foundations final practice questions ati

Compliance of hand washing among staff members is less than 50% Hand hygiene is the most important step to prevent spreading of infection Alcohol-based hand gel is an acceptable method of hand hygiene Clients should be instructed about hand hygiene

A charge nurse is teaching a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching?

Provide under-bed lighting at night Lock the wheels on the bed Place breaks on clients' wheelchairs

A charge nurse is teaching a newly licensed nurse about fall prevention strategies when caring for clients. Which of the following information should the nurse include in the teaching?

implementation

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

blood pressure anxiety irregular heart rate chest tightness

A nurse if caring for a client who has a history of angina. Which of the following findings require follow-up by the nurse?

take the client to the bathroom ever 2 hours

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

"ill use the cleansing wipe from the front to the back"

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

after each medication prior to administering each medication after giving multiple medications

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)

check the clients airway

A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first?

Partial-thickness skin loss with red tissue in wound bed

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

vomiting altered mental status elevated WBC

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis?

tachycardia

A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

dark colored urine

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

dehydration

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

decreased circulation

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

Burning sensation in feet

A nurse is assessing a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

Atelectasis

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

hyperventilation

A nurse is assessing a client who is experiencing anxiety. Which of the following findings should the nurse expect?

peripheral edema

A nurse is assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

oliguria

A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

poor skin turgor, hypotension, and flat neck veins

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

Conjunctivae

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

890 mL

A nurse is calculating a client's fluid output for a 12-hr period. It includes Jackson-Pratt (JP) drainage 35 mL, NG suction 120 mL, and incontinence pads weighing 240 g, 275 g, 310 g, and 270 g. The dry weight of the incontinence pads is 90 g. The nurse should record how many mL of output on the client's record?

1720 mL

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

urinary tract infection

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

aspiration

A nurse is caring for a client who had a stroke and has dysphagia. The nurse should monitor the client for which of the following complications?

respiratory acidosis

A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances?

Place a perforated gauze pad around the drain

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

tape the connections on the clients chest tube

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Face the client when speaking to them

A nurse is caring for a client who has a moderate vision impairment. Which of the following actions should the nurse take?

oxygenation saturation on day 2 tracheal secretions respiratory rate day 2

A nurse is caring for a client who has a tracheostomy. Select the 3 findings that require immediate follow-up.

Perform tracheostomy care for the client every 4 hr

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

4.0

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

withdraw 3 to 5 mL of urine from the port

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

temperature urine clarity heart rate WBC

A nurse is caring for a client who has an indwelling urinary catheter. Select the 4 findings from day 2 that require immediate follow-up.

back pain urine color blood pressure temperature

A nurse is caring for a client who has anemia. Select the 4 findings that require immediate follow-up.

Temperature at 1800 drooling hoarse voice

A nurse is caring for a client who has had a stroke. Select the 3 findings that require immediate follow-up.

allow extra time to communicate with the patient

A nurse is caring for a client who has impaired speech. Which of the following actions should the nurse take?

metabolic alkilosis

A nurse is caring for a client who has nausea and is vomiting. The nurse should identify the client is at risk for which of the following acid-base imbalances?

Attach a humidifier bottle to the base of the flow meter

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

have the client breathe into a paper bag

A nurse is caring for a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?

raise the head of the bed

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

metabolic-acidosis

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?

provide the client with a high calorie diet

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

Place a towel under the client's head

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

conduct a mental status exam for the client

A nurse is caring for a client who is experiencing stress. Which of the following actions should the nurse take first?

Auscultate beach sounds at least every 2 hours

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?

dry between folds in the clients skin

A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take?

apply a warm compress to the iv site

A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the following actions should the nurse take?

stop the transfusion

A nurse is caring for a client who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first?

use two acceptable client identifiers verify that the surgical site has been marked ask the client to state the surgery being performed ask the client to point to the surgical site

A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out?

INR preoperative medication WBC count

A nurse is caring for a client who is scheduled for a surgical procedure. Select the 3 findings that require immediate follow-up.

Aspirate fluid from the IV cannula

A nurse is caring for a client who receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take?

A client who is unresponsive to verbal commands and changes position occasionally

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

the client who has a nasogastric (NG) tube to suction

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

A client receiving continuous enteral feeding through NG tube

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration?

