Fundamentals ATI exam

A nurse is caring who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Reach around the pack and open the top flap away from the body.

A nurse finds an open vial of morphine lying on top of the cabinet in a clients room. Which of the following actions should the nurse take?

Report the discrepancy immediately

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the clients family

A nurse is preparing to administer an IM injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

Respiratory rate

A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?

Respite care allows the primary caregiver time away from day to day care responsibilities.

A nurse is assessing a clients bowel sounds. At which of the following points in the assessment should the nurse auscultate the clients abdomen?

Prior to percussing the abdomen

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? Select all that apply.

*report of feeling pressure *tenderness over the symphysis pubis * distended bladder * voiding 30 mL frequently

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution.

1) remove the bottle cap 2) place the bottle cap face up on clean surface. 3) pick up the bottle with the label facing his palm. 4) pour 1 to 2 mL into a receptacle. 5) pour the solution onto the gauze.

A nurse is assessing a client for putting edema and notes and indentation of 6mm at the point of pressure. Which of the following notations should the nurse use to document the severity of the clients edema?

3+

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses station?

A client who sustained a head injury and is having periods of confusion.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse is caring for a client who had urinary incotinence. Which of the following actions should the nurse implement to improve the development of skin breakdown?

Apply a moisture barrier ointment to the clients skin.

A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full min

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the clients plan of care?

Auscultate breath sounds at least every 2 hrs

An assistive personnel reports a clients vital signs as tympanic temp 98.8, pulse 92/min, resp rate 18/min, and BP 98/58. Which of the following vital signs should the nurse re-measure?

BP

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Blood

A nurse is helping an older adult client ambulated in the hallways for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

A nurse is caring for a client who invested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Check the patency of the clients airway

A nurse is receiving change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76, and temp 98.2. Which of the following actions should the nurse perform?

Complete a neurological check

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci. Which of the following types of precautions should the nurse plan to initiate?

Contact

A nurse is preparing a clients evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Discard the tablet and obtain another dose of medication

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of ppe should the nurse remove first?

Gloves

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

Hold the container of solution 30 cm (12in) above the anus.

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

Hold the ophthalmic solution 2cm above the lower conjunctival sac.

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I watch television until I fall asleep at night

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

I'll apply ice to my ankle today and tomorrow

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

Interpersonal

A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erickson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?

Intimacy vs. isolation

A nurse intercepts a messenger at the nurses station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What is happening to her? Which of the following responses should the nurse provide?

It's my responsibility to remind you that we have to respect our clients privacy

A nurse is caring for a client who requires droplet precautions. Which of the following ppe should the nurse wear when setting up the clients meal tray?

Mask

A nurse is caring for an older adult client who is alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the clients safety?

Move client to a room closer to the nurses station

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is caring for a client in a long term care facility who is receiving enteral feedings via an ng tube. Which of the following actions should the nurse take prior to administrating the fine feeding?

Test the pH of gastric aspirate

A nurse in a long term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver?

The client is not making any sounds

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

The client was lying on the floor next to his bed.

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen restraint?

The clients hand is cool and pale

A nurse is preparing an in service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

The nurse has already considered alternatives to restraints.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitation care. The clients family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

The services began with the clients admission to the hospital.

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When then client asks what the stockings do, which of the following responses should the nurse make?

They improve your circulation to keep blood from pooling in your legs

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

Turn the client on his side before starting oral care

A nurse is planning care for an older adult who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin?

Use a transfer device to lift the client up in bed.

A nurse is orienting a new assistive personnel to the unit. For which of the following actions should the nurse intervene?

Washes and rinses her hands for 10 seconds

A nurse is admitting a client from a long term care facility. The nurse should use closed ended questions when assessing which of the following factors?

When asking if the client took his medications this morning