ATI Funds Practice Test 8
A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? "Life has its ups and downs" "I believe that I control my own destiny" "God is punishing me for something" "I like to keep my rosary beads in bed with me"
"God is punishing me for something"
A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? Palpation of both carotid arteries simultaneously Auscultation of the arteries for bruits with the bell of the stethoscope Palpation of the arteries for murmurs bilaterally Auscultation of the arteries for thrills with the diaphragm of the stethoscope
Auscultation of the arteries for bruits with the bell of the stethoscope (the bell is more effective than the diaphragm in transmitting blowing or swishing sounds)
A nurse is beginning her shift and reviewing the medication administration record (MARs) for the clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? Call the nurse to verify the client received that dosage Give the medication in a safe dosage Give the dose the provider prescribed Call the provider to clarify the dosage
Call the provider to clarify the dosage
A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. Which of the following actions should the nurse take first? Complete an incident report Check the client for injuries Make sure the client has skid-free footwear Remind the client to ask for help when getting out of bed
Check the client for injuries
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Urinary retention Cold extremities Hypertension Tachycardia
Cold extremities
A newly licensed nurse is preparing to administer medication to a client. The nurse notes that the provider has prescribed medication that is unfamiliar to him. Which of the following actions should the nurse take? Consult the medication reference book available on the unit Ask a more experienced nurse for information about the medication Call the client's provider and verify the prescription Ask the client if she takes this medication at home
Consult the medication reference book available on the unit
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. Which of the following ethical principles is the nurse demonstrating? Autonomy Fidelity Nonmaleficence Justice
Fidelity (keeping a promise) INCORRECT: Autonomy= ensuring they have the right to make personal decisions Nonmaleficence= doing no harm Justice= treating everyone fairly
A nurse is caring for a client who has the head of his bed elevated to a 45 degree angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? Sims' Prone Supine Fowler's
Fowler's
A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? From the middle of the thigh toward the wound From the left lower abdominal quadrant toward the wound From the left hip toward the wound From the wound toward the surrounding skin
From the wound toward the surrounding skin
A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Constipation Gastric ulcers Respiratory depression Liver damage
Liver damage (3-4 grams per day) INCORRECT: Constipation= opioid analgesics Gastric ulcers= aspirin Respiratory depression= opioid analgesics
A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub
Pericardial friction rub (high-pitched scratching)
A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider Sodium 140 mEq/L Potassium 3.0 mEq/L Chloride 100 mEq/L Magnesium 2.0 mEq/L
Potassium 3.0 mEq/L
A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document his findings as which of the following alterations? Palpitation Bradycardia Tachycardia Dysrhythmia
Tachycardia
A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change The emphasis the provider places on the dietary changes The learning theory the nurse uses to teach dietary changes The extent of the dietary changes planned for the client
The involvement of the client in planning the change
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Sweeping the floor Shoveling snow Cleaning windows Washing dishes
Washing dishes
A nurse is teaching client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "If I do this often, I wont experience muscle wasting" "If I do this often, I wont get pneumonia" "If I do this often, I wont get constipation" "If I do this often, I wont have a fast heartbeat"
"If I do this often, I wont get pneumonia" (to prevent respiratory complications)
A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A client who has multiple sclerosis and uses a wheelchair A client who has end-stage cirrhosis A client who has hemiplegia due to a stroke A client who has cancer and receives weekly radiation therapy
A client who has end-stage cirrhosis (life expectancy <6 months)
A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? Document the client's food allergies in the medical record Ask the client to identify the specific food allergies Monitor the client for indications of anaphylaxis Have epinephrine available for administration
Ask the client to identify the specific food allergies
A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? Document the administration of the medication Count the amount of available medication on hand and sign for it Measure the client's respiratory rate Check the medication dose and the client's identification
Check the medication dose and the client's identification
A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? Client's level of comfort and ability to participate in the interview Previous illnesses and surgeries Events surrounding the client's recent illness Sociocultural history
Client's level of comfort and ability to participate in the interview INCORRECT: WORKING PHASE for all
A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? Measure the pulse using a Doppler ultrasound stethoscope Check the client's pedal pulses Count the apical pulse rate for 1 full minute and describe the rhythm in the chart Take the pulse at each peripheral site and count the rate for 30 sec
Count the apical pulse rate for 1 full minute and describe the rhythm in the chart
A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? Place an oxygen mask on the client Check the client's pulse Determine whether the client is able to breathe Wrap arms around the client from behind
Determine whether the client is able to breathe
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Leave the bag in place for 45 mins Fill the bag 2/3 full with ice Place the bag of ice uncovered on the client's ankle Tell the client that numbness is expected when the ice bag is in place
Fill the bag 2/3 full with ice
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? The wound edges are well-approximated The wound is closed at a later date A skin graft is placed over the wound bed Granulation tissue fills the wound during healing
Granulation tissue fills the wound during healing (the wound is left open to drain and heal by secondary intention for 5-21 days) INCORRECT: The wound edges are well-approximated= PRIMARY INTENTION The wound is closed at a later date A skin graft is placed over the wound bed =both are TERTIARY INTENTION
A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? "Call me when you are ready, and I will return with the medication" "Since you were taking this medication at home, I will leave it for you to take" "I will come back in 30 mins to check that you took the medication so I can chart the time" "if you refuse to that the medication now, I cant give it to you until your next scheduled time"
I will return with the medication"
A nurse is caring for a client who is 48 hour postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Blood loss NPO status after surgery Nasogastric tube suctioning Impaired peristalsis of intestines
