ATI Funds Practice Test 5
A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client developed delirium? Gradual memory loss Reduced level of consciousness Difficulty with abstract thought Verbalized feelings of hopelessness
Reduced level of consciousness
A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new like in 30 min. Which of the following actions should the nurse take? Return the blood to the laboratory Place the blood in the medication room Place the blood in the refrigerator Leave the blood at the client's bedside
Return the blood to the laboratory
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection? WBC 15,000 mm^3 Erythrocyte sedimentation rate (ESR) 15 mm/hr Urine pH 7.2 Urine specific gravity 1.0063
WBC 15,000 mm^3
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? Place the client in a semi-private room Wear a mask when providing care Wear a gown when in the client's room Dispose of all bed linens used by the client
Wear a gown when in the client's room (contact isolation=gloves and gown)
A nurse in a provider's office is measuring a client and notes a loss height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? Osteoporosis Scoliosis Kyphosis Lordosis
Osteoporosis
A nurse is preparing to administer an intramuscular injection to a young client which of the following injection sites is the safest for this client? Vastus lateralis Dorsogluteal Deltoid Ventrogluteal
Ventrogluteal (safest for all adults)
A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teachings? "Fats provide energy" "Carbohydrates repair body tissue" "Fats regulate fluid balance" "Carbohydrates prevent interstitial edema"
"Fats provide energy" (9cal/g of energy) INCORRECT: "Carbohydrates repair body tissue"--> PROTEIN "Fats regulate fluid balance"--> PROTEIN "Carbohydrates prevent interstitial edema"--> ALBUMIN aka protein
A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscle he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? Antigravity Antagonistic Synergistic Skeletal
Antagonistic INCORRECT: Antigravity=stabilizing the knee joint Synergistic=contracting in sync Skeletal=support and posture
A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take? Have a client urinate 20 min before the scan Assist the client into a semi-Fowler's position Position the scanner head at the symphysis pubis Apply light pressure to the scanner head once it is in position
Apply light pressure to the scanner head once it is in position (hold it steady while pointing it slightly down toward the client's bladder) INCORRECT: Have a client urinate 20 min before the scan--> should be 10 MIN before Assist the client into a semi-Fowler's position--> SUPINE position Position the scanner head at the symphysis pubis--> ABOVE the symphysis pubis
A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? Pulse rate 90/min Rectal temp 38C (100.4F) Pulse ox 95% BP 145/90 mmHG
BP 145/90 mmHG
A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? Select all that apply Canned peaches White rice Black beans Whole-grain bread Tomato juice
Black beans Whole-grain bread
A nurse in a provider's office is assessing a 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? Sunken eyeballs Hypotension Poor skin turgor Bounding pulse
Bounding pulse
A nurse is caring for a client who requires a peripheral IV insertion. When choosing a site, which of the following sites should the nurse select? Select a vein in the client's dominant arm Choose the most proximal vein in that extremity Choose a vein that is soft on palpation Select a site distal to previous venipuncture attempts
Choose a vein that is soft on palpation (bouncy feeling)
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? Check the client's name and medical record number on the MAR against the room and bed number Call the client by name and check the name on her identification band against the MAR Compare the medical record number and name on the MAR with the client's identification band Ask the client's visitor to identify the client by name and to state the client's birth date
Compare the medical record number and name on the MAR with the client's identification band
During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? Confrontation test Symmetry of palpebral fissures Corneal light reflex Accommodation test
Corneal light reflex (the eyes will not align when the client focuses)
A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? Acceptance Bargaining Anger Denial
Denial
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? Don a gown before entering the room and remove it before exiting Wear a mask while in the client's room Don gloves when entering the room and use hand sanitizer when exiting Take no special precautions unless engaging in direct contact with the client
Don gloved when entering the room and use hand sanitizer when exiting (no direct contact with client)
A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? Eggs Cereal Peanut butter Pasta
Eggs
A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? Limit the client's fluid intake Assist the client into a supine position Administer oxygen at 2 L/min Encourage the client to cough
Encourage the client to cough
A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hr fluid intake in millimeters that the nurse should document for this client?
