ATI Fundamentals Practice Questions 2017 B

A nurse is performing a Romberg test for a client who reports episodes of dizziness. Which of the following instructions should the nurse give the client A. Walk in a straight line, placing the toes of one foot against the heel of the other foot. B. Stand with your feet together C. Close your eyes and stand on your right foot. D. Hold your arms out in front of you

B. - the romberg test measures clients stability when standing with their feet together, first with eyes open, then with eyes closed. the test is negative if clients can remain upright and keep their balance with minimal swaying and without moving their feet to another position for 5 seconds

A nurse is talking with a client who states that her teenage child has become rebellious and might be using illegal substances. Which of the following responses should the nurse make? A. If I were you, Id ask your child directly if they are using drugs B. I think you're right. Substance use would explain the changes in your childs behavior C. You're suspecting that your childs behavior changes could indicate substance use D. Why do you think your child would want to use drugs?

C. - with this response. the nurse is using therapeutic communication technique of paraphrasing by restating th clients message in the nurses own words. This lets the client know that the nurse is interested in understanding her concerns and hearing more about them

A nurse is reviewing the documentation of a newly hired nurse who provided discharge instructions to a client who speaks a different language than the nurse. Which of the following statements in the clients record reflects that the nurse followed guidelines to meet the clients language needs? A. Confirmed clients understanding of discharge instructions B. Clients adult child nodded when asked if she understood discharge instructions C. Client discharged with written instructions for home care. D. Used the facility's medical interpreter to convey and confirm discharge instructions

D. - This example is specific, objective, and factual. The nurse used a medical interpreter, not a family member, to convey the discharge instructions and confirm that the client understood them

A nurse is caring for a client who is receiving palliative care at the end of life. The client tells the nurse that one of her worst fears is dying alone. Which of the following actions should the nurse take? A. Remind the client that they need to rest and cant have someone with them all the time B. Tell the client not to worry about being alone and that it is a common fear. C. Assure the client that the nursing staff will never leave them alone D. Encourage the clients family members to stay overnight

D. - nighttime is especially difficult and lonely for clients who are dying. No matter what the facility visiting times are the nurse should make expectations to help prevent the client from feeling alone. It is also comforting for families to have open access to the client.

A nurse is reinforcing discharge teaching with a client who is to receive home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. Ill keep my oxygen tank lying on the floor next to my recliner B. Ill keep my oxygen at least 4 feet away from any source of heat C. When my brother visits, ill make sure he smokes in the next room D. Ill avoid wearing any wool or synthetic fabric when my oxygen is on

D. - the nurse should verify that the client understands that wool and synthetic fabrics can generate static electricity, which could cause a spark and therefore, combustion. The nurse should instruct the client to wear cotton clothing and use cotton bedding

A nurse is caring for a client who is grieving following the death of her parent. Which of the following actions should the nurse take? A. Refer the client for psychological care if she is not eating or sleeping well B. Avoid discussion of the facts surrounding the death C. Discourage reminiscence about the past experiences with her parent D. Offer personal presence and silence

D. - this approach encourages the client to express her feelings and to assure her that the nurse will take the time to understand how she feels

A nurse is reinforcing teaching about range of motion of exercises for a client who is postoperative and has a history of thrombophlebitis. Which of the following instructions should the nurse include to help prevent thrombophlebitis? A. You should alternate pointing your toes upward and downward B. You should move your leg out to the side and then bring it back to the center C. You should spread your toes apart and then bring them back together D. You should lift your entire leg upward and then back down

A. - to help prevent thrombophlebitis, the client should perform antiembolic exercises, including ankle pumps, foot circles, and knee flexion. for ankle pumps, the nurse should instruct the client to alternate plantar and dorsiflexion

A nurse is caring for a client who is immobile. To help prevent hip flexion contractures, the nurse should periodically assist the client into which of the following positions? A. Prone B. Supine C. Lateral D. High-Fowlers

A - prone position is the only bed position in which the client has full extension of the hip and knee joints. the nurse should use this position to help prevent flexion contractures of the hip and knee joints while the client is immobile. the nurse should ensure that the clients back is correctly aligned when the client is placed in the position

A nurse is preparing to assist a provider with a sterile procedure on a client's surgical wound. Which of the following actions should the nurse take? A. Prepare a container of sterile solution before putting on sterile B. Place the cap of a bottle of sterile solution on the sterile field with the caps interior surface facing downward C. Open the outside packaging of a sterile instrument and drop it onto the edge of the sterile field D. Open the sterile pack by first unfolding the flap closest to their body

A. - a bottle of sterile solution is sterile inside and contaminated on the outside. Handling the bottle with sterile gloves contaminates the gloves. The nurse should pour the sterile solution

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include? A. Try to suppress the urge to urinate until the scheduled time B. Drink carbonated beverages to help with urinary retention C. Awaken every 2 hr during the night to urinate D. Restrict fluid intake to no more than 1 L during waking hours

A. - when clients follow a schedule of voiding intervals and feel the urge to urinate before the next time, they should try slow, deep breathing to help diminish the urge. clients can also try performing five or six strong and quick pelvic muscle exercises.

