Fundamental ATI practice test
Which of the following is an advantage of using alcohol-based gel?
It takes less time to use than washing with soap and water.
Which of the following actions demonstrates correct use of one of the Ten Rights of Medication Administration?
Administering a client's medication by the route the provider has prescribed.
which of the following actions should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing?
Ascultate The clients lungs-Silent aspirations are common complication of swallowing impairment
A nurse is planning morning hygiene care for a postoperative client. Which of the following actions should the nurse take?
Ask the client in what order they typically perform their morning routine.
what should the nurse do to maintain standard precautions
Disinfect hands immediately after removing gloves.
a nurse is caring for a client who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the client with feeding?
Elevate the head of the bed 45 to 90°.The patient's head should be sufficiently elevated to prevent aspiration.
A nurse is assessing a client's respiration. Which of the following actions should the nurse take?
Elevate the head of the clients bed 45-60 degrees This is a comfortable position for most clients and it allows full ventilatory movement. Discomfort can increase a client's respiratory rate.
A nurse is preparing to record the difference between a clients sys and diastol BP. WHich of the following terms defines this info when documenting
Pulse Pressure
A nurse is performing a complete bed bath for a client which of the following actions should the nurse take
Raise the room temperature
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?
Respirations 30/min
After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE Separately.
the gloves
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the top of the client's nose to the earlobe and from the earlobe to the
xiphoid process plus 20 to 30 cm more. tip of the nose to earlobe earlobe to diploid process
a nurse is administering a return-flow enema to a client. after instilling 100 ml of enema fluid which of the following actions should the nurse take?
A- lower the container to allow the solution to flow back out
while a nurse is administering a cleansing enema, the client reports abdominal cramping. which of the following action should the nurse take?
A- lower the enema fluid container
A nurse is preparing to administer a cleansing enema to a client who has poor spinster control. Which of the following actions should the nurse take?
A- place the client in the dorsal recumbent position on a bed pan
a nurse is preparing to administer serval po medications to a client. the client states they can only take one pill at a time. which of the following actions should the nurse take
A- remain at the bedside until the client has taken all of the medication
which of the following routes of mediation administration has no barriers to absorption
A- intravenous
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequete nutrients orally. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe?
nasointestinal tube
a nurse is preparing to administer medications for a client who has a nasogastric tube. which of the following actions should the nurse take prior to administering the medications?
observe the amount of residual volume left in the stomach
A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement
obtain an x-ray
Which of the following terms indicates that the medication is given via an injection
parenteral
A nurse is providing teaching about risk for aspiration with a client who is recieving intermitted bolus nasogastric feedings. WHich of the following should the nurse instruct the client to report?
persistent coughing
which of the following products can affect the permeability of latex gloves?
petroleum-based hands lotion
A newly hired nurse is reviewing information about the HIPAA privacy rule during facility orientation. Which of the following statements by the nurse indicates an understanding of the privacy rule?
"I can give information about a client over the phone if the client gives permission."
A nurse is teaching a newly licensed nurse about using a computer to document in a client's health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I should remain aware of my surroundings when documenting in the computer."
A nurse is measuring a clients temp orally. Which of the following actions should the nurse take?
Place the probe in the posterior lingual pocket lateral to the midline
which of the following food choices are appropriate for a client who is prescribed a full liquid diet?
Plain yogurt, custard, ice cream, gelatin
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following protective equipment should the nurse wear?
A face shield
A nurse is observing an assistant personnel AP make a clients bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure?
The AP reuses the clients clean blanket and spread.
A nurse is washing their hands with soap and water prior to repositioning of a client in bed. During the handwashing procedure, it is important to take which of the following actions?
Wash for at least 20 seconds.
A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority?
confirm the client's identity using two methods.
A nurse is reviewing a group of prescriptions. Which of the following should the nurse identify as an example of a complete prescription?
digoxin 1.25 mg po daily
a nurse is caring for a client who is receiving a medication that typically causes drowsiness. while assessing the client, the nurse note that the medication has caused the client to become hyperactive. which of the following term describes the client unexpected response to the medication?
idiosyncratic effect
A nurse is preparing to administer a subcutaneous injection to a client, Which of the following should the nurse assess first?
if the client has allergies to the medication
a nurse is preparing to administer several medications to a client who is receiving enteral feedings through a small bore nasogastric tube. which of the following actions should the nurse take to ensure the medications are administered correctly
infuse each medication by gravity and flush with water before and after instillation
a nurse is preparing to assist a client with a tub bath. identify the sequence of steps the nurse should take
1. gather all necessary supplies is the first step 2. place a rubber mat on the tub floor is the second step 3. assist the client into the bathroom is the third step 4. instruct the client on using safety bars when getting in and out of the tub is the fourth step 5. instruct the client to remain in the tube for no longer than 20 min
A nurse is caring for a client who has a new prescription for prednisone 12.5mg by mouth daily. The medication is available in 5 mg tablets. How many tablets should the nurse administer for each dose?
2.5 tablets
A client drinks 8 oz of water. Which of the following is a correct conversion of the client's intake?
240 ml
A nurse is caring for a client who has a Health care-associated Infection (HAI). Which of the following describes an exogenous HAI?
A Salmonella infection that occurs after eating contaminated food at the cafeteria.
a nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. which of the following actions should the nurse take?
A- warm the enema solution prior to instillation
A nurse is caring for a group of client. The nurse should identify that which of the following clients requires an enteral tube feeding?
A client who has dysphagia.
Which of the following clients is exhibiting medication tolerance?
A client who requires an increased dose of medication to achieve continued therapeutic benefit.
A nurse in a pediatrician's office is speaking on the telephone with a guardian of a school-age child who will become a new client at the office. The nurse should instruct the guardian to call the child previous provider's office to request which of the following?
A form authorizing release of copies of the child's medical records to be signed by the guardian
a nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. to which of the following lengths should the nurse insert the rectal tube?
A- 7.5 cm to 10 cm (3-4 in )
a nurse is preparing to administer an oil retention enema to a client who has constipation. the nurse should instruct the client to retain the solution for which of the following durations
A- at least 30 min
a nurse is preparing an adult client for an enema. the nurse should assist the client into which of the following positions?
A- left lateral with the right leg flexed
A nurse has a handwritten prescription that is difficult to read. Which of the following actions should the nurse take to avoid an error in medication administration?
Call the provider for clarification of the prescription
A nurse is assisting a client with personal hygiene care which of the following actions should the nurse take to reduce the risk of infection
Clean the least soiled areas prior to cleaning the most soiled areas
A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following?
Closing off the glottis.
Which of the following actions should the nurse take after witnessing a breach of a client's confidentiality in a provider's office?
Complete a health information privacy complaint form
When teaching the guardian of the toddler about feeding and eating the nurse should include which of the following safety measures
Do not offer the child raw vegetables
A nurse id preparing to administer a client's medication. The client states the medication makes them feel nauseated and refuses to take it. Which of the following actions should the nurse take?
Document the reason for refusal along with the date and time in the client's medical record.
Which of the following dietary modifications should an adolescent engaging in sports implement?
Drink water before and after sports activities.An adolescent should drink water before and after sports activities to prevent dehydration.
A nurse is caring for a client who has COPD. For which of the following inhalation medications delivery methods should the nurse assess the client's ability to inhale deeply?
Dry powder inhaler (DPI)
To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has been evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?
Drying provides the full antiseptic effect.
a nurse is caring for a client who has dysfunctional gastrointestinal tract and requires enteral feeding. which of the following formulas should the nurse administer to the client
Elemental
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experience social isolation. Which of the following interventions should the nurse recommend?
Encourage the client to go to the dining room at meal times to talk with other clients.
A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?
Hold the crutches on the unaffected side when preparing to sit in a chair
Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits?
Identify the food location as though the plate were a clock.
a nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. which of the following statements by the newly licensed nurse indicates an understanding of the teaching
Ill swab the clients mouth with chlorhexidine
Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?
Infectious diarrhea
A nurse in the emergency department is caring for a client following a motor vehicle crash. The client is unresponsive and the client's spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client's surgery?
Inform the provider of the spouse's contact information so consent can be obtained over the telephone
a nurse is taking an adult client's temperature rectally. which of the following actions should the nurse take?
Insert the probe about 2.5 to 3.5 cm into the client's anus
Which of the following describes a medication's generic name?
It is the same as its nonproprietary(noncommercial) name.
a nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth korotkoff sound. which of the following factors does this pressure reading correlate to
It might not follow with the fitfh Korotkoff sound.
A nurse in a long-term care facility is caring for a client who is on bedrest and requires frequent linen changing. Which of the following should the nurse identify as a priority rationale for frequent linen changes?
Moisture from excessive diaphoresis can cause skin breakdown
A nurse stands facing a client to demonstrate active range of motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension
Move their leg behind their body
A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?
Observe the clients chest movements while appearing to assess their pulse
A nurse is collecting data about a clients respiratory condt. Which of the following actions should the nurse take to determine the depth of the clients respiration?
Observe the degree of chest wall movement during inspiration and expiration
A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instruct the client to file the complaint?
Office for civil rights (OCR)
A nurse is preparing to provide oral care for a client who is an NPO. The client tells the nurse, I don't need oral care because I haven't eaten anything. Which of the following responses should the nurse make?
Oral care is still important even though you're not eating
a nurse is preparing to osculate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope
Overt the fifth intercostal space at the left midclavicular line
A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration
Place the client in Fowler's position.
a nurse is preparing to administer an insulin injection to a client. which of the following actions should the nurse take?
Rotate the injection sites
A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurse is take to ensure the study complies with the HIPAA privacy rule?
Submit their proposal to the institutional review board for review and describe how they will de-identify client information
A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following?
Swallowing examination Patients at high risk for aspiration include those with a decreased level of consciousness. This patient has some periods of decreased alertness, thus a swallowing examination is essential to determine his ability to ingest food safely by mouth.
A nurse is documenting a client's response to a pain medication. Which of the following is an example of correct documentation regarding the client's response to pain?
The client reports pain decreased 30 min after medication administration to 3 on a scale of 0 to 10.
A charge nurse is reviewing anthropometric that I use with a newly licensed nurse which of the following statements by the newly licensed nurse indicates an understanding of the teaching
The client should be weighed on the same scale at the same time each day
A nurse is administering aspirin 81 mg PO daily to a client who has a history of myocardial infarction. The medication is scheduled for 0800. Which of the following scenarios demonstrates proper use of one of the Ten Rights of Medication Administration?
The nurse documents that the aspirin was given at 0825.
Which of the following is the primary purpose for asking a patient to keep a 3- to 7-day food diary?
To assess the pattern of intake and compare with daily reference intakes explanation- A time period of 3 to 7 days is an adequate amount of time for assessing dietary habits and patterns and thus the adequacy of the patient's nutritional intake
A nurse is preparing to minister an intradermal injection. Which of the following actions should the nurse take to assure proper technique?
Use a tuberculin syringe with a 5/8 in, 25 gauge needle
A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle.Which of the following actions should the nurse take to locate the site of injection?
Use the heel of the hand and index finger to locate the vastus lateralis muscle
A nurse is preparing to obtain a clients BP. Which of the following actions should the nurse take to measure the bood pressure accurately?
Using the wrong cuff size for the client will result in an erroneous reading
Which of the following methods of information exchange can occur without client authorization?
Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take?
Wash their hands with soap and water.
A nurse is auscultating a clients apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?
When the semilunar valves close The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.
To determine the length of a nasointestinal tube to inset, a nurse should measure the distance from the top of the client's nose to the earlobe and from the earlobe to the
Xiphoid process plus 20 to 30 cm more.
A nurse is reviewing a clients laboratory values which of the following information is correct regarding albumin levels and nutritional status
Albumin level is a short term poor indicator of proteins status
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique
Aligning the nurses knees with the clients knees just before the transfer
Which of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent
Making helpful food choices more convenient and available for the adolescent
a nurse is caring for a client who has a prescription for knee-length anti embolic stockings. which of the following actions should the nurse take?
Measure the clients calf circumference and leg length from heel to knee
A nurse is teaching the adult child of a client about instilling eye drops in the client's right eye. Which of the following statements by the client's adult child indicates an understanding of the teaching?
"I will put down her lower eyelid and drop the medication inside."
A nurse is caring for a client who has a prescription for a fluticasone propionate inhaler with a spacer. The client asks the nurse why a spacer is needed with the inhaler. Which of the following responses should the nurse make?
"More medication is delivered to the lungs when you use a spacer."
A nurse i preparing to administer an intramuscular injection at the ventrogluteal sure. Which of the following needle lengths should the nurse select for an adult of average size?
1 1/2 inches
A patient has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. Which of the following should the nurse document as intake?
1 fluid oz = 30 mL16 fluid oz = 480 mL
a client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. the nurse should expect the provider to prescribe which of the following types of enema
A- return- flow
Which of the following represents the correct administration of the prescribed medication?
Amoxicillin 1 g PO prescribed; two 500-mg tablets given
A nurse is obtaining a clients vital signs. The client has anew onset of a temp of 39 degrees C(102 deg F). Which of the following other vital signs should the nurse expect
An elevated pulse rate
A nurse is caring for a client who has mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client?
Protect their eyes.
A nurse is preparing to instill antibiotic ear drops into the ear of a 2-year-old child. Which of the following techniques should the nurse use when administering ear drops to this client?
Pull the client's auricle down and back to open the canal when administering the ear drops.
A nurse is assisting in the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?
Extend one leg and allow the client to slide down the leg to the floor
A nurse is caring for a client who has been hospitalized and is performing active range of motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder
Flexing the shoulder by raising the arm from a side position to a 180 angle
Nurse is preparing to use a tympanic thermometer to acquire a clients temp. Which of the following actions should the nurse take to ensure an accurate reading?
Pull the pinna band and upward gently
A nurse is observing an AP who is using a mechanical lift with a hammock sling to transfer a patient from the bed to the chair. For which of the following actions by the AP should the nurse intervene
Leaves the bed in the lowest position throughout the procedure
A nurse is preparing to administer a continuous enternal tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding?
Limit the time the formula hangs to 8 hr.
