Fundamentals ATI

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it

Administering IV fluids to a client. When monitoring for adverse affects which of the following assessment should the nurse identify as a priority?

Auscultation of lung sounds

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

During the admission process

A nurse is caring for a client who has a limited mobility and their lower extremities. Which of the following action should the nurse take to prevent skin breakdown

Have the client use a trapeze bar when changing position

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate.

"Would you like it if we discussed the transfer with your family memeber"

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?

"You should receive a pneumococcal vaccine when you are when you are 65 years old"

A nurse in a provider's clinic is caring for a client who has HF. A nurse is evaluating teaching for a client who has HF. Which of the following 3 statements by the client indicates an understanding of the teaching.

- "I am limiting my sodium intake to 2 grams daily" -"I am eating fewer potato chips and more fruit for snacks" -"I know to call my doctor if I gain 3 pounds or more in 2 days"

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

- Assist the client with a partial bed bath -Measure the client's BP after the nurse administers an antihypertensive medication -Use a communication board to ask what the client wants fro lunch

A nurse in the ED is caring for a client. Which of the following indicate malnourishment.

-Cachectic with flaccid muscle tone -Skin dry and scaly with bruises on extremities -Pulse rate 119/min -Abdomen distended -BMI 17

A nurse is discussing the use of herbal supplements for health promotion with 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 with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care.

"I want you to tell me about measures available to keep me comfortable"

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

-Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -wash the clients body -ask the clients family members if they would like to view the body -place a name tag on the body

A nurse is caring for a client who has TB. Which of the following actions should the nurse take? Select all.

-Place the client in a room with negative-pressure airflow -Wear gloves when assisting the client with oral care -Use antimicrobial sanitizer for hand hygiene

A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all.

-Place the client on droplet isolation precautions -apply oxygen at 2L/min via nasal cannula -Request a prescription for an antipyretic medication -Remain 1m (3 feet) from the client

A nurse is caring for a client who has a pressure injury. What findings should the nurse report to the provider.

-Temperature -WBC count -Prealbumin level -Pain level -Odor of wound

A nurse is caring for a client who is postoperative following abdominal surgery. What findings should the nurse report to the provider.

-Urinary output -Reported pain level -Vital signs

A nurse is caring for a group of clients are the MedSurg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity

A client who was unaware of the recent cancer diagnosis ask the nurse if they have cancer, and the nurse response affirmatively

A nurse is calculating a clients fluid and take over the past eight hours. Which of the following items are the nurse plant a document on the client intake and output record as 120 mLs of fluid?

8 ounces of ice chips

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm.

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

Erythema on pressure points

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

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

A nurse is a preparing to apply addressing for a client who has a stage two pressure injury. Which of the following types of dressings should the nurse use?

Hydrocolloid

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 their room if there is construction in the area

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

Make sure two fingers can fit under the sleeves

Nurse is completing the admission assessment for a client reports vomiting and diarrhea for the past three days. Which of the following findings should the nurse expect?

Rapid heart rate

A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which of the following action should the nurse take?

Reassure the client that this is an expected response to grief

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

Regulate oxygen via a nasal cannula at a flow rate of no more than 6 L per minute

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"

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 nurse is checking a patient in a med-surg unit. After reviewing the assessment findings, which of the following actions should the nurse plan to take?

-Delegate the application of sequential compression devices to assistive personnel -Assist the client to dangle their legs at the bedside prior to standing -Administer analgesic prior to planned activities

A nurse in a provider's clinic is caring fro a client who has diarrhea. The nurse is providing teaching for the client who has diarrhea. Select 4 instructions that the nurse should include in teaching.

-Eat probiotic, such as yogurt -Avoid alcohol while experiencing diarrhea -Avoid caffeine while experiencing diarrhea -Follow a low-fiber diet

A nurse in the ED is caring for a client reports a abdominal pain. Based on the clients clinical findings which of the following actions should the nurse take?

-assist the client to a left side lying position with the right knee flexed -administer a cleansing enema -auscultate the clients bowel sounds -perform a manual digital examination of the clients rectum

The nurse is preparing the skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy?

A mole with an asymmetrical appearance

A nurse is admitting a client who has rubella.Which of the following types of transmission-based precautions should the nurse initiate.

Droplet

A client who is non-ambulatory notifies the nurse that their trashcan is on fire. After the nurse confirms the presence of the fire, which of the following action should the nurse take next?

Evacuate the client

A charge nurse is discussing the responsibility of nurse is caring for a client who have C.diff infection. Which of the following information should the nurse include in the teaching?

Have Family members wear a gown and gloves when visiting

For a client who requires an NG tube for stomach decompression. Which of the following action should the nurse take when inserting the NG tube?

Have the client takes sips a water to promote insertion of the NG tube into the esophagus

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

I Flushed when I urinated at 7 AM and have saved all urine since

a nurse us caring for a client who has recently started using it behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

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

A nurse is providing discharge instructions to a client will be using a walker. Which of the following statement by the client indicates the teaching has been effective?

I will hire someone to trim the tree that overhangs the front porch stairs

A nurse is providing teaching to a client who has protective isolation precautions. Which of the following client statements indicates an understanding of the teaching?

I will wear a facemask when leaving my hospital room

A nurse is a med-surg unit is caring who has prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

A nurse is caring for a client reports pain. When documenting the quality of the clients pain on an initial assessment the nurse should record which of the following client statement?

The pain is like a dull ache in my stomach

A nurse is caring for a client who ask about the purpose of advance directives. Which of the following statements should the nurse make?

They indicate the form of treatment a client is willing to accept in the event of a serious illness

A nurse is caring for a client who has dementia. Which of the following intervention should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system

A nurse is caring for a client who has terminal diagnosis and whose health is declining. The client request 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 educating a client who has a terminal illness about declining resuscitation in a living will. The client ask, "what would happen if I arrived at the emergency department and had difficulty breathing?" Which of the following responses should the nurse make?

We would give you oxygen through a tube in your nose

A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure

Wrap monitoring cords with stockinette and tape them in place.

a nurse is assessing an older adult client risk for falls. which of the following assessment should the nurse use to identify the client safety needs?

-pupil clarity -visual fields -Visual acuity

The nurse is caring for a client who has a peripheral IV inserted or fluid replacement. The nurse is assessing a client. Which of the following action should the nurse take?

-stop the IV infusion -elevate the client left arm -apply heat to the client left hand

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

Abdominal cramping

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

Apply intermittent section when withdrawing the catheter

A nurse is preparing to insert an IV catheter into a clients are in prior to initiating IV fluid therapy. Which of the following intervention should the nurse implement to prevent infection?

Apply transparent dressing over the IV insertion site in securement device

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

Applying ankle foot orthotic device to the client be

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 consistent pattern on the client's plate.

The nurse is preparing do you administer an injection of an opioid medication to a client. The nurse draws out 1 ML of the medication from a 2 ML vial. Which of the following action should the nurse take?

Ask another nurse to observe the medication waste

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 action should the nurse take next?

Assess the client for orthostatic hypotension

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate.

Contact precautions

The nurse is planning to teach a client who has a new diagnosis of type 1 diabetes mellitus about insulin self administration. Which of the following action should the nurse take first?

Determine the clients learning style

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer for a major abdominal surgery. Which of the following actions is the nurses priority?

Determine the reason why the client is refusing to use the incentive spirometer

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

"It might help me to listen to music while I'm 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 manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the manager plan to include in the teaching.

"Use the complete name of the medication magnesium sulfate"

The nurse is caring for a client who has COPD. Select the three findings that require follow up.

-breath sounds -temperature -oxygen saturation

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

-check the cord routinely for frays or tearing -consider purchasing a generator for power back up -observe for signs of hypoxia

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 of air into the bottle of NPH insulin -inject 5 units of air into the bottle of regular insulin -withdraw the correct dose of regular insulin -withdrawal the correct dose of NPH insulin from the bottle

A nurse is caring for a client who had a spinal cord injury and has paraplegia. The nurse is reviewing the clients medical record. Click to highlight the findings that require intervention by the nurse.