740 mL

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

1140 mL

A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record?

bid 30 mL

A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? (Select all that apply.)

encourage the client to hold her breath when feeling the urge to urinate

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

Determine the length of the NG tube to be inserted prior to the procedure

A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?

Wait 30 minutes and return to measure the oral temperature

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

dim lighting installed throughout the house the water heater is set at 54 degree Celsius medications are stored in a clear bag area rugs are placed in the living room

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client?

Suction two to three times with a 60-second pause between passes.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

dextrose 5% in water

A nurse is planning care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate?

dermatitis

A nurse is planning care for a client who has urinary incontinence. The nurse should plan to monitor the client for which of the following findings?

Ensure 2 nurses check the label on the unit of blood

A nurse is planning to administer a unit of PRBCs for a client. Which of the following actions should the nurse plan to take?

telephone number

A nurse is preparing a client for a procedure. Which of the following is an acceptable identifier to use identify the client?

inject 20 units of air into the NPH insulin vial

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?

Flush the NG feeding tube with 30 mL of water immediately following medication administration

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Irrigate the wound until the solution that is draining is clear

A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take?

obtain vital signs for both client

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

medical condition

A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

repeat your breathing excursuses every 2 hours

A nurse is providing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make?

apply a barrier cream to the clients skin

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

suction the tracheotomy of a client who has copious secretions

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first?

Sodium 126mEq/L

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?

metabolic acidosis

A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3- 18 mEq/L, and PaCO2 36 mm Hg. Which of the following conditions should the nurse anticipate when interpreting these findings?

macular degeneration electrical cord on floor over walkway throw rugs in the kitchen

A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall?

Urine Specific Gravity 1.035

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

client has an NG tube to gastric suction

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

increased blood glucose level

A nurse is teaching a class about physical manifestations that occur during the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

impaired immune function

A nurse is teaching a class about stress. The nurse should include that which of the following is a manifestation of prolonged stress?

point the toes toward the foot of the bed rotate the feet in a circular motion point the toes toward the head

A nurse is teaching a client about performing leg exercises to reduce the risk for deep vein thrombosis. Which of the following instructions should the nurse include?

"install hand rails in your bathroom"

A nurse is teaching a client about reducing the risk for falls. Which of the following statements should the nurse make?

"You will have control of administering your own pain medication."

A nurse is teaching a client about using a PCA device for postoperative pain management. Which of the following statements should the nurse make?

"inhale through the incentive spirometer 10 times with each use"

A nurse is teaching a client how to use an incentive spirometer. Which of the following statements should the nurse make?

"You should inhale through your nose and exhale through your mouth during purse-lipped breathing."

A nurse is teaching a client who has COPD about purse-lipped breathing. Which of the following statements should the nurse make?

"increase your daily fluid intake"

A nurse is teaching a client who has constipation. Which of the following statements should the nurse include?

avoid walking barefoot

A nurse is teaching a client who has diabetic neuropathy about foot care. Which of the following instructions should the nurse include?

caffeinated beverages

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

baked potato

A nurse is teaching a client who is at risk for hypokalemia. The nurse should instruct the client that which of the following foods is the best source of potassium?

"you will have a stoma in your left lower abdomen"

A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

"you will have a stoma placed in your right lower abdomen"

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

"splint your incision with a pillow when coughing"

A nurse is teaching a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make?

A nonrebreather mask should fit snugly over a client's face

A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include?

Confirm that the client is competent to sign for the procedure

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process?

Use chlorhexidine gluconate to clean skin on clients who are preoperative.

A nurse is teaching a newly licensed nurse about reducing the risk for healthcare-associated infections. Which of the following instructions should the nurse include?

increase dietary intake of raw vegetables

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

"My partner should tilt their head forward when swallowing"

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?

contact the provider to clarify the prescription

A nurse is transcribing a client's medication prescriptions and is having difficulty reading a written prescription by the provider. Which of the following nursing actions should the nurse take?

type 2 diabetes mellitus Smoking history prednisone

The nurse is reviewing the client's electronic medical record. Which of the following findings places the client at risk for a surgical complication?

Diabetes mellitus Medication history Prealbumin level

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing?