ATI: Fundamentals questions

a nurse in the ED is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse ID as an indication of hypovolemic shock?

tachycardia

a nurse is teaching a client who has a new hearing aid. which statement indicates to the nurse that client has understanding of the teaching?

"I will reinsert the hearing aid if I hear a whistling sound" --> whistling sound can indicate incorrect insertion of the hearing aid, improper fit, or ear wax build up

A nurse is teaching a client who has lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"bear weight on both of your legs" -- the client has 3 points on the ground at all times. Therefore, he must be able to bear weight on both legs

A nurse is assessing a client who reports increased pain following PT. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"is your pain sharp or dull"-- (trying to get the quality= the characteristics of the pain, not quantifiable data)

A nurse is planning care for a client who has a single-lumen NG tube for gastric decompression. Which of the following actions should the nurse include in the plan of care?

- provide oral hygiene frequently - measure drainage from the NG tube every shift - secure the NG tube to client's gown - apply a water-soluble lubricant to the nares to prevent/relieve dry skin

a nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to make?

position the client on his left side

a nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. which of the following actions should the nurse take first?

check the pH of the client's stomach contents --> EBP: nurse should first check the pH of the aspirate by drawing up 5mL of gastric fluid. the pH should be less than 5 to conform gastric placement

a nurse is performing guaiac testing for a client to screen for colon cancer. the nurse should identify that ingestion of which foods can cause a false negative result?

citrus fruits --> clients should not consume citrus fruits or juices for 3 days prior to guaiac stool testing because vit C can make a false - result

A nurse if performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse ID as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance-- (an uneven or asymmetrical shape is a potential indication of a skin malignancy)

A nurse is preparing to administer enoxaparin sub-Q to a client. Which of the following actions should the nurse take?

Administer the med with the needle at a 45 degree angle

A nurse is caring for a client who is post-operative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing-- (nurse should apply safety and risk reduction priority-setting framework. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect client)

a nurse in a provider's office is reviewing the lab reports for a client who is at risk for heart disease. which of the following results should the nurse report to the provider?

LDL 170 mg/DL --> this is above the expected reference range and places the client at increased risk for heart disease, therefore, nurse should report this finding to provider

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 nurse is reviewing a client's ABG lab results. which of the following ABG results should the nurse report to the provider?

PaCO2 32 mmHg --> this is below the expected range of 35-45 mmHg, should be reported to provider

a nurse is planning care for 4 clients. which of the following clients should the nurse see first?

a. client with diabetes mellitus and a fasting blood glucose of 68 mg/dL b. client who has moderate serosanguinous drainage on a surgical dressing c. client who has pneumonia and expiratory wheezing d. client who has a PCA pump and reports pain as 7/10 --- C. ABC approach- assess the client's airway and breathing, which could be impaired as a result of the pneumonia. Nurse should auscultate lungs and measure their oxygen saturation.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which therapy?

acupuncture-- (the nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. an open portal on the skin's surface could increase the risk of further infection)

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

airway-- (nurse should apply ABC framework)

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of client's fluid status?

daily weight--> daily weight provides important information about client's fluid status. A gain or loss of 1 kg (2.2lb) indicates a gain or loss of 1 L of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement - not intake and output; it does reflect client's fluid status, but not the most accurate method to measure fluid changes

A nurse is reviewing the lab values for a client who has a positive Chvostek's sign. Which of the following lab findings should the nurse expect?

decreased calcium-- calcium is necessary for nerve conduction and muscle contractions. When client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of client's ear. If facial twitching follows this stimulus, it's a positive Chvostek's sign and an indication of hypocalcemia

a nurse is reviewing the medical record for a client receiving continuous enteral feedings. which of the following findings should the nurse report to the provider?

gastric aspirate pH of 7 --> nurse should identify that a gastric pH of 7 is an indication that the nasogastric tube is not in the stomach. Gastric pH is usually between 1-4 but can be up to 6, if client receives med that alters gastric pH. client is at risk for aspiration and the nurse should report this finding to provider

a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which type of dressing should the nurse use?

hydrocolloid-- (bc this type of dressing promotes healing in stage 2 pressure injuries by creating a moist wound bed

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 the ED and I had difficulty breathing?" which response should the nurse make?

"we would give you oxygen through a tube in your nose"-- (oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula; intubation is a resuscitative measure [ex:breathing tube insertion])

a nurse is completing an informed consent document for a 16 year old adolescent who is married and is scheduled for an emergency appendectomy. which of the following actions should the nurse take?

ask the client if they understand the provider's plan for the appendectomy-- to ensure informed consent the nurse should ask client if they understand planned procedure

a nurse in a community health center is teaching a group of clients about the use of aromatherapy. the nurse should include in the teaching that which essential oil is used to alleviate swollen joints?

chamomile --> has anti-inflammatory properties that can be used to alleviate swollen joints and muscle aches

a nurse is performing a preoperative assessment on 4 clients. the nurse should identify that which of the following clients is at risk for a latex allergy?

client who has spina bifida --> bc of their history of frequent contact with latex products, such as urinary catheters. nurse should use latex-free products to reduce risk for a hypersensitivity reaction

a nurse is evaluating the developmental motor skills of a 4 month old infant. which of the following findings should the nurse expect?

sits up with support--> by this age, infant should have no head lag when sitting

nurse is repositioning a client in bed. which action should the nurse take when using ergonomic principles to move the client?

tighten the abdominal muscles --> this prevents muscle injury

a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement?

use the planning step of the nursing process to prioritize client-care delivery-- (setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. the priority to-do list is an efficient tool for optimal time management)

a nurse is planning to perform postmortem care for a client. which of the following actions should the nurse plan to take?

verify whether the client requires an autopsy--> nurse should verify whether client needs autopsy before completing postmortem care or removing any indwelling lines, tubes, or catheters

a nurse is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin. which of the following actions should the nurse take first when mixing the insulin?

inject 25 units of air into the NPH vial of insulin --> according to EBP: nurse should first inject 25 units of air into the NPH vial of insulin to prevent contamination of the rapid-acting regular insulin with the intermediate-acting NPH insulin and to equalize the pressure in the vial when insulin is later removed

nurse is preparing a room for a client who is transferring from ED and is on seizure precautions. which of the following items should nurse place in client's room?

oral-nasal suction--> to clear client's airway, which reduces the risk for aspiration

a nurse is performing medication reconciliation with a client. which of the following actions should the nurse take first?

ask the client if she takes any OTC medications --> first action when using the nursing process is to assess the client's current use of prescription and nonprescription medications, vitamins, and herbal supplements to obtain a complete list for comparison to the provider's admission prescriptions

A nurse is assessing a client who has heart failure. Client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

bounding pulse

a nurse is teaching a client how to perform active ROM exercises of the lower extremities to improve mobility. which of the following instructions should the nurse include in the teaching?

complete each session 2 times per day --> doing ROM exercises 2x/day reduces the risk for injury. *also should perform each exercise 3x/session to reduce risk for injury.

the nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

tie the restraint with a quick-release knot-- (so that it can be untied easily in case the client's well-being requires quickly removing the restraints)