ATI Fundamentals Practice Questions
According to ATI, how far above last palpated pulse should nurse inflate bp cuff?
30 mmHg
A nurse is teaching a client with lower extremity weakness to use a 4 point crutch gait. Which of the following instructions should the nurse include in the teaching? a. support the weight on your axillae b. keep your elbows extended c. bear weight on both of your legs d. move both crutches forward at the same time
Answer: C b/c need 3 points of contact with ground at all times
Injured Left Leg: Crutch Use a. when descending stairs, I will first shift my weight onto my L leg b. I should place my crutches 12 in in front and to side of cane
Answer: A --> first shift body weight onto unaffected leg b--> place crutches 15cm (6 in) in front and to side of cane
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? a. Hyperoxygenate the client before suctioning b. Insert the catheter during exhalation c. Apply suction during insertion of catheter d. Apply suction for no more than 15 sec
Answer: A b/c nurse should use manual resuscitation bag to hyperoxygenate client for several minutes prior to suctioning b--> insert during inhale c --> no suction during insertion d --> suction for no more than 10 sec
Older adult with dysphagia. What action is appropriate? a. encourage client to drink fluids before swallowing food b. offer client tart or sour foods first c. tilt client's head backward when swallowing d. turn on television
Answer: B b/c stimulates saliva production to aid in swallowing NOT A b/c thin fluids risk for choking, best to suggest dry swallows to clear mouth between bites of food
A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify the purpose of inflating the cuff is (SATA) a.allowing client to speak b. stabilize position of tube c. prevent aspiration of secretions d. prevent air leaks e. prevent tracheal injury
Answer: B, C, D NOT E b/c overinflation could cause tracheal injury
A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect? a. BUN 18 mg/dL b. Cap refill 1.5 seconds c. Hct 55% d. Urine specific gravity 1.001
Answer: C A & B normal Hypovolemic Shock: elevated hematocrit, weak pulse, tachycardia, hypotension, tachypnea, slow cap refill, elevated BUN, increased urine specific gravity, decreased urine output this is a low urine specific gravity indicating hypervolemia (normal 1.005 - 1.030)
A hospice nurse is reviewing religious practices with new nurse. Which indicates understanding? a. Islamic: pray over decreased 5 days before burial b. Hindu: bury with head facing N c. Judaism: stay with body of deceased until burial d.Buddhist: female family prep body following death
Answer: C Islam: body washed, wrapped, buried ASAP Hindu: head faces N, but cremation more common Buddhist: Male family members prep body
Which client can have an MRI? a. coronary artery stents b. aneurysm clip c. hearing aids d. automated internal defibrillator
C. b/c hearing aids can be removed
Blowing sounds indicate what?
bruit --> narrowed arterial lumen
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which action should nurse take? a. maintain suction while removing NG tube b. instill 100mL of air into NG tube before removal c. pinch NG tube while removing tube d. instruct client to breath in and out during removing
Answer: C Pinch, instill 50mL of air into tube to clear drainage contents, take +hold deep breath --> decreases risk of aspiration of gastric contents Disconnect from suction
A nurse is administering a cleansing enema to a client who is scheduled to have a diagnostic procedure. Which of the following actions should the nurse take? a. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube b. Position client on right side c. Insert Tip of tubing 8cm (3.1 in) d. Hold enema container 61 cm (24 in) above the rectum
Answer: C a -->lubricate 5-8cm (2-3 in) b --> left Sim's to promote retention of enema d --> max of 45 cm (18 in) above rectum to prevent painful distention of colon
A nurse is caring for a client who is receving fluid through peripheral IV catheter. Which indicates infiltration? a. Purulent edema b. Warmth c. Skin blanching d. bleeding
Answer: C (also edema, coolness) b--> phlebitis
A nurse is assisting a client who has R-sided weakness while ambulating using a cane. Which of the following client actions indicate that the client understands procedure of cane walking? a.client holds cane on affected side b. client advances unaffected leg followed by cane c. client support weight on unaffected leg when moving cane forward d. client keeps 2 points of support on ground
Answer: D NOT C b/c client should support weight on both legs when moving cane forward
Administer multiple meds for enteral tube feeding. a. dissolve each med in 5mL of sterile water b. draw up meds together in syringe c. push syringe plunger gently when feeling resistance d. flush tube with 15 mL of sterile water
Answer: D flush w/ 15-30mL before admin & between admin of each med flush w/ 30-60mL after last admin of med dissolve meds in 30mL of water
Perioperative pt concerned about infection from blood transfusion. What should nurse say? a. ask HCP to prescribe epoetin b. ask HCP abt taking iron supplements c. ask family member to donate blood for your surgery d. Donate autologous blood before surgery
Answer: D b/c collection & re-infusion of client's own blood (3-5weeks before elective surgery) Epoetin to boost hematocrit for anemic pt Iron for low hemoglobin pt
A nurse is caring for client who has 24 hour urine collection. Which statement indicates understanding of teaching? a. I had a bm but was able to save the urine b. I have specimen in bathroom from 30 minutes ago c. I flushed what I urinated at 7:00 am and have saved all urine since d. I drink a lot, so I will fill up the bottle and complete the test quickly
Answer: c a--> 24 hr urine should be free of feces b. -->on ice c. --> discard 1st voiding then save d. -->no specified amount, save all