ATI Funds Practice Test 7
A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush". Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? Judgement Short-term memory Attention span Abstract reasoning
Abstract reasoning
A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Using clean technique to perform the procedure Apply suction while inserting the catheter Lubricating the suction catheter with an oil-based lubricating jelly Administering high-flow oxygen prior to the procedure
Administering high-flow oxygen prior to the procedure (3-4 breaths of 100% oxygen via a resuscitation bag before suctioning to reduce the risk of hypoxia) INCORRECT: Using clean technique to perform the procedure= STERILE Apply suction while inserting the catheter= insert GENTLY Lubricating the suction catheter with an oil-based lubricating jelly = STERILE SALINE
A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis? Albumin Calcium Sodium Potassium
Albumin
A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? Assessment Background Situation Recommendation
Assessment INCORRECT: Background (medical history) Situation (probs they are experiencing) Recommendation (for treatment)
After assessing the client's radial pulses, the nurse document "radial pulses 4+ bilaterally". The nurse should document this finding when a client's pulses have which of the following qualities? Bounding Full Variable Weak
Bounding INCORRECT: Full= 3+ Variable not for pulses Weak= 1+
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? Administer 0.9% sodium chloride until TPN is available from the pharmacy Check the client's capillary blood glucose level every 4 hours Obtain the client's weight each week Change the IV tubing every 3 days
Check the client's capillary blood glucose level every 4 hours (due to risk of hyperglycemia bc of the dextrose concentration) INCORRECT: Administer 0.9% sodium chloride until TPN is available from the pharmacy--> 10%-20% OF DEXTROSE in water Obtain the client's weight each week --> DAILY Change the IV tubing every 3 days--> EVERY 24 HOURS
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? Apply a fecal collection system Apply a barrier cream Cleanse and dry the area Check the client's perineum
Check the client's perineum
A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium Decreased potassium Increased potassium Increased calcium
Decreased calcium INCORRECT: all Hyperkalemia
A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? Popliteal Posterior tibial Dorsalis pedis Femoral
Dorsalis pedis
A nurse is caring for a client who has terminal illness the client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Change the topic because the client is trying to divert attention from the illness Encourage the client to express thoughts about death and dying Tell the client that religious beliefs are a personal matter Offer to contact the client's minister or the facility's chaplain
Encourage the client to express thoughts about death and dying
A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? Close the door to the client's room Evacuate the client from the room Sound the fire alarm Activate the fire extinguisher
Evacuate the client from the room
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? Ask the client if he wants to self-administer his insulin Have the client list the steps of the procedure Have the client demonstrate the procedure Ask the client if he understands the purpose of the insulin
Have the client demonstrate the procedure
A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? BUN 18 mg/dL Capillary refill 1.5 sec Hct 55% Urine specific gravity 1.001
Hct 55% (elevated hematocrit) INCORRECT: BUN 18 mg/dL= expected Capillary refill 1.5 sec= expected Urine specific gravity 1.001= (Low) HYPERVOLEMIA
A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI? Infection acquired from improper hand hygiene Infection acquired by drug resistance Infection acquired by inappropriate waste disposal Infection acquired from a diagnostic procedure
Infection acquired from a diagnostic procedure (result from diagnostic or therapeutic procedures)
A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching? Ovo-vegetarian diets exclude eggs Kosher diets have restriction regarding how the food must be prepared Macrobiotic diets are plant-based and exclude all animals and seafood Flexitarian diets exclude the consumption of dairy products
Kosher diets have restriction regarding how the food must be prepared INCORRECT: Macrobiotic--> include fish and seafood
A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings Peripheral pulses equal bilaterally at a rate of 60/min Radial, brachial, and pedal pulses bilaterally weak Peripheral pulses bilaterally symmetric, equal, and strong, in all 4 extremities Brachial, radial, popiteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable
Peripheral pulses bilaterally symmetric, equal, and strong, in all 4 extremities (peripheral pulses = radial, brachial, ulnar, femoral, popiteal, tibial, and dorsalis pedal pulses)
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply) Set the suction machine at 120 mmHg Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown Apply petroleum jelly to the client's nares
Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown INCORRECT: 80-100mmHg Water-soluable lubricant
