ATI Fundamental part B

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."

A nurse is assessing an adult client 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 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 that teaching?

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

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

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

A. "Drink a cup of hot cocoa before bedtime" (NO) B. "Maintain a consistent time to wake up each day" (MAYBE) C. "Exercise 1 hour before going to bed" (NO) D. "Watch a TV program in bed before going to sleep"

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 while at the facility

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?

Have the client use a trapeze bar when changing positions

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?

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

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

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

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 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? a. Assign a staff member to feed the client b. Provide small-handled utensils for the client c. Thicken liquids on the client's tray d. Arrange the food in a consistent pattern on the client's plate

d. Arrange the food in a consistent pattern on the client's plate

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? a. The tube aspirate has a pH of 7. b. An x-ray shows the end of the tube above the pylorus c. Bowel sounds are present on auscultation d. The client reports relief of nausea

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

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 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.

1. Inject 10 units of air into the bottle of NPH insulin insulin 2. Inject 5 units of air into the bottle of regular 3. Withdraw the correct dose of regular insulin from the bottle 4. Withdraw the correct dose of NPH insulin from the bottle

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading 0 if it applies. Do not use a trailing zero.)

8 mL/hr

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth everyday." Which of the following components of the prescription should the nurse verify with the provider?

Medication dose

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following statements indicates an understanding of herbal supplement use? a. "I can take echinacea to improve my immune system." b. "I can take feverfew to reduce my level of anxiety." c. "I can take ginger to improve my memory." d. "I can take ginkgo biloba to relieve nausea."

a. "I can take echinacea to improve my immune system."

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates 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?

**PICTURE**

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 provide to the client and his family? (SATA) -Check the cord routinely for frays or tearing -Keep the unit atleast 1.2m (4 ft) away from a gas stove -Consider purchasing a generator for power backup -Observe for signs of Hypoxia -Select synthetic clothing and bedding

-Check the cord routinely for frays or tearing -Consider purchasing a generator for power backup -Observe for signs of Hypoxia

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (SATA) -Place the client in a room with negative-pressure airflow -Wear gloves when assisting the client with oral care -Limit each visitor to 2 hour increments -Wear a surgical mask when providing client care -Use antimicrobial sanitizer for hand hygiene

-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 is correct.

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 sounds b. Measure urine output c. Monitor blood pressure readings d. Monitor electrolyte levels

a. Auscultate lung sounds

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions 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 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 side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "Incident report completed" b. "Client climbed over the side rails" c. "Client found lying on floor" d. "Client was trying to get out of bed"

c. "Client found lying on floor"

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? a. Current flow sheet b. Acuity ratings c. Current medications d. Incident reports

c. Current medications ???

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the pas 3 days. Which of the following findings should the nurse expect? a. Neck vein distension b. Urine specific gravity 1.010 c. Rapid heart rate d. BP 144/82 mm Hg

c. Rapid heart rate ????

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. A client who has a history of physical abuse b. A client who has a permanent pacemaker c. A client who has ulcerative colitis d. A client who has asthma

d. A client who has asthma

A nurse is caring for a patient who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a. Purulent exudate b. Warmth c. Skin blanching d. Bleeding

c. Skin blanching

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? a. Droplet b. Airborne c. Contact d. Protective equipment

a. Droplet

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

Flush the tube with 15 mL of sterile water

A nurse is calculating a client's fluid intake over the past 8 hrs. Which of the following items 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 of ice chips d. 6 oz of tea

c. 8 oz of ice chips

A community health nurse is checking BP for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. A client who is 52 years old b. A client who smokes one pack of cigarettes each day c. A client who walks for 30 mins a day d. A client who drinks one glass of wine 3x a week

b. A client who smokes one pack of cigarettes each day

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse b. A nurse asks a nurse from another unit to assist with documentation for a client c. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care d. A nurse discusses a client's status with the physical therapist who is caring for the client

b. A nurse asks a nurse from another unit to assist with documentation for a client

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? a. Gown b. N95 respirator c. Shoe covers d. Surgical cap

b. N95 respirator

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 members will assist with the procedures

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

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? a. Ensure sterilization of non disposable items with ethylene oxide b. Wrap monitoring cords with stockinette and tape them in place c. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. Wear hypoallergenic latex gloves that contain power

b. Wrap monitoring cords with stockinette and tape them in place

A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine." b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7:00 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly"

c. "I flushed what I urinated at 7:00 am and have saved all urine since" ????

