ATI: Proctored Fundamentals I

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?

circle the injection area with a pen

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

instruct the guard to ask the inmate

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

intraoperative

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?

lentils

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

limiting drinking fluid with foods

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?

"All of this equipment can be frightening."

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?

"I am going to listen to your abdomen"

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group?

"I think I have done a good job with my children since they are all independent now."

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?

"I'll make sure to keep the collection bottle in the container of ice they gave me."

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 min after eating a meal."

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include?

"Try to block the urge to urinate until the next scheduled time."

A nurse is teaching a client how to perform range-of-motion 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."

A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the inhaler and shaking the canister, what sequence of instructions should the nurse give the client?

"hold the mouth piece 1 to 2 inches infront of your mouth" "tilt your head back slightly and open your mouth wide" "Depress the canister while taking a slow, deep breath" "Hold your breath for 10 seconds"

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland?

"tilt your head back and swallow"

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?

Exert pressure on the bony prominences when holding the eyelids open

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4°C. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

101.1 38.4 x 1.8 + 32 = 101.12 (round to the nearest tenth)

A nurse is measuring the blood pressure of several clients. Which of the following results are within the expected reference range for blood pressure?

116/70

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 ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560 Follow these steps for the conversions of oz to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz / 30 mL = 4 oz / X mL X = 120 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, it makes sense that 4 oz = 120 mL. Follow these steps for the conversions of pints to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 pint / 480 mL = 0.5 pint / X mL X = 240 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 pint = 480 mL, then 1/2 pint = 240 mL. For the total intake, calculate 150 mL x 8 hr = 1200 mL + 120 mL + 240 mL = 1560 mL

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz 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? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

660 8 oz + 10 oz + 4oz = 22 oz Follow these steps to convert ounces to milliliters: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X.1 oz / 30 mL = 22 oz / X mLX = 660 mL Step 3: Round if necessary. Step 4: Reassess to determine if the conversion to mL makes sense. If 1 oz = 30 mL, then 22 oz = 660 mL.

A nurse is caring for a client whose intake and output flow sleet from 0700 to 1500 indicates the following: voids x3: 350mL, 200mL, 150mL ; wound drainage 2 tsp; and emesis 2oz. What total output in milliliters should the nurse document for this 8hr period? Fill in the blank with the numeric value only, round to the nearest whole number, and use a leading zero if applicable. (do not use a trailing zero)

770 Follow these steps for the conversions of tsp to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 tsp/5mL = 2 tsp/X mL X = 10 Step 3: Round if necessary. Step 4: Determine if the conversion to mL makes sense. If 1 tsp = 5 mL, then 2 tsp = 10 mL. Follow these steps for the conversions of oz to mL: Step 1: What unit of measurement should the nurse calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL = 2 oz/X mL X = 60 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, then 2 oz = 60 mL. For the total intake, calculate: 350 mL + 200 mL + 150 mL + 10 mL + 60 mL = 770 mL

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." D. "Keep your elbows away from your body." E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it.

A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard."

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

A. Gown B. Gloves

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication

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?

Apply pressure to the puncta after instilling the medication

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with gritty sensation while sawing wood. Which of the following actions should the nurse take?

Ask the client about first aid preformed at the scene

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply.) A. Gingivitis B. Dry, brittle hair C. Edema D. Spoon-shaped nails E. Poor wound healing

B. Dry, brittle hair C. Edema E. Poor wound healing

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 nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply.) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury

B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks

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 tube placement? (Select all that apply.) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus

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.) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

C. Black beans D. Whole-grain bread

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with others

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 should the nurse take?

Clamp the tubing below the collection port

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform?

Cleanse the wound with 0.9% sodium chloride irrigation

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?

Clients who are age 65 or older are reluctant to report pain.

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

Cranial nerve XII

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?

Death is viewed as an interruption of what might have been.

A nurse is caring for a client whos is unstable and has vital signs measured every 15 minutes by an electric blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 minutes.

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

Ensure the interpreter and the client speak the same dialect.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

Halo of erythema on the surrounding skin

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

Hold the breath for 5 sec after goal volume is reached

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure

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?

Insert the tip of the tubing 8 cm (3.1 in)

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 with 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 instillation.

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?

Pinch the NG tube while removing the tube

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial.

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 extremities

A nurse is obtaining the blood pressure 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 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 The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe.

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

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

Side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?

Soak the inner cannula of the tracheostomy tube in normal saline

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Apply a skin protectant or a barrier film to the skin around the wound. Apply sterile or clean gloves and irrigate the wound. Connect the tubing to transparent film and turn on the NPWT unit. Remove the soiled dressing and perform hand hygiene. Turn off the vacuum on the NPWT device and administer the prescribed analgesic. Place prepared foam into the wound bed and cover with a transparent dressing.

Step 1: The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. Step 2: The nurse should gently remove the soiled dressing and perform hand hygiene. Step 3: The nurse should apply sterile or clean gloves and irrigate the wound to remove debris. Step 4: The nurse should apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and protect the skin. Step 5: The nurse should place foam in the wound bed and cover it with a transparent dressing to provide an airtight seal. Step 6: The nurse should attach the drainage tube to the transparent dressing and turn on the NPWT unit. Step 7: The nurse should check for air leaks and patch the dressing as needed with transparent film.

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching?

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique?

The nurse holds her hands higher than her elbows while washing.

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?

The signature on the preoperative consent form is the client's

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigating solution to 37°C (98.6°F)

A nurse is preparing to administer a unit of packed RBC's to a client. Which of the following pieced of information must the nurse verify with another nurse prior to administration? (select all that apply) a.) The clients ID number b.) The clients room number c.) The clients name d.) ABO compatibility e.) RH capability

a.) The clients ID number c.) The clients name d.) ABO compatibility e.) RH capability Never use a client's room number as identification because the client may change rooms.

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?

accompany the client back to his room

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 types of transmission precautions should the nurse initiate?

airborne

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

ask the adolescent to sign the consent Unemancipated minors (i.e. those who do not live on their own, are not married, and are not in the military) can legally give informed consent for diagnostic procedures and treatment in some situations. These situations include treatment for STIs and substance use disorders.

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

brainstem

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

cough deeply after each use

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

daily weight

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

depressed deep-tendon reflexes

A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross?

depression

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound?

excessive wax in the ear canal

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening?

eye examination every 2 years

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

glaucoma

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?

hearing aids

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

hyperglycemia

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicating to the nurse that the client is experiencing fluid volume deficit?

increased heart rate an increased heart rate should indicate to the nurse to the nurse that the client is experiencing fluid volume deficit. Other findings can include increased BUN levels, dry mucous membranes, and dark yellow urine.

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

independent moral development

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

loss

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

metabolic acidosis

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

nutrition

A nurse is using the braden scale to predict the pressure ulcer risk of a client in a long-term care facility. using this scale,which of the following parameters should the nurse evaluate?

nutrition

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

obtaining client information

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

oil retention

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

osteoporosis

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?

plasma volume expanders Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situations, such as after hemorrhage or burns.

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver?

respite care Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance.

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?

sitting

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs?

skin

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

test for the presence of the clients gag reflexes

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

the client holds the cane on the unaffected side

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

us ethe pain scale to determine the clients pain level

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

use a gait belt during ambulation

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

ventrogluteal

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?

vesicular

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

wrap the clients finger in a warm washcloth