ATI Fundamentals

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer?

"All of this equipment can be frightening"

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make?

"Call me when you are ready, and I will return with the medication."

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

"Fats provide energy."

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

"I will put a night-light in the hallway."

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?

"I will shake the inhaler well right before I use it."

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care."

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period?

2130

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake?

660

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse?

8

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?

A client who has end-stage cirrhosis

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

A nurse will show me how to care for my wound.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (Select all that apply.)

A. The client's ID number C. The client's name D. ABO compatibility E. Rh compatibility Check

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?

Advise the client to perform range-of-motion exercises while in bed

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate?

Airborne

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care?

Airborne

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?

Antagonist

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?

Areas with no public access

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?

Attempt to increase the clients' self-motivation

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?

Auscultation

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries with the bell of the stethoscope

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter?

Bear down gently

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage.

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with others

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A. Select a vein in the client's dominant arm B. Choose the most proximal vein in the extremity C. Choose a vein that is soft on palpation D. Select a site distal to previous venipuncture attempts Check Answer Question Feedback Show Explanation Grade Pause Previous

Choose a vein that is soft on palpation

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?

Chronic hypoxemia

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decreased estrogen and testosterone production

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding?

Elevate the head of the bed

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration?

Elevate the head of the bed to 30° or 45°

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

Feedback is provided

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

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

Gown and gloves

A nurse is reviewing a client's 24 hr 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 client's diet is deficient in which of the following food groups?

Grains

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

Halo of erythema on the surrounding skin

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001 Check Answer Question Feedback Show Explanation Grade Pause Previous

Hct 55%

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?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is caring for a client who has a temperature of 38.7°C(101.7°F). Which of the following actions should the nurse take?

Keep the client's bed linens dry

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Leave the bag in place for 45 min B. Fill the bag 2/3 full with ice

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following conditions?

Leukopenia

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor

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

Lungs

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 should the nurse take? A. Assist the client to the floor B. Perform an abdominal thrust C. Open the airway with a head-chin tilt D. Observe the client closely Check Answer Question Feedback Show Explanation Grade Pause Previous

Observe the client closely

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain services of an interpreter

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

Osteoporosis

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial.

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean blood spills. B. Discard empty blood bags in a bedside trash can. C. Break used needles before discarding. D. Place soiled linen in a single linen bag. Check Answer Question Feedback Show Explanation Grade Pause Previous

Place soiled linen in a single linen bag

A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container.

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?

Plasma volume expanders

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

Provide more water with feedings

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hr

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

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?

Renew the prescription for the use of restrains within 24 hr

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication

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 stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

Suction equipment

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

Support the client's decision

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? A. Rectal B. Tympanic C. Oral D. Temporal Check Answer Question Feedback Show Explanation Grade Pause Previous

Temporal

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

Test for the presence of the client's gag reflex

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side.

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?

The client keeps 2 points of support on the ground

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain.

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record?

The client threw the medication on the floor

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden.

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

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?

Use a gait belt during ambulation

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? A. Discourage the use of unregulated medications and supplements B. Verify the herbal supplements do not interact with medications the provider has prescribed C. Tell the client to limit the number of herbal supplements to no more than 2 D. Describe the dangers of taking plant-derived medications and supplements Check Answer Question Feedback Show Explanation Grade Pause Previous

Verify the herbal supplements do not interact with medications the provider has prescribed

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection?

WBC 15,000 mm^3

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

Wrap the client's finger in a warm washcloth

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group?

"I go home on the weekends to be with my family because I do not have any good friends here on campus."

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

"Tell me more about how you feel about dying"

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands."

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures." D. "What worries you about being without your teeth?" Check Answer Question Feedback Show Explanation Grade Pause Previous

"What worries you about being without your teeth?"

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability to cry or speak

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

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

Insert the tip of the tubing 8 cm (3.1 in)

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation.

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client?

Avoid beverages that contain caffeine