ATI Fundamentals!!

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?

"I need to learn how to perform a dressing change on my leg.

A nurse is reinforcing teaching with a client who has a prescription for knee-high antiembolism stockings for home use. Which of the following statements by the client indicates an understanding of the teaching?

"I will replace the stockings when they no longer seem to stretch."

A nurse is reinforcing discharge instructions with a client who is walking with crutches. Which of the following statements by the client indicates an understanding of the instructions?

"I will support my weight on the hand grips of the crutches."

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

"I'm glad to have the opportunity to choose what kind of care I receive while I still can."

A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?

I can expect to have regular periods until I am in menopause

A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?

I understand that you decided not to receive blood products

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

I will press down on the skin barrier for 30 seconds to ensure adherence

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

I'll think about my grandfather's farm to reduce pain

A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

Interlock her fingers and hold her hand away from her body above her waist

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Measure the client's BP in the other arm.

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

Measure the intake and output of a client who has received furosemide

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Prepare a dry work surface above the waist level. Open the outside cover of the sterile kit and remove the dust cover. Grasp the outermost flap of the sterile kit while opening away from the body. Open each side flap of the sterile kit individually while pulling to the side. Open the innermost lower flap of the sterile kit while standing away from the sterile field.

A nurse is preparing to obtain a capillary blood specimen from a client for blood glucose testing. Which of the following actions should the nurse take?

Squeeze the puncture site lightly until a blood droplet forms.

A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?

Twist the catheter gently.

A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

Use direct quotes made by the client to describe the incident.

A nurse is caring for a client who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the nurse take to determine the client's level of pain?

Use the FACES pain scale to gauge the client's level of pain.

A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Using two gloved fingers to open the client's mouth for cleaning

A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?

Wrap the client's hand in a warm washcloth

A nurse is caring for a client who is angry and states, "The doctor gave me the wrong information. I was lied to!" Which of the following responses by the nurse is appropriate?

You feel as if the doctor hasn't been honest with you

A nurse is collecting data from a client who had a stroke and is unable to name common items. The nurse should recognize that the client is experiencing which of the following types of aphasia?

expressive aphasia

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

hyponatremia (low blood sodium)

A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration?

speech

A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

"Assume your partner can hear you, even if they do not respond."

A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

"Call me so that I can help you change your position."

A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, "I don't know what to do because he's not eating." Which of the following responses should the nurse make?

"Tell me more about what happens at mealtime."

A nurse is documenting information in a client's medical record. Which of the following notes indicates that the nurse understands legal documentation guidelines?

"The client reported nausea that was unrelieved by an antiemetic."

A nurse is caring for an older adult client who has dementia. Which of the following findings places the client at risk for falls?

"The four side rails on the client's bed are raised."

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

"This type of device is useful for a client who cannot assist."

A nurse is assisting with the care of four clients in an inpatient mental health facility. The nurse should recognize that which of the following clients can give informed consent?

A 30-year-old client who has postpartum depression

A charge nurse is reinforcing teaching with a newly licensed nurse about informed consent. Which of the following information should the nurse include?

A client can withdraw consent at any time.

A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?

A client who has had varicella

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

A client's bed alarm is malfunctioning.

A nurse is performing postmortem care for a client who was a devout Muslim. Which of the following actions should the nurse take?

Allow the family to participate in washing the client's body.

A nurse is collecting data from a client who is receiving IV fluid replacement to treat diarrhea but now has oliguria. Laboratory results include a potassium level of 5.6 mEq/L. The nurse should report which of the following findings to the provider immediately?

Abdominal cramps

A nurse is reinforcing teaching with a client who has recurrent back injuries related to lifting. Which of the following lifting instructions should the nurse include?

Align the back with the neck and feet.

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

Avoid entering the client's room unless requested during the night.

A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

Avoid placing the toilet tissue in the bedpan after defecation.

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

Bear weight on the unaffected leg.

A nurse is caring for a client who has a hip fracture and plans to administer pain medication prior to turning the client. Which of the following ethical principles is the nurse implementing?

Beneficence

A nurse is collecting data from a client who is malnourished due to inflammatory bowel disease. Which of the following findings should the nurse expect?

Brittle hair

A nurse is replacing a dressing for a client who has an abdominal incision with a closed wound drain. Which of the following actions should the nurse take?

Clean around the drain site using horizontal strokes.

A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Clean the hearing aid with isopropyl alcohol.

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Cleanse the tip of the ampule with an alcohol swab after opening

A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

Consume probiotic sources.

A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

Contact the previous nurse to determine if the client received the medication.

A nurse is collecting data from a client who has diarrhea and dehydration. Which of the following findings should the nurse expect?

Decreased capillary refill

A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?

Decreased edema formation

A nurse is caring for a client who is pulling on his NG tube. Which of the following actions should the nurse take first?

Determine the clients level of comfort

A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during death and dying. Which of the following information should the nurse include?

Devout practitioners of Islam prefer to have their heads turned toward Mecca at death.

A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider?

Gastric contents are present in the air vent.

A nurse has just finished a wound care procedure for a client. Which of the following should the nurse remove first?

Gloves

A nurse is preparing to administer an opioid analgesic IM to a client. The vial contains 2 mg of medication, but the client's prescription is for 1 mg. After administering the medication, which of the following actions should the nurse take when handling the remaining medication in the vial?

Have another nurse witness the disposal of the remaining medication.

A nurse is collecting data from a female client who has a body mass index of 32. The nurse should classify the client as which of the following?

Obesity class I

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Orthostatic hypotension

A nurse at an urgent care clinic is collecting data from a client. Which of the following information should the nurse identify as an example of subjective data?

Palpitations

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

Place a pillow between the client's legs prior to logrolling.

A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)

Place moist compresses over the eyes every 2 to 4 hr. Instill lubricating eye drops into the lower lid of each eye Apply eye patches over the eyes if the eyelids do not close completely.

A nurse is assisting with the care of a client who has a closed chest tube drainage system. Which of the following actions should the nurse take?

Place the drainage system below the client's chest level.

A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

Question the client about allergies before the procedure.

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

Record the urinary output at the end of each shift.

A nurse is reinforcing discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Request that a medical interpreter assist with translating the discharge teaching for the client.

A nurse is assisting with discharge planning for an older adult client who has vision loss. Which of the following instructions about home safety should the nurse include in the plan?

Set the maximum water heater temperature to 54.4 C (130 F)

A nurse is preparing to reinforce discharge teaching with a client who has hearing loss. Which of the following communication techniques is appropriate? (Select all that apply.)

Sit at the same level as the client. Provide the client with written information. Rephrase for better understanding.