Impaired peristalsis of intestines (normal bowel function is delayed for up to several days following a bowel resection)
A nurse is preparing to anchor the catheter tube with tape for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh
Lower abdomen (or upper thigh)
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which fo the following actions by the newly licensed nurse requires intervention? Obtaining hydrogen peroxide for tracheostomy care Obtaining cotton balls for tracheosotmy care Obtaining sterile brush for tracheostomy care Obtaining sterile gloves for tracheosotmy care
Obtaining cotton balls for tracheosotmy care
A nurse is caring for an older adult who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? Encourage the client to drink fluids before swallowing food Offer the client tart or sour foods first Tilt the client's head backward when swallowing Turn on the television
Offer the client tart or sour foods first (to stimulate saliva)
A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? BT for bedtime SC for subcutaneously PC for after meals HS for half-strength
PC for after meals
A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurses take? Select all that apply Carefully reinsert the intestine through the opening in the wound Place the client in a supine position with the hips and knees flexed Leave the room to call the surgeon Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock
Place the client in a supine position with the hips and knees flexed (this helps prevent further tearing) Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? Stand toward the client's stronger side Instruct the client to lean backward from the hips Place the wheelchair at a 45 degree angle to the bed Assume a narrow stance with the feet 15 cm (6in) apart
Place the wheelchair at a 45 degree angle to the bed (allows the client to pivot, lessening the amount of rotation required)
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Aim the hose at the base of the fire Squeeze the handle of the extinguisher Remove the safety pin from the extinguisher Sweep the hose from side to side to dispense material
Remove the safety pin from the extinguisher
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? Holding a community clinic to administer influenza immunizations Screening groups of older adults in nursing care facilities for early influenza manifestations Educating parents of young children about the dangers of influenza Finding rehabilitation programs for older adults who have complications related to influenza
Screening groups of older adults in nursing care facilities for early influenza manifestations
A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? Redness at the IV catheter entry site Palpable cord along the vein used for the infusion Taut skin around the IV catheter site that is cool to the touch Bleeding at the IV insertion site
Taut skin around the IV catheter site that is cool to the touch (the nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or cold compress) INCORRECT: Redness at the IV catheter entry site= local infection Palpable cord along the vein used for the infusion= phlebitis Bleeding at the IV insertion site= IV in not intact
A nurse is demonstrating postoperative deep breathing and coughing exercises surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client asks the nurse to repeat the instructions before attempting the exercises The client reports severe pain The client asks the nurse how often deep breathing should be done before surgery The client tells the nurse that this exercise will probably be painful after surgery
The client reports severe pain
A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent? Illness is not influenced by culture The meaning of disease can vary widely across cultures Assigning clients to specific cultural categories facilities communication Predetermined criteria should generate client care activities
The meaning of disease can vary widely across cultures
A nurse is caring for a semiconscious client who had a small bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct placement? Select all that apply Auscultate injected air Verify the initial xray examination Measure the length of the exposed tube Determine the pH of the aspirated fluid Check the aspirated fluid for glucose
Verify the initial xray examination Measure the length of the exposed tube Determine the pH of the aspirated fluid
A nurse is caring for a client who has Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown Use alcohol-based hand sanitizer to cleanse the hands Wear a mask when assisting the client with his meal tray Place the client on complete bed rest
Wear gloves when changing the client's gown
A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells A client who is being transported for a radiograph of the kidneys, ureters, and bladder A client who has a prescription for a tuberculin skin test A client who has distended bladder and need urinary catheterization
A client who has a prescription for a transfusion of packed red blood cells (procedure carries risks)
A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching? Client who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients Clients who are 65 or older are reluctant to report pain Clients who are 65 or older should not receive opioid narcotics Clients who are 65 or older experience a shorter duration
Clients who are 65 or older are reluctant to report pain
A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hour. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose?
2 Have/ Quantity= Desired/X 80mg/1 tablet= 320 mg/X tablet X=4???
The nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
30 Volume (ml)/Time (min) x drop factor (gtt/mL)= X 40 mL/20 min x 15 gtt/mL = X gtt/min X=30
A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? Decreased respiratory rate Pinpoint pupils Increased blood pressure Bronchiolar construction
Increased blood pressure
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous". Which of the following responses should the nurse offer? "You wont need the equipment for very long" "All this equipment can be frightening" "Why does the equipment bother you?" "Let me tell you about what each machine does"
"All this equipment can be frightening"
A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? Airborne Droplet Contact Protective environment
Airborne
A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress
Assessment
A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis an is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? Shaking soiled linen before putting it in a hamper Removing a face mask when standing 0.5m (1.6ft) from the client Assigning another client with the same infection to share the room with the client Allowing the client to visit a family member in the lobby of the facility
Assigning another client with the same infection to share the room with the client INCORRECT: Removing a face mask when standing 0.5m (1.6ft) from the client--> 3.3 FEET
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? Tell the client it is too late for her to change her mind because the surgery is already scheduled Telephone the operating room and cancel the surgery Inform the client's family about the situation Notify the provider of the client's decision
Notify the provider of the client's decision
A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? "Include at least 3 g of sodium in your daily diet" "Limit wine consumption to 230mL daily" "Include 2.5 cups of vegetables in your daily diet" "Limit water intake to 1.5 L each day"
"Include 2.5 cups of vegetables in your daily diet"