Fundamentals ATI Review Questions

the nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch"

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you."

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?" quality of pain refers to is it- dull, sharp, throbbing, aching, burning, etc.

A nurse is caring for a client who asks 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 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 would give you 02 through a tube in your nose" -02 is not a resuscitative measure when in the nasal cannula

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.

-Obtain the pronouncement of death from the provider-Remove tubes and indwelling lines-Wash the client's body-Ask the client's family members if they would like to view the body-Place a name tag on the body

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 AP?

-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 for lunch

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

-pupil clarity -visual fields -visual activity

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

Administer the medication with the needle at a 45-degree angle. *45-90 degrees for subQ*

Nurse is preparing an education program for staff about advocacy. What information should the nurse include?

Advocacy ensures the client's safety, health, and rights. -ensures ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning?

Apply intermittent suction when withdrawing he catheter *not more than 10 seconds*

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 -w/o padding it can abrade the client's skin

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

SBAR

A nurse is performing a 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 uses no acetone nail polish remover.

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 -this will protect the client's airway from cold air/dust

A nurse is performing a 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 a skin malignancy?

a mole with an asymmetrical apperance

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 -hyponatremia includes: abdominal cramping, weakness, confusion, lethargy, HA, nausea

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

administer the medication into the abdomen -admin. at least 2 inches from the umbilicus -pt should pinch or spread the skin at the injection site

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

calf swelling

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?

decreased HR -fluid volume deficit causes tachycardia

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 the admission process

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

examine personal values about the issue -in order to provide care that is w/o bias

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

have the client take sips of water to promote insertion of the NG tube into the esophagus

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 *allogeneic stem cell transplant compromises the client's immune system*

A nurse is planning to insert a peripheral IV, catheter in an older adult client. Which of the following actions should the nurse plan to take?

place the clients arm in a dependent position - this will allow the veins to dilate d/t gravity *insert at a 15-30 degree angle or less*

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 trigs of the client's ear

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

regulate O2 via nasal cannula at a flow rate or no more than 6L/min -rates above this have a drying effect

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

the clients caregiver washes out the feeding bag with warm water once every 24 hr -Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination

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

use a bed exit alarm system

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

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