ATI Test B Fundamentals

A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?

1. A 16 yo client who is married 2. a 27 yo who has schizophrenia 3. an adoptive parent who brings in his 8 yo son 4. a 17 yo mother who brings in her toddler.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

1. Assist the client with a partial bed bath 2. Measure the client's BP after the nurse administers an antihypertensive medication 3. use a communication board to ask what the client wants for lunch

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

1. Check the cord routinely for frays or tearing 2. consider purchasing a generator for power backup 3. observe for signs of hypoxia

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr?

107mL/hr

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?

8 oz ice chips

A nurse is caring for a group of clients on a medical-surgical unit. In 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. Following the ethical principle of veracity, the nurse must tell the truth at all times and never decieve others.

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy.

A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping. The client has hyponatremia, a low sodium level. Manifestations include abdominal cramping, weakness, headache, and nausea.

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45 degree angle The nurse should insert the needle for a subcutaneous injection at a 45 to 90 angle

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?

Albumin level of 3g/dL An albumin level below 3.5 g/dL indicates protein deficiency, placing the client at risk for pressure ulcer formation and poor wound healing.

A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

An uneven shape An uneven shape is a possible indication of a cutaneous malignancy. Each half of the lesion looks different from the other half.

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

An x-ray shows the end of the tube above the pylorus. An abd x-ray showing the end of the tube above the pylorus indicates gastric placement

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter. The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

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

Assess the client for orthostatic hypotension The first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. The nurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair.

A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client ass to his diet?

Avocados Avocados contain no cholesterol. Plant foods contain no cholesterol; foods from animals contain cholesterol.

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

Bladder scan shows 525mL of urine A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve a blockage.

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

Breath sounds When using the airway, breathing, circulation approach to clients care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

a nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?

Bruises on the arms in various stages of healing Bruises in various stages of healing is an indicator of abuse. Other indicators include burns, abrasions, fractures, bite marks, dried blood, and pressure ulcers

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

Check the IV tubing for obstruction. The first action the nurse should take using the nursing process is to assess the client. By checking the IV tubing for obstruction, the nurse might be able to facilitate the flow through the tubing. This could re establish the infusion rate the provider prescribed.

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

Cheddar cheese. Complete proteins contain enough of all nine of he essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good sources of complete protein.

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

Clean sutures along the incision site. The greatest risk to this client is injury form infection; therefore, the first action the nurse should take is to clean the incision to minimize the risk of infection.

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?

Compare prescriptions with medications the client received during hospitalization. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to expected range.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process. Discharge planning should begin as soon as the client is undergoing admission. The nurse should begin to assess the client's needs and plan for care during and after hospitalization.

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?

Elevate the head of the client's bed. This action promotes postural drainage and also allows maximal chest expansion, which makes it easier for the client to breathe and decreases noisy respirations.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

Evacuate the client According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

Evaluate electrolytes. The first action nurse should take when using the nursing process is to assess the client's electrolytes; therefore, the nurse should evaluate the client's laboratory results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalance.

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue. The nurse should examine her own personal values about the issue to help her provide care that is without bias

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?

Insert the IV catheter without using a tourniquet. The nurse should insert the IV catheter using the tourniquet minimally or not at all to avoid injury of fragile skin or veins

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area? An allogeneic stem cell transplant compromises the client's immune system, putting her a high risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves. Less space than two fingers between the sleeves and the legs can inhibit circulation when the sleeves inflate

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.

Normal breath sounds

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

Notify the nursing manager The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefor, the next action the nurse should take is to activate the chain of command to ensure the necessary care is provided to the client.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints. Restraints without padding can abrade the client's skin.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Place a client who has tuberculosis in a room with negative-pressure airflow. A client who has tuberculosis requires airborne percautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission

A nurse is planning teaching for 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 learning?

Practice sessions Practice sessions require psychomotor skills when learning.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate no more than 6l/min

A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?

Second intercostal space at the left sternal boarder. This is the area over the pulmonary valve. The nurse should listen over this, the apex, and the other valves areas for rate and rhythm as well as gallops and murmurs

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter

Swelling and coolness are observed at the IV site Swelling and coolness are indications of IV infiltration, which warrant removing the catheter and restarting the IV infusion with a new catheter at a different site.

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?

Talk directly to the client, instead of the interpreter, when speaking. When using an interpreter, the nurse should speak directly to the client and observe the client when the interpreter is translating.

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

Tap just bellow the kneecap

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

The family member washed out the feeding bag with warm water once every 24 hours. The family member should wash out the feeding bag at each refiling throughout the day (every 4 to 8 hr) and replace it with a new feeding bag every 24 hr to prevent bacterial contamination. Therefore, the nurse should reinforce this information with the family member

A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

The nurse opens the sterile field on a wet surface Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria through the sterile drape

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Thread the IV catheter so that the hub rests at the insertion site. Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors Tracheostomy covers protect the client's airway form cold air, dust, and other airborne particles

a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

Wash her hands before and after contact with the client Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contact with every client regardless of their diagnosis.

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?

Wrap blankets around all four side of the bed. The nurse should affix linens or blankets around the head, foot and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures

A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document?

"Client was found lying on floor." The nurse should include documentation that is descriptive, objective info about what she actually observed, w/o any opinions or judgment about motive or cause.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind." When a client does not wish to share their feelings with the nurse, it is important for the nurse to convey a willingness to be available when they need her.

A nurse is caring for a patient with behind the ear hearing aid.

"I will be sure to remove my hearing aid before taking a shower." Water can damage the hearing aid.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while im lying in bed."

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?

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

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." With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

"We need to document the exact medication you were taking because you might be allergic to it." If there is any possibility that a client had an allergic reaction to a medication, it is imperative that the provider be aware and does not prescribe that same medication again. Subsequent allergic reactions could be life-threatening.

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?

"We will apply oxygen through a tube in your nose" Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal cannula

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?

"When descending stair, I will first shift my weight to my right leg." To descend stairs, the client should first shift his body weight to his right (unaffected) leg.