ATI Fundamentals Quiz

A nurse observes assistive personnel (AP) preparing to obtain bp w/ a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

"Using a cuff that is too small will result in an inaccurately high reading"

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

-Provide oral hygiene -Measure the amount of drainage from the NG tube every shift -Secure the NG tube to the client's gown

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of info should the nurse include?

A 10-month-old infant can pull up to a standing position

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear

A nurse is admitting a client who has measles. Which of the following transmission precautions should the nurse initiate?

Airborne

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the med, which of the following actions should the nurse take?

Apply pressure to the puncta after instilling the medication

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally" Which of the following qualities?

Bounding

A nurse in a provider's office is assessing a client who has heart failure. The client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

Bounding pulse

A nurse is performing a neurological assessment for a client. By asking the client to stick out the tongue, which of the following cranial nerves is the nurse testing?

CN XII (Hypoglossal)

A nurse is caring for a client who is having *difficulty w/ muscle coordination* following a head injury. The nurse should suspect injury to which of the following areas of the brain?

Cerebellum

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding ?

Chronic hypoxemia

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect data?

Corneal light reflex

A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect?

Crackles in the lung

The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document as expected finding

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye med into the lower conjunctival sac

A nurse is teaching assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level

A nurse is auscultating a client's lungs and identifying ronchi over the trachea and bronchi. Which of the following actions should the nurse take?

Encourage the client to cough

A nurse is performing eye irrigation for a client who has exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. The manifestation is consistent with which of the following eye disorders?

Glaucoma

A nurse is caring for a client who has tracheostomy and requires suctioning. Which of the following actions should the nurse take?

Hyperoxygenerate the client before suctioning

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid w/ a facial tissue. After observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after installation

A nurse is reviewing a client's lab result results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following conditions?

Leukopenia

A nurse is performing a physical exam of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

Lungs

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

Palpation

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Perform a blanch test checks capillary refill, indicates peripheral circulation and tissue perfusion

Nurse auscultates a high pitched scratching sound during systole and diastole w/ diaphragm of the stethoscope. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremeities

A nurse is obtaining the bp in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position w/ the head turned to the side before beginning the procedure (reduces the risk of aspiration of fluids and secretions)

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in the Trendelenburg position

A nurse is performing a neurological assessment of a client. To promote safety during the exam, the nurse stands nearby as the client follows the instructions for which of the following tests?

Romberg

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain

A nurse is assessing a client's respiratory sys. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields

Vesicular

A nurse is planning care for an adult who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising