ATI RN Fundamentals Practice B

A nurse has accepted a verbal prescription for "three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse is preparing a heparin infusion for a client who was hospitalized with DVT. The order reads 25,000 unit of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round to nearest whole number)

8 ml/hr

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?A. Auscultate lung soundsB. Measure urine outputC. Monitor blood pressure readingsD. Monitor electrolyte levels

A. Auscultate lung sounds

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record what? A. "I am having mild pain." B. "The pain is like a dull ache in my stomach." C. "I notice it get worse after i eat." D. "The pain makes me nauseous"

B. "The pain is like a dull ache in my stomach."

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?A. Describe the procedure to the client.B. Witness the client's signature on the consent form.C. Inform the client of alternatives to the procedure.D. Tell the client which team member will assist with the procedure.

B. Witness the client's signature on the consent form.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A. 2 cups of soup B. 1 quart of water C. 8 oz ice chips D. 6 oz tea

C. 8 oz of ice chips

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include?

Current medications

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins

A nurse is assessing an adult who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points

A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water

A nurse is preparing to administer 0.5ml of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

A nurse is planning teaching to a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to the learning?

Practice sessions

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is preparing to transfer a client who can bear weight in one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?

assess the client for orthostatic hypotension

A nurse is caring for a group of clients on a medical surgical unit. Which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?A. "When descending stairs, I will first shift my weight to my right leg."B. "I should place my crutches 12 inches in front and to the side of each foot."C. "As I sit down, I will hold one crutch in each hand."D. "I will make sure the shoulder rests are snug against my armpits."

A. "When descending stairs, I will first shift my weight to my right leg."

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family? Select all that apply.A. Check the cord routinely for frays and tearingB. Keep the unit at least 4 feet away from a heat sourceC. Consider purchasing a generator for power backupD. Monitor for signs of hypoxiaE. Select clothing and bedding made of synthetic materials

A. Check the cord routinely for frays and tearing C. Consider purchasing a generator for power backup D. Monitor for signs of hypoxia

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?A. DropletB. AirborneC. ContactD. Protective environment

A. Droplet

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?A. Instruct the family to refrain from pushing the button for a client while she is asleep.B. Inform the client that because she is on a PCA, vital signs will be taken every 8 hours.C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10.D. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

A. Instruct the family to refrain from pushing the button for a client while she is asleep.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the clients plate

A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.B. A nurse asks a nurse from another unit to assist with her documentation.C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.D. A nurse discusses a client's status with the physical therapies that is caring for the client's bedside.

B. A nurse asks a nurse from another unit to assist with her documentation.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. What assessment finding should the nurse expect?A. Neck vein distentionB. Urine specific gravity 1.010C. Rapid heart rateD. Blood pressure 144/82 mmHg

C. Rapid heart rate

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?A. Seal unused hospital medications in a plastic bag.B. Evaluate the client's ability to self-administer medications.C. Report an identified discrepancy to The Joint Commission.D. Compare prescriptions with medications the client received during hospitalization.

D. Compare prescriptions with medications the client received during hospitalization.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?A. Assign the client to a room with a negative air-flow systemB. Use alcohol-based hand sanitizer when leaving he client's room.C. Clean contaminated surfaces in the client's room with a phenol solution.D. Have family members wear gown and gloves when visiting.

D. Have family members wear gown and gloves when visiting.

A nurse is discussing the use of herbal supplements for health promotion to a client. Which of the following client statements indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system

A nurse is caring for a client who is receiving 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

I flushed what I urinated at 7:00 am and have saved all urine since

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the scope of RN practice?

Initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

The caregiver insists on remaining in the room

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place

A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

You should have a fecal occult blood test every year

A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures?

Apply an ankle foot orthotic device to the clients feet

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?A. Rinse the feeding bag with water between feedingsB. Tell the client to keep the head of the bed elevated at least 30ºC. Make sure the enteral formula is at room temperatureD. Wipe the top of the formula can with alcohol

B. Tell the client to keep the head of the bed elevated at least 30º

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?A. Ask the client to consider a direct donationB. Withhold the blood transfusionC. Request a consultation with the ethics committeeD. Ask the client's family to intervene

B. Withhold the blood transfusion

A nurse is preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

N95 respirator

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpated the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

120 mmHg (Cuff should be inflated 30 mmHg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mmHg, then 122 mmHg would be the correct pressure to inflate the cuff to)

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) A. Place the client in a room with negative pressure air flow B. Wear gloves when assisting the client with oral care C. Limit each visit to 2 hr increments D. Wear a surgical mask when providing client care E. Use antimicrobial sanitizer for hand hygiene

A. Place the client in a room with negative pressure air flow B. Wear gloves when assisting the client with oral care E. Use antimicrobial sanitizer for hand hygiene

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm the correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?A. "Incident report completed."B. "Client climbed over the bedrails."C. "Client found lying on floor."D. "Client was trying to get out of bed."

C. "Client found lying on floor."

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?A. Wear sterile gloves when removing the old dressing.B. Warm the irrigation solution to 40.5 CC. Cleanse the wound from the center outward.D. Use a 20 mL syringe to irrigate the wound.

C. Cleanse the wound from the center outward.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? A. Activate the emergency fire alarm. B. Extinguish the fire. C. Evacuate the client. D. Confine the fire.

C. Evacuate the client.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?A. "Most people are happy when their children grow up and leave home."B. "You should be proud that your children are becoming independent."C. "Maybe you should consider why you are feeling useless."D. "People in middle adulthood often find satisfaction in nurturing and guiding young people."

D. "People in middle adulthood often find satisfaction in nurturing and guiding young people."

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure

Inject 10 units air into the bottle of NPH insulin Inject 5 units air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse placed the cap of the bottle of sterile saline solution on the sterile field

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

What could I have done to deserve this illness

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device?A. "This type of hearing aid does not allow for fine tuning of volume."B. "I shouldn't have trouble keeping the hearing aid in place during exercise."C. "I expect to hear a whistling sound when I first insert the hearing aid."D. "I will be sure to remove my hearing aid before taking a shower."

D. "I will be sure to remove my hearing aid before taking a shower."

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?A. Wrap blankets around all four sides of the bed.B. Apply restraints during seizure activity.C. Place the client in a supine position during seizure activity.D. Have a tongue depressor at the client's bedside.

A. Wrap blankets around all four sides of the bed.

A nurse is reviewing protocol in prep for suctioning secretions from a client who has a new tracheostomy. What action should the nurse plan to take?A. Use a resuscitation bag with 80% oxygen prior to the procedure.B. Select a suction catheter that is half the size of the lumen.C. Place the end of the suction catheter in water-soluble lubricant.D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

B. Select a suction catheter that is half the size of the lumen.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as an indication of infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

C. Skin blanching

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?A. The medicationB. The routeC. The doseD. The frequency

C. The dose

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?A. "You should have an eye exam every 2 years."B. "You should receive a tetanus booster every 5 years."C. "You should have a fecal occult blood test every 5 years."D. "You should receive a pneumococcal immunization every 10 years."

D. "You should receive a pneumococcal immunization every 10 years."

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fowler's position B. Increase the client's intake of carbohydrates C. Massage reddened areas with unscented lotion D. Have the client use a trapeze bar when changing position.

D. Have the client use a trapeze bar when changing position.

A nurse is preforming a peripheral vascular assessment for a client, when placing the bell of the stethoscope on the clients neck, the nurse hears the following sound. This sound indicates which of the following? *audio clip*

Narrowed arterial lumen (bruit)