A nurse is discussing the responsibility of nurses caring for clients who have 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 airflow system b. Use alcohol-based hand sanitizer when leaving the client's room c. Clean contaminated surfaces in the client's room with a phenol solution d. Have family members wear a gown and gloves when visiting

c. ??

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? a. Rock the client up to a standing position b. Pivot on the foot that is the farthest from the chair c. Assess the client for orthostatic hypotension d. Apply a gait belt to the client

c. Assess the client for orthostatic hypotension

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 degrees C. (105F) c. 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 nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? a. Touch the face with a cotton ball b. Apply a vibrating tuning form to the client's forehead c. Have the client stand with their arms at their sides and their feet together d. Perform direct percussion over the area of the kidneys

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

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 take? a. "You should have an eye examination every 2 years" b. "You should receive a tetanus booster every 5 years" c. " You should have a fecal occult blood test every 2 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 decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. Place a pillow under the client's knees b. Position a trochanter roll under each of the client's hips c. Advise the client to wear rubber-soled slippers d. Apply an ankle-foot orthotic device to the client's feet

d. Apply an ankle-foot orthotic device to the client's feet ????

A nurse is discussing the responsibility of nurses caring for clients who have 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 airflow system b. Use alcohol-based hand sanitizer when leaving the client's room c. Clean contaminated surfaces in the client's room with a phenol solution d. Have family members wear a gown and gloves when visiting

d. Have family members wear a gown and gloves when visiting

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include is within the RN scope of practice? a. Insert an implanted port b. Close a laceration with sutures c. Place an endotracheal tube d. Initiate an enteral feeding through a gastrostomy tube

d. Initiate an enteral feeding through a gastrostomy tube

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 uses as a psychomotor approach to learning? a. Role Play b. Group discussions c. Question-answer meetings d. Practice sessions

d. Practice sessions

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? a. The caregiver is the client's financial power of attorney b. The client is in a wheelchair with the wheels locked c. The client reports receiving a full bath twice each week d. The caregiver insists on remaining in the room

d. The caregiver insists on remaining in the room.

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 patient is experiencing spiritual distress? a. "What could I have done to deserve this illness?" b. "I blame medical science for not curing me" c. "Where is my daughter at a time like this?" d. "Will i ever begin to feel in charge of my life again?"

a. "What could I have done to deserve this illness?"

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration b. Transfer the medication to a medicine cup c. Place the client in a semi-fowler's position prior to medication administration d. Verify the dosage by measuring the liquid before administering

a. Gently shake the container of medication prior to administration

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 which of the following client statements? a. "I'm having mild pain." b. "The pain is like a dull ache in my stomach." c. "I notice that the pain gets worse after I eat." d. "The pain makes me feel nauseous."

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

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? a. Admitting diagnosis b. Breath sounds c. Body temperature d. Diagnostic test results

b. Breath sounds

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 followingactions should the nurse take? a. Ask the client to consider a direct donation b. Withhold the blood transfusion c. Request a consultation with the ethics committee d. Ask the client's family to intervene

b. Withhold the blood transfusion

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? a. Instruct the family refrain from pushing the buttons for the client while she is asleep b. Inform the client that because she is on 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 to 10 d. Increase the basal rate and shroten the lock-out interval time if the client's pain level is too high

a. Instruct the family refrain from pushing the buttons for the client while she is asleep ????

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 performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse heard the following sound. This sound indicates which of the following? a. Narrowed arterial lumen b. Distended jugular veins c. Impaired ventricular contraction d. Asynchronous closure of the aortic and pulmonic valves

***SOUND*** a. Narrowed arterial lumen

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 preparing to delegate client care task to an assistive personnel. (AP). Which of the following tasks should the nurse delegate? a. Ambulating a client who is postoperative b. Inserting an indwelling catheter for a client c. Demonstrating the use of an incentive spirometer to a client d. Confirming that a client's pain has decreased after receiving an analgesic

a. Ambulating a client who is postoperative ????

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program for regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics

a. Walking briskly

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 patient'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 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 the client 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 exercises." 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."