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Tie the restraint to the side of the bed rail Perform ROM exercises to the wrists every 3 hours Remove the restraints one at a time Obtain a PRN prescription for the restraints
Remove the restraints one at a time
A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? Change the tube feeding bag every 48 hrs Chill the formula prior to administration Increase the infusion rate Request a prescription for an isotonic enteral nutrition formula
Request a prescription for an isotonic enteral nutrition formula (easier to digest) INCORRECT: Change the tube feeding bag every 48 hrs= EVERY 24 HOURS
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? Start chest compressions Provide breaths with a manual resuscitation bag Administer oxygen Establish an airway
Start chest compressions
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? Test for the presence of client's gag reflex Place the client in the supine position Use a firm toothbrush for tooth and gum care Use 2 gauze-wrapped fingers to hold mouth open
Test for the presence of client's gag reflex (should do this prior to oral care to determine the risk of aspiration)
A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? The RDA is a comprehensive term that includes various dietary standards and scales The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein
The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups
A nurse is assisting a client who has a right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking? The client hold the cane on the affected side The client advances the unaffected leg followed by the cane The client supports his this weight on the unaffected leg when moving the cane forward The client keeps 2 points of support on the ground
The client keeps 2 points of support on the ground
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? "Social services can contact various community resources that will be helpful" "I will review the care plan the make the necessary changes "Lets set up a meeting time with the doctor to discuss your options for home care" "I will make a list of things we need to do before discharge"
"Lets set up a meeting time with the doctor to discuss your options for home care"
A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4 C. Above what F temper should the nurse administer acetaminophen to the client?
101.1 F= (C x 9/5) + 32 F= (38.4 x 9/5) + 32 F= 101.12
A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure? 142/85 mmHg 116/70 mmHg 130/76 mmHg 124/82 mmHg
116/70 mmHg
A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? Hyperglycemia Hypotension Heightened immune response Bleeding tendencies
Hyperglycemia (increased cortisol--> can lead to hypertension or hyperglycemia)
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? Lock the wheels on the bed and stretcher Instruct the client to raise his arms above his head Elevate the stretcher 2.5cm (1in) above the height of the bed Log-roll the client
Lock the wheels on the bed and stretcher
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with. client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss Trust Self-disclosure Risk-taking
Loss
A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? Heart Lungs Thyroid gland Skin
Lungs (creates a vibration that helps determine the density of the underlying tissue--> lungs are hollow organs)
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? Select all that apply The client's ID number The client's room number The client's name ABO compatibility Rh compatibility
The client's ID number The client's name ABO compatibility Rh compatibility ( to prevent transfusion reactions due to human error)
A nurse is caring for a client who is admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? One week prior to the client's discharge Upon the client's admission to the care facility Once the discharge date is identified When the client addresses the topic with the nurse
Upon the client's admission to the care facility
A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? Sodium 123 mEq/L Blood glucose 100 mg/dL Potassium 3.5 mEq/L Hemoglobin 13 g/dL
Sodium 123 mEq/L (ref range= 136-145 this can lead to seizures, coma, death) INCORRECT: Blood glucose ref range= 70-110 Potassium =3.5-5 Hemoglobin= 12-18
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedel pulses Obtain a medical history Measure vital signs Assess for leg pain
Evaluate pedel pulses
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse taken when performing tracheostomy care for the client? Perform tracheostomy care using medical asepsis Allow enough slack under the tracheostomy ties to insert 3 fingers Soak the inner cannula of the tracheostomy tube in normal saline Cut a sterile gauze pad to place between the neck and tracheostomy tube
Soak the inner cannula of the tracheostomy tube in normal saline (or a mixture of normal saline and hydrogen peroxide to loosen secretions) INCORRECT: Perform tracheostomy care using medical asepsis--> SURGICAL SEPSIS (STERILE) Allow enough slack under the tracheostomy ties to insert 3 fingers--> 2 fingers Cut a sterile gauze pad to place between the neck and tracheostomy tube--> NO client could aspirate on loose threads
A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? Assign the client to a private room Keep 4 side rails up while the client in in bed Monitor the client at least once every hour Request a PRN prescription for restraints
Monitor the client at least once every hour
