ATI Fundamentals A

A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure the medication reaches the inner ear? A. Press gently on the tragus of the client's ear B. Pack a small piece of cotton deep into the client's ear canal C. Move the client's auricle down and back toward her head D. Tilt the client's head backward for 5 minutes

A

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? A. "Use the complete name of the medication magnesium sulfate" B. Delete the space between the numerical dose and the unit of measure C. Write the letter U when noting the dosage of insulin D. Use the abbreviation SC when indicating an injection

A

a nurse on a med surg unit is caring for a client who has a new prescription for iris restraints. Which of the following actions should the nurse take? A. Pad the client's wrists before applying the restraints. B. Evaluate the client's circulation every 8 hr after application C. Remove restraints every 4 hrs to evaluate the client's status D. Secure the restraint ties to the bed's side rails

A

A nurse is education a pt who has a terminal illness about declining resuscitation in a living will when the client asks, "What would happen if I arrived at the ER and had difficulty breathing?" Which of the following responses should the nurse make A. We would consult the person appointed by your healthcare proxy to make decisions B. We would give you O2 through a tube in your nose C. You would be unable to change your previous wishes about your care D. We would insert a breathing tube while we evaluate your condition

B

A client who is post op is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication the client understands the preoperative teaching she received about pain management A. I think I should take the pain meds more often, since it is not controlling my pain B. Breathing faster will help me keep my mind of the pain C. It might help me listen to music while I'm lying in bed D. I don't want to walk today because I have some pain

C

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. A lesion with uniform pigmentation B. New appearance of Petechiae C. A mole with an asymmetrical appearance D. The presence of a papule

C

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? A. Is your pain constance or intermittent? B. What would you rate your pain on a scale of 0 - 10? C. Does the pain radiate? D. Is your pain sharp or dull?

D

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? A. Have the client wear a mask when recieving visitors. B. Limit the clients time with visitors to no more than 30 minutes per day C. Assign the client to a room with Negative pressure airflow exchange D. Wear a gown when caring for a client

D

A nurse is preparing to administer enoxaparin SC to a client. Which of the following actions should the nurse take? A. Administer the medication with the needle at a 45 degree angle B. Administer the medication into the client's non dominant arm C. Pull the clients skin laterally or downward prior to administration D. Massage injection site after administration

A

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? A. Check the client for injuries B. Move hazardous objects away from the client C. Notify the provider D. Ask the client to describe how she felt prior to fall

A

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses tx options and leaves the client's 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? A. I will return shortly after I document this in your record B. Most men live a long time with prostate cancer C. I am available to talk if you should change your mind D. I will make a referral to a cancer support group

C

A nurse is caring for a client who is postoperative following knee arthroplasty to require the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take A. Assist the client into a prone position B. Place a sleeve over the top of each leg with the opening at the knee C. Make sure two fingers can fit under the sleeves D. Set ankle pressure at 65mmHg

C

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 18 inches forward C. The client holds the cane on the stronger side of her body D. The client moves her stronger limb forward with the cane

C

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? A. Insert the needle at a 15 degree angle B. Aspirate for blood return prior to administration C. Administer the medication into the abdomen D. Massage the site following the injection

C

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 am not sure I want to retire. Which of the following responses should the nurse make A. You would have so much more time to spend with your family B. You should consider getting a part time job doing volunteer work C. Let's talk about how the change in your job status will affect you D. Why wouldn't you want to retire and relax?

C

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? A. Bend at the waist B. Keep his feet close together C. Use his back muscles for lifting D. Stand close to cabinet when lifting it

D

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? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their ID bracelet with the MAR B. Call the pharmacy to determine whether the clients medications are available C. Compare the clients home medications with the provider's prescriptions D. Place the clients home medication bottles in a secure location

C

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of 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 A. Biofeedback B. Aloe C. Feverfew D. Acupuncture

D

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 priority action? A. Encourage the client to relax and take deep breaths during the dressing change B. Educate the client about the importance o dressing change to prevent infection C. Assist the client to a comfortable position for dressing change D. Administer pain medication 45 mins before changing the client's dressing

D

A nurse is assessing a clients readiness the learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. I can concentrate best in the morning B. It is difficult to read the instructions because my glasses are at home C. Im wondering why I need to learn this D. You will have to talk to my wife about this

A

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize risk for injury to the client? A. Use bed exit alarm system B. Raise four side rails while the client is in bed C. Apply one soft wrist restraint D. Dim the lights in the client's room

A

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? A. Make sure the client has at least 6 air exchanges per hour B. Make sure the client wears a mask when outside her room if there is construction in the area C. Place the client in a private room with negative pressure airflow D. Wear an N95 respirator when giving the client direct care

B

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? A. Place the client in a side lying position B. Instill 15 mL of irrigation fluid into the catheter with each flush C. Subtract the amount of irritant used from the client's urine output D. Perform the irrigation using a 20mL syringe

C