-passive range of motion exercises to lower extremities performed weights each day -plantar flexion contractures noted bilaterally -left heel with 1.3 cm x 1.3 cm area of non-blanchable arrhythmia, skin intact

A nurse is admitting a client of a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include?

-where an N 95 mask when caring for the client -place a container for soiled linens inside the clients around -placed the client in a negative air flow room -remove mask after exiting the clients room

The nurse is caring for a client who has herpes zoster and ask the client about the use a complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

Acupuncture

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

Administer pain medicine 45 min before changing the client's dressing.

The nurse is providing discharge teaching to a client about self administering heparin. Which of the following instruction should the nurse include in the teaching?

Administer the medication into the abdomen

A nurse is planning care of a adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding their daily routine

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

Ambulating a client who is postoperative

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

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

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?

Assist the client to an upright position

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should the nurse include in the clients diet?

Avocado

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

Bladder scan shows 525 mL of urine

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

Breath sounds

Nurses responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following action should the nurse take?

Cleanse the wound from the center outward

A nurse and there's a clients room and find them on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements are the nurse document about this incident

Client found lying on the floor

A nurse is admitting a new client. Which of the following should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions.

A nurse is administering 1 L 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

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take care?

Notify the nursing manager

A nurse is assessing a client readiness to learn about insulin self administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

I can concentrate best in the morning

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?

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

A nurse is reviewing a clients medication prescription that reads "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

Medication dose

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

Place a client who has tuberculosis in a room with negative pressure airflow

The nurse is planning to insert a peripheral IV catheter or an older adult client. Which of the following action should the nurse plan to take?

Place the clients arm in a dependent position

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.5 MEQ / L

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of a ostomy. Which of the following method should the nurse use as a psycho motor approach to learning?

Practice sessions

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the clients ear

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress.

Role overload

The nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following action should the nurse plan to take?

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

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings of the IV site should the nurse identify as indicating infiltration?

Skin blanching

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

A nurse is caring for a client who has a NG tube and is receiving intermittent feeding through the open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees

The client demonstrates anger when the nurse does not respond within five minutes of ringing for the nurse. Which of the following is an appropriate response by the nurse?

That must be frustrating for you. How can I help you right now?

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 insist on remaining in the room

A nurse is caring for a client who is receiving a unit of packed RBCs. Complete the following sentence by using the list of options.

The client has manifestations of allergic reaction as evidence by itching

The nurse is evaluating a clients use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of the body

A nurse is performing at home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher

A nurse is caring for a client. Complete the following sentence by using the list of options.

The client is at risk for bleeding as evidenced by clients platelet count.

A nurse in the MedSurg unit is caring for six clients. Complete the following sentence by using the list of options.

The first client the nurse should assess is client 3 followed by client 4.

A charge nurse is observing a newly licensed nurse prepares 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 places the top of a bottle of sterile saline onto the sterile field

A nurse is caring for a client in the MedSurg unit. Click to highlight the findings indicate an improvement in the clients condition.

The nurse identifies findings of granulation tissue covering the wound bed, no odor present, increased comfort level, and the decrease in the size of the wound bed and tunneling indicate an improvement of the clients condition.

A nurse is caring for a client who has a new diagnosis of seizure disorder. Complete the following sentence by using the list of options.

The nurse should first address the client's physical safety followed by the clients positioning.

A nurse is an emergency departments is caring for a client. Complete the following sentence by using the link of options.

The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery

A nurse is teaching a client in their family how to care for the clients tracheostomy at home. Which of the following instruction should the nurse include in the teaching?

Use the tracheostomy covers went outdoors

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

Walking briskly

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

Wear a gown when caring for the client

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

What can I have done to deserve this illness

The nurse is teaching a client who's left leg hangs in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teachings?

When descending stairs I will first shift my way to my right leg

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 a blood transfusion. Which of the following action should the nurse take?

Withhold the blood transfusion

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following action should the nurse add to the clients plan of care?

Wrap blankets around all four sides of the bed

A nurse in the clinic is caring for a middle age adult client who states "the doctor says that since I am at 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 test every year