ATI fundamentals Practice Test A
Steps for postmortem care
1-obtained the pronouncement of death from the provider 2-remove to the indwelling lines 3-wash the clients body 4-ask the clients family if they would like to view the body 5-please a name tag on the body
The clients caregiver washes out the feeding bag with warm water once every 24 hours
A home health nurse is performing a follow up visit for a client who has a gastrostomy Tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
Press gently on the tragus of the clients ear
A nurse is a ministering in otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
Decrease in the heart rate
A nurse is administering one L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Calf swelling
A nurse is assessing A client who has required a bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
A: Is your pain sharp or dull
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following question should the nurse asked when assessing the quality of the clients pain?
-visual acuity -visual fields -pupil clarity
A nurse is assessing an older adult clients risk for falls. Which of the following assessment shut the nurse to use identify the client safety needs?
Ensure the bladder of the blood pressure cuffs around 80% of the clients arm
A nurse is assessing for adult clients. Which of the following physical assessment take me to share the nurse use?
Examine personal values about the issue
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
Where again when caring for the client
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
Advocacy ensures client safety health and rights
A nurse is preparing education program for staff about advocacy. Which of the following information should the nurse include?
Ask another nurse to observe the medication wastage
A nurse is preparing to administer an injection of an opioid medication to the client. The nurse draws out 1 mL of the medication from eight to milliliter vials. Which of the following actions should the nurse take?
Have a client take sips of water to promote insertion of the NG tube into the esophagus
I'm nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
Use tracheostomy covers when outdoors
Nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
"I can concentrate best in the morning"
The nurse is assessing a client waiting is to learn about insulin self administration. Which of the following statement should the nurse identify as an indication that the client is ready to learn?
Notify the Nursing manager
The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhaging shock. The nurse notified the surgeon who tells the nurse to continue to measure the clients vital signs every 15 minutes and report back within one hour. Which of the following actions should the nurse take next?
Check the client for injuries
The nurse is responding to a call light and find a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Abdominal cramping
A nurse is caring for a client who has a sodium level of 125mEq/L Which of the following findings should the nurse expect?
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
107
During the admission process
A nurse is admitting a client who is having in exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning.
Compare the clients home medications with the providers prescriptions
A nurse is admitting a new client. Which of the following actions should the nurse take my performing medication reconciliation?
" they indicate the form of treatment a client is willing to except in the event of a serious illness"
A nurse is caring for a client who ask about the purpose of advance directives. Which of the following statements shit the nurse make?
Apply intermittent section when withdrawing the catheter
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Turn the client every two hours
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in there airway. Which of the following actions should the nurse take?
" I am rely on support from our family during this time"
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the clients partner indicates effective coping?
" I am available to talk if you would like to change your mind"
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discuss his treatment options and then leave the room. When the nurse asked if the client would like to discuss any concerns, the client declines. Which of the following statements at the nurse make?
Use a bed exit alarm system
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
Acupuncture
A nurse is caring for a client who has herpes zoster and asked the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contradiction for which of the following therapies?
Droplet
A nurse is caring for a client who has pharyngeal diphtheria . Which of the following types of transmission precaution should the nurse initiate?
Reassure the client that this is an expected a response to grief
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Determine the reasons why the client is refusing to use the incentives spirometer
A nurse is caring for a client who is post operative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurses priority?
Make sure to fingers can fit under the sleeves
A nurse is caring for a client who is post operative following a knee arthroplasty and requires the use of a Thigh sequential compression sleeves. Which of the following actions should the nurse take?
Leominster pain medication 45 minutes before changing the clients dressing
A nurse is caring for a client who is post operative. When the nurse prepares to change her dressing she says " every time you change my bandage, it hurts so much" Which of the following interventions is the nurse is priority action?
Place a client who has tuberculosis in a room with negative pressure airflow
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
We will give you oxygen through a tube in your nose
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks " what would happen if I arrived at emergency department and I had difficulty breathing?" Which of the following response that shit the nurse make?
The client holds the cane on the stronger side of her body
A nurse is evaluating a clients use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
Make sure the client wears a mask went outside her room if there is construction in the area
A nurse is initiating a protective environment for a client who has had an allergenic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Stay in close to the cabinet when lifting it
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self injury, which of the following actions should the nurse take when lifting this object?
The client identifies the location of a fire extinguisher
A nurse is performing a home safety Assessment for a client who is receiving supplemental oxygen. Which of the following observation shit the nurse identify as proper safety protocol?
A mole with the asymmetrical appearance
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
Use the planning step of the nursing process to prioritize client care delivery
A nurse is planning strategies to manage time affectively for client care. Which of the following strategy should the nurse implement?
Place the client's arm in a dependent position
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse take?
SBAR (situation-background-assessment-recommendation)
A nurse is preparing a change of shift report. Which of the following tools or document should the nurse use to communicate continually of care?
Administer The medication with the needle at 45° angle
A nurse is preparing to administer enoxaparin Subcutaneously to a client. Which of the following actions should the nurse take?
Hydrocolloid
A nurse is preparing to apply addressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
Administer the medication into the abdomen
A nurse is providing discharge teaching to the client about self administering heparin. Which of the following should the nurse include in the teaching?
Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
A nurse is reviewing evidence-based practice principles about administering of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Let's talk about how the change in your job status will affect you
A nurse is talking with the older dog client who is contemplating retirement. The client states "I keep thinking about how much I enjoy my job. I'm not sure I want to retire". What are the following responsive to the nurse make?
role overload
A nurse is talking with the partnerI have a client who has dementia. The clients partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role performance stress?
Subtract the amount of irrigant used from the clients urine output
A nurse is using an open irrigation tech need to irrigate a clients indwelling urinary catheter. Which of the following actions should the nurse take?
Use the complete name of the medication magnesium sulfate
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements at the nurse manager plan to include in the teaching?
Pad the clients wrist before applying the restraints
A nurse on a MedSurg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?