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Fasten the ties on the restraint to the side rails of the bed Tie the restraint with a quick-release knot Allow a fingerbreadth between the restraint and the client's chest Place the restraint under the client's clothing
Tie the restraint with a quick-release knot
A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? "I'm afraid this injury will cause my to lose my job" "I can't sleep well because whenever I move in my sleep the pain wakes me up" "I don't know what I will do if my car isn't safe or even drivable after the crash" "I wonder how I am going to be able to take care of my family"
"I can't sleep well because whenever I move in my sleep the pain wakes me up"
A middle-aged client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? "We miss out daughter so much that we are going to move closer to her" "I think this year I can plan on managing the funding at the church" "I really wish I could lose some of this weight" "I find I am spending more time at work now that my son is at college"
"We miss out daughter so much that we are going to move closer to her"
A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I will use a staple remover and remove each suture individually" "Bandage scissors are used to cut the sutures" "Tweezers are necessary only for removing retention sutures" "I will clip each suture close to the skin and pull it through from the other side"
"I will clip each suture close to the skin and pull it through from the other side" (does not disrupt wound healing" INCORRECT: "I will use a staple remover and remove each suture individually" =removes staples not sutures "Bandage scissors are used to cut the sutures"= too blunt and tip is loo large "Tweezers are necessary only for removing retention sutures"= not retention sutures
A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home which of the following statements should the nurse identify as an indication that the client understands medical asepsis? "Ill wrap the old dressing in a paper bag and put it in the trash" "Ill wash my hands before I remove the old dressing and again before putting on the new one" "Ill need to take a pain pill 30 mins before I change the dressing" "Ill wear sterile gloves when I apply the new dressing"
"Ill wash my hands before I remove the old dressing and again before putting on the new one"
A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo an magnetic resonance imaging (MRI)? Coronary artery stents Aneurysm clip Hearing aids Automated internal defibrillator
Hearing aids (they can be removed!!!!)
A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? Hydrocolloid Collagen Calcium alginate Proteolytic enzyme
Hydrocolloid INCORRECT: Calcium alginate--> stage IV Proteolytic enzyme-->unstageable pressure ulcer
A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? Document the finding Measure the client's apical pulse rate Talk with the client about factors that can affect pulse rate Notify the provider about the client's radial pulse rate
Measure the client's apical pulse rate (to determine if there is a pulse deficit)
A nurse in an emergency department is caring for a client who reports developing severe eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? Instill proparacaine hydrochloride eye drops Perform ocular irrigation of the right eye Place the client in a supine position with the head turned toward the affected side Ask the client about first aid performed at the scene
Ask the client about first aid performed at the scene (must collect adequate data from the client like if eye irrigation was performed in order to proceed)
A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? Auscultation Light palpation Percussion Deep palpation
Auscultation (palpate/percuss after in order to not stimulate bowel sounds and create a false result)
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? Wear sterile gloves when collecting the specimen Cleanse the wound with 0.9% sodium chloride irrigation Allow the collection swab to absorb old exudate Rotate the collection swab over the edges of the wound
Cleanse the wound with 0.9% sodium chloride irrigation (to remove any surface debris or old exudate) INCORRECT: Wear sterile gloves when collecting the specimen (CLEAN gloves) Rotate the collection swab over the edges of the wound (areas in the base of the wound)
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? Instruct the client to defecate into the toilet bowl Transfer the specimen to a sterile container Refrigerate the collected specimen Place the stool specimen collection container in a biohazard bag
Place the stool specimen collection container in a biohazard bag (with the client label ) INCORRECT: Instruct the client to defecate into the toilet bowl--> into a bed pan Transfer the specimen to a sterile container--> CLEAN container Refrigerate the collected specimen--> take it directly to the lab
While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able" The nurse should identify that the client is referring to which of the following documents? Informed consent form Living will document Do-not-resuscitate (DNR) directive Durable power of attorney document
Durable power of attorney document (health care proxy)
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic Febrile Circulatory overload Sepsis
Hemolytic (occurs when the client's blood is incompatible with the donor's blood)