1560 1oz/30ml= 4oz/Xml x=120 1pint/480mL= 0.5 pint/XmL x=240 150ml x 8 hr= 1200 ml+ 120 ml+ 240 ml= 1560 mL
A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? 6 2 10 8
2 (0-4 for gastric secretion) ACIDIC INCORRECT: 6= lungs 10=false reading 8=intestines
A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? Assume an open position Sit upright and lean back into the chair Avoid direct eye contact until the client makes it Sit next to the client
Assume an open position (sit with arms and legs uncrossed)
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the the following actions should the nurse perform first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing Have the client lie on his back with his knees flexed Call the client's surgeon Reassure the client
Cover the incision with a moist sterile dressing
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? Auscultate bowel sounds after each feeding Ensure the formula is cold before administering Elevate the head of the bed to 45 before the feeding Flush the tubing with 15 mL of water after the enteral feeding
Elevate the head of the bed to 45 before the feeding (30-45) INCORRECT: Auscultate bowel sounds after each feeding--> BEFORE Ensure the formula is cold before administering --> ROOM TEMP Flush the tubing with 15 mL of water after the enteral feeding--> 30ML
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Limit the total caloric intake to 25 kcal/kg of body weight Provide an intake of 500 mg/day of vitamin E Limit fluid intake to 20 mL/kg of body weight per day Provide a protein intake of 1.5 g/kg of body weight per day
Provide a protein intake of 1.5 g/kg of body weight per day (necessary to maintain a positive nitrogen balance--> this promotes wound healing)
A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? Vesticular Bronchial Rhonchi Bronchovesicular
Vesticular (soft and low-pitched) INCORRECT: Bronchial (trachea) Rhonchi (trachea) Bronchovesicular (sternal border)
A nurse is planning care for an adult client who has fluid volume excess. Which fo the following interventions should the nurse plan to include to monitor the client's weight? Calibrate the scales weekly Use a different scale each time Weigh the client on arising Weigh the client without clothing
Weigh the client on arising
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? Instruct the client to blink several times after instilling the medication Ask the client to look straight ahead during instillation of the medication Apply pressure to the puncta after instilling the medication Place the eye drop of the medication directly onto the client's cornea
Apply pressure to the puncta after instilling the medication (1-2 min)
A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? Complete a medication error report Notify the prescribing provider Assess the client Notify the charge nurse
Assess the client
A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? Calcium 9.5 m/dL Sodium 150 mEq/L Potassium 4mEq/L Magnesium 1.5 mEq/L
Sodium 150 mEq/L (135-145) INCORRECT: magnesium= 1.3-2.1 potassium= 3.5-5
A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature Rectal Tympanic Oral Temporal
Temporal
A nurse on a med-surg unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique? The nurse washes each part of her hands with 5 stroked The nurse washes from the elbows down to the hands The nurse holds her hands higher than her elbows while washing The nurse uses minimal friction when washing her hands
The nurse holds her hands higher than her elbows while washing
A nurse is calculating a client's intake for a 12 hour shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, ranitidine 50 mg in 50 mL at 1000 and 1600, 250 mL every 2 hours. What is the total intake in millimeters the nurse should document for this 12 hour period.
2130 125ml x 12hr= 1500+100+(50 x 2=100)+250+ (30 x 6= 180)= 2130
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? "It provides a distraction from the pain" "It modulates the transmission of the pain impulse" "It promotes increased circulation to the painful area" "It elicits a relaxation response"
"It modulates the transmission of the pain impulse"
A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods". Which of the following statements should the nurse make? "During this phase, feed your child anything that she will eat" "Increase the amount of calories and water your child consumes" "Keep a diary of the foods your child eats each day" "Provide a large variety of fruit juices for your child to choose from"
"Keep a diary of the foods your child eats each day"
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask the encourage discussion with the client? "Does the medication you're taking relieve the pain?" "Can you point to where the pain is the worse?" "What do you think caused the onset of your pain?" "Changing positions makes your pain worse, right?"