A nurse is caring for a client who is postoperative and has a prescription for a clear liquid diet. The nurse should remove which of the following items from the client tray? A. Lime-flavored gelatin B. Orange sherbet C. Black coffee D. Cranberry juice

B. - clear liquid diet includes only foods that are clear at room or body temperature

A nurse is assisting with the admission of a client who has streptococcal pharyngitis. Which of the following types of transmission-based precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

B. - droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, diphtheria, pertussis, mumps, and streptococcal pharyngitis.

A nurse is caring for a client who is experiencing pain. The nurse administers pain medication and informs the client. "I will return in 30 minutes to check on you." Which of the following ethical principles in the nurse demonstrating upon returning within 30 min to check on the client? A. Veracity B. Fidelity C. Justice D. Nonmaleficence

B. - the nurse follows through by returning within 30 min to check on the client

A nurse is caring for a client who has been prescribed wrist restraints. Which of the following actions should the nurse take? A. Check that three fingers fit under the restraint B. Remove the restraints at least every 2 hr C. Tie a double knot with the restraint straps D. Attach the restraints straps to the side rails

B. - the nurse should remove the restraint every 2 hr to reposition the client, provide fluids and nutrients, assist with range of motion exercises, and evaluate the clients status

A nurse in a long term care facility is assisting with the admission of a client who had a stroke. The nurse should report which of the following findings as a possible manifestation of dysphagia? A. Rapid speech B. Dry mouth C. Pocketing food D. Hiccups

C. - incomplete oral clearance or retaining food in the cheeks under the tongue or on the hard palate is a common manifestation of dysphagia

A nurse in an orthopedic clinic is reinforcing teaching with a client who has a back injury from loading a desk onto a truck. Which of the following instructions about lifting objects should the nurse include? A. Relax your stomach muscles when lifting an object B. Stand with your feet close together when lifting an object C. Hold the object to your body as you lift it D. Twist at the waist when you move an object to the side

C. - the client should keep the object as close to their body as possible to keep it close to the clients center of gravity. This should help to maintain balance and prevent further injury

A nurse is observing a client who is using a cane while recovering from an injury to the left ankle. Which of the following actions should the nurse identify as an indication that the client is using the cane correctly? A. Holding the cane on the weaker side of the body B. Moving the cane foward 40 cm(16 in) C. Moving the left leg foward to the cane D. Keeping at least one point of support on the floor

C. - after moving the cane foward the client should advance the weaker leg foward to the cane. For this client that is the left leg

A nurse is providing handoff report for a client who has a chest tube in place. Which of the following information should the nurse include in the report? A. The clients visits from family and friends B. The clients family history of cardiovascular disease C. The amount and characteristics of drainage D. The need to check vitals signs at 1600 and 2000

C. - for a client who has a chest tube, the amount and characteristics of the drainage provide important information about the clients current respiratory and immune status and are an essential component of change of shift report

A nurse is assisting with obtaining informed consent for a client who is perioperative. Which of the following actions should the nurse take? A. Explain the risks and the benefits of the surgery B. Describe alternative treatments that are available C. Inform the client about the procedure D. Witness the clients signature

D - the nurse role during the informed consent process includes witnessing the clients signature on the informed consent form. the nurse confirms that the client is competent to give voluntary consent and to sign the form

A nurse has administered and intramuscular injection to a client. To prevent a needlestick injury, which of the following actions should the nurse take? A. Recap the needle while at the bedside B. Place the needle and syringe in a biohazard bag C. Dispose of the needle and syringe in the waste basket. D. Discard the needle and syringe in a sharps disposal container

D. - without recapping the needle, the nurse should immediately drop the needle and syringe in a designated puncture-proof and leakproof and sharps disposal container. This prevents any further handling of the needle by the nurse or any other staff members and thus reduces the risk for needlestick injuries

A nurse enters a clients room and finds smoke and flames coming from a wastebasket. Which of the following actions should the nurse take first? A. Activate the fire alarm system B. Attempt to extinguish the fire C. Close the door to the clients room D. Move the client to the nearest common area

D. - the greatest risk to this client is injury from burns and smoke inhalation; therefore the first action the nurse should take is to remove the client from the dangerous area. The acronym RACE is a reminder of the order of the actions to take in a fire; Rescue or remove the client from the immediate danger, activate the fire alarm system, confine the fire by closing doors and windows, and extinguish the fire, if possible with a fire extinguisher.