ATI Fundamental Practice A

A nurse is caring for a patient who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the clients 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"

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the clients partner indicates effective coping?

"I am relying on support from our family during this time."

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

"I can concentrate best in the morning"

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 clients 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 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 This client has hyponatermia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea

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

Acupuncture The nurse should inform the client tht herpes zoster, or any infection, is a contraindication of the use of acupuncture. An open portal could increase the risk of further infection

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 nurses priority action?

Administer pain medication 45 minutes before changing the clients dressing

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 The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue

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?

Assist the client with a partial bed bath Measure BP after the nurse administers a antihypertensive medication Use a communication board to ask what the client wants for lunch

A nurse is assessing a client who has required 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 Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility

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 notes that the client has received only 80 mL over the last 2 hr. 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. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed

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

Compare the clients home medications with the providers prescriptions The nurse should compare the clients home medications with the providers prescriptions when performing medication reconciliation

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 precaution Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client

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

Examine personal values about the issue Nurses should examine their own personal values about the issue in question in order to provide care that is without 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 Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed

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 The nurse should ensure the there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when he sleeves inflate

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhage shock. The nurse notifies the surgeon, who tells the nurse to continue to monitor the clients vital signs every 15 minutes and to report back in 1 hour. 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 a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client received the necessary care

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

Place the clients arm in a dependent position The nurse should place the clients arm in a dependent position because the views will dilate due to gravity

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

Potassium 5.4 mEq/L Normal ranges: - Potassium: 3.5-5mEq/L - Sodium: 135-145mEq/L - Creatine: 0.5-1.1 mg/dL - BUN: 10-20 mg/dL

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?

Situation, background, assessment, and recommendation (SBAR)

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

Subtract the amount of irrigation used from the clients urine output The nurse should calculate the fluid used for irrigation and subtract it from the clients total urinary output

A 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 her body The client should hold the cane on the stronger side of her body to increase and maintain alignment

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 hours Feeding bags should be washed out after each feeding and replace with a new feeding bag every 24 hour to prevent bacterial contamination. The nurse should reinforce this information with the clients caregiver to avoid future contamination

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

Turn the client every 2 hours The nurse should turn the client at least once every 2 hr to break up the secretions in the clients lungs and prevent noisy respirations.

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 Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do-lists is an effective tool for optimal time management

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

Use tracheostomy cover when outdoors

A client who is postoperative is verbalizing pain as a 2. 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 laying in bed"

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

"Lets talk about how the change in your job status will affect you"

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" Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency of serious illness.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate" The institution of safe-medication practices designates that nurses and providers write the complete medication name to avoid any misinterpretation

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasogastric 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. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

A nurse is preparing to 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 actions should the nurse take?

Ask another nurse to observe the medication wastage A second nurse must watch the disposal of any portion of a dose of a controlled substance

A nurse is initiating a protective environment for a client who has had a 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 clients immune system, greatly increases the risk of infection. The client will need protection from breathing in any pathogens in the environment

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 Pressing gently on the tragus of the ear will help the medication get into the inner ear

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 identifies the location of a fire extinguisher

A 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 lower than the stairs of my front porch." Clearing stairs of any objects that could cause the client to trip or require them to bend over while walking will decrease the risk for falls

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks "what would happen if i arrived at the emergency department and i had difficulty breathing?". Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula

A nurse in a long-term care facility is caring for a client who dies during the nurses 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 clients body 4. Ask the clients family members if they would like to view the body 5. Place a name tag on the body

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

A mole with asymmetrical appearance

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 at a 45 degree to 90 degree angle for a subcutaneous injection

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients' safety, health and rights

A nurse is 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 administering 1 L of NS to a client who is postoperative and has fluid 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 the expected range

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

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

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

Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m of the client who has disorder requiring droplet precautions

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients 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. The nurse should begin to assess the clients needs and plan for care both during and after the clients time in the facility

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 client arm

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 clients wrists before applying the restraints

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 precautions, which include placing the client in a room that has negative pressure airflow to reduce the risk of infection transmission

A nurse is assessing an older adult clients risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs?

Pupil clarity- cloudy pupils could mean cataracts Visual Fields- peripheral view Visual acuity- distance vision

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

Reassure the client that this is an expected response to grief During the anger stage of the client of the clients psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected cancer diagnosis

A nurse is reviewing evidence-based 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 floe rate of no more than 6L/min Evidence-based practice supports a flow rate of 1-6 L/min via nasal cannula. Rates above 6L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen

A nurse is talking with the partner if a client who has dementia. The client 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 partners expression of frustration is an example of role overload, which refers to having responsibilities within a role than one person can manage

A nurse is lifting a bedside cabinet to move it closer to a client 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 This action keeps the cabinet close to the nurses center of gravity and decreases back strain from horizontal reaching

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

Use a bed exit alarm system The nurse should identify that a client who has dementia requires assistance when existing their bed and might be unstable to remember to ask for help. The clients condition places then at a higher risk for falling, therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance

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 patient The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who required contact precautions due to the risk of contact with bodily fluids and contaminated surfaces