"What do you think caused the onset of your pain?"
A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? Eggs Soybeans Lentils Yogurt
Lentils (missing 1 or more of the essential amino acids= lentils, veggies, grains, nuts, seeds)
A nurse is teaching a client how to perform ROM exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? "With your palm facing down, move your wrist sideways toward your thumb" "Move your palm toward the inner part of your forearm" "With your palm facing down, move your wrist sideways toward your little finger" "Bring the back of your hand as far back toward the wrist as you can"
"With your palm facing down, move your wrist sideways toward your thumb" INCORRECT: "Move your palm toward the inner part of your forearm"= flexing "With your palm facing down, move your wrist sideways toward your little finger" =abducting "Bring the back of your hand as far back toward the wrist as you can"= hyperextending
A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8oz of milk, 10oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake?
660mL
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? Encourage the client to listen to soft music Instruct the client to practice tai chi Place a jasmine-scented air freshener in the client's room Offer the client ginger tea
Encourage the client to listen to soft music (music therapy)
A new resident provider asks the charge nurse for an access code to review client's online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? Explain that it is against policy to share access codes and refer the resident to the supervisor Access the client's online data and monitor the resident as he reads them Access the online system and allow the resident to locate the client's data Ask each client to give permission for the resident to access medical records
Explain that it is against policy to share access codes and refer the resident to the supervisor
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? Give the client a glass of water Assist the client in a sitting position Explain the procedure to the client Measure the length of tubing to be inserted
Explain the procedure to the client
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? Hyperoxygenate the client before suctioning Insert the catheter during exhalation Apply suction during insertion of the catheter Apply suction for no more than 15 sec
Hyperoxygenate the client before suctioning (use a manual resuscitation bag to hyperoxygenate the client for several mins before suctioning)
A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? Whole milk Chicken Oranges Dried peas
Whole milk
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Redness at the infusion site Edema at the infusion site Warmth at the infusion site Oozing of blood at the infusion site
Edema at the infusion site (due to fluid entering subcutaneous tissue) INCORRECT: Redness= phlebitis or infection Warmth= phlebitis or infection Oozing of blood= IV system is not intact
A nurse is caring for a client who had a stroke and is at risk for of fallings. Which of the following actions should the nurse take? Assign the client to a private room Keep 4 side rails up while the client is in bed Monitor the client at least once every hour Request a PRN prescription for restraints
Monitor the client at least once every hour
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? Hold the irrigator 1.25 cm (0.5 in) above the eye Direct the irrigation solution up toward the upper eyelid Exert pressure on the bony prominences when holding the eyelids open Direct the irrigation from the outer canthus to the inner canthus of the eye
Exert pressure on the bony prominences when holding the eyelids open (upper lid=against eyebrows lower lid= against cheekbone) INCORRECT: Hold the irrigator 1.25 cm (0.5 in) above the eye--> should be 2.5 in
A nurse is teaching a client about the lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? Identify the risks of nonadherence Schedule learning sessions to demonstrate the psychomotor skills the client will read Provide clearly written and easy-to-understand materials Help the client identify ways that these changes will result in positive personal outcomes
Help the client identify ways that these changes will result in positive personal outcomes
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following type of drainage? Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate
Purulent exudate (thick yellow, green, or brown drainage= sloughing or infection) INCORRECT: Sanguineous exudate (accumulation of RBCs from the plasma that appears bright red on the dressings) Serous exudate (plasma= appears watery and clear to light yellow) Serosanguineous exudate (pale yellow to blood tinged)
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observed the client crying? Contact the family and ask someone to stay with the client Offer to call the client's minister Sit and hold the client's hand Leave the room and allow the client to cry privately
Sit and hold the client's hand
