lumbar puncture. To minimize the client's discomfort, the nurse should administer analgesics, offer fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider.)

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

It must be difficult facing this type of surgery. (stating that is must be difficult to be in this position is an open-ended and nonjudgmental statement that allows the client to talk about their fears.)

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to attention of the charge nurse prior to the initiation of the therapy?

Latex. (Nurses use products containing latex, including gloves, tourniquets, and IV tubing, to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives, or a more serious reaction, such as dyspnea or laryngospasm.)

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

Notify the charge nurse of the client's concerns. (The nurse should notify the charge nurse of the clients concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure.)

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

Pallor with scaly skin. (The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of the sun-exposed skin in clients who are well-nourished.)

A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?

Perform a bladder scan. (The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations.)

A nurse is caring for a client who reports itching 30 minutes after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

The client states, "I started to itch after taking that medication." (The nurse should document information using an objective description, putting the client's exact words in quotation marks.)

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

The client's output was 60 mL for the past 3 hr. (When using urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function.)

A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent dressing should the nurse include?

The dressing allows the wound bed to breathe. (A transparent dressing is applied to allow oxygen to pass through the dressing. This is referred to as "breathing" and promotes healing of the wound.)

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

Three point. (The nurse should identify that the client needs to be able to bear weight on the unaffected leg; therefore, a three point gait provides at least points of support.)

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

You should cleanse your eye from the inner to the outer edge prior to putting in the drops. (The nurse should instruct the client to cleanse the eye from the inner to the outer canthus to prevent contamination of the lacrimal duct.)