ATI Fundamentals

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask B. A client who has emphysema and is receiving oxygen 3L/min via a transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen 2L/min via nasal cannula

A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? A. "Lunch trays should be here within the hour" B. "I am going to listen to your abdomen" C. "I'll get you some water to drink" D. "I would wait a bit, or you could feel sick"

B. "I am going to listen to your abdomen" Delayed gastric emptying or decreased peristalsis is common after surgery, so you want to listen for the presence of bowel sounds first

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction catheter back 1cm (0.5inch) if the client starts coughing B. Allow 30 seconds between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 seconds D. Perform a maximum of 4 passes with the suction catheter

A. Pull suction catheter back 1cm (0.5inch) if the client starts coughing

A nurse is helping a client change his hospital gown. The client hsa an IV infusion on an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown

A. Remove the sleeve of the gown from the arm without the IV line

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the clients diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A. Vitamin C and zinc

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

A. Don clean gloves to remove the old dressing

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating D. Walk 2 feet behind the client during ambulation

A. Use a gait belt during ambulation

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take FIRST? A. Use the pain scale to determine the clients pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the clients vital signs D. Check the clients allergies

A. Use the pain scale to determine the clients pain level

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower, medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and anterior iliac spine C. The tissue of the posterior upper arm D. The lower, inner thigh 4 finger widths above the patella

B. The side hip between the iliac crest and anterior iliac spine

A nurse is preparing to inset an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. provide the client with a glass of water B. Assist the client to a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

C. Explain the procedure to the client

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2cm (1.25 inches) of the tip of the rectal tube B. Position the client on his right side C. Insert the tip of the tubing 8cm (3.1 inches) D. Hold the enema container 61cm (24 inches) above the rectum

C. Insert the tip of the tubing 8cm (3.1 inches) Insert the tip of the tubing 3-4 inches. Lubricate 2-3 inches of the tip of the rectal tube.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound head D. Granulation tissue fills the wound during healing

D. Granulation tissue fills the wound during healing

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

D. Place the stool specimen collection container in a biohazard bag

A nurse is changing the dressings for a client who is postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate

D. Purulent exudate

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? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure in the outer opening of the eye for 2 minutes C. Hold the eye dropper 0.5cm (0.2inches) from the cornea D. Instruct the client to close eyes tightly after administration

A. Drop the eye medication into the lower conjunctival sac

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. Provide breaths with a manual resuscitation bag C. Administer oxygen D. Establish an airway

A. Start chest compressions CPR needs to be done and chest compressions is the first step

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? A. Exhale slowly to reach goal volume B. Hold breathe for 5 seconds after goal volume is reached C. Continue to deep breath between each cycle D. Limit repeat pattern of breathing to 5 breaths

B. Hold breathe for 5 seconds after goal volume is reached hold breath for 3-5 seconds after max inspiratory volume to decrease the collapse of alveoli, which prevents the risk of atelectasis and pneumonia.

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "help my baby is choking on his food". Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability of the toddler to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time 1.5 sec

B. Inability of the toddler to cry or speak

A nurse is preparing to insert an indwelling catheter for a male client. Which of the following locations should the nurse secure the urinary catheter? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen secure the catheter tubing to the clients upper thigh or lower abdomen to decrease tension and trauma to the urethra

A nurse is applying anti-embolic stockings for a client who has a history of deep vein thrombosis (DVT). Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long B. Remove the stocking once per day C. Bunch and pull the stocking half way up the calf D. Turn the stocking inside out up to the heel before applying

D. Turn the stocking inside out up to the heel before applying

A nurse is caring for an older client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing B. Offer the client tart or sour foods first C. Tilt the clients head back when swallowing D. Turn on the TV

B. Offer the client tart or sour foods first Clients with dysphagia are at risk of choking when liquids are offered while eating solid food. Tart and sour foods stimulate saliva production which helps with chewing and swallowing

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates teh nurse is maintaining sterile technique? A. Applies sterile gloves to open catheter package B. Wipes the labia minor in an anteroposterior direction C. Spreads the labia with the dominant hand D. Uses one cotton ball to wipe. the right and left labia majora

B. Wipes the labia minor in an anteroposterior direction

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes the pain worse, right?"

C. "What do you think caused the onset of your pain?"

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the clients pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

C. Determine whether the client is able to breathe

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 inch) above the eye B. Direct the irrigation solution upward toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye

C. Exert pressure on the bony prominences when holding the eyelids open

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Intill 100mL of air into the NG tube before removal C. Pinch the NG tube while removing D. Instruct the client to breathe in and out during the removal of the tube

C. Pinch the NG tube while removing

A nurse is caring for a client who is recieving an IV fluid replacement. Which of the following findings should the nurse identify as a infiltration of the IV infusion site? A. Redness at the IV B. A palpable cord is felt along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding around the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the clients weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weight the client without clothing

C. Weigh the client on arising

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device of air after emptying

D. Collapse the device of air after emptying

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the clients perineum

D. Check the clients perineum

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions hould the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

D. Clamp the tubing below the collection port Fresh urine would need to be obtained near the indwelling catheter to prevent contamination. Cleanse port with an antimicrobial swab. Place specimen in a sterile specimen cup. *Clamp the tubing below the port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup