Fundamentals ATI Practice

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?

A. Pad the clients wrists before applying the restraints.

A nurse is caring for a patient 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?

A. Turn the patient every 2 hours.

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

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

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?

B. SBAR

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?

B. The client identifies the location of a fire extinguisher.

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

C. Subtract the amount of irrigant used from the clients urine output.

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?

C. The client holds the cane on the stronger side of the body.

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?

D. Contact Precautions.

Patient is experience diarrhea. What are 4 teachings to include?

Eat probiotic food, avoid alcohol, avoid caffeine, follow low fiber diet.

A nurse is caring for a client who has pneumonia. 1300 patient reports intense pain at IV catheter site. Complete the following sentence: The nurse should identify that the client might be experiencing (______) as evidenced by the clients (______)

Extravasation (from the IV vancomycin), IV catheter site

A nurse is caring for a client who has a new diagnosis of seizure disorder. Complete the sentence: The nurse should first address the clients (_______) followed by the clients (_______)

Physical safety, Positioning

A nurse in an emergency department is caring for a client. Complete the sentence: The nurse should first (______) followed by (_______).

Review medications that might be causing confusion, using other methods to keep the client safe.

The nurse is assessing a client with a peripheral IV inserted for fluid replacement. On day 2 the site is edematous, taut, blanched, and cool to touch. Which of the following actions should the nurse take?

Stop the IV infusion, elevate clients left arm, apply heat to clients left hand.

A nurse is caring for a client who is postoperative following abdominal surgery. Click which assessments need to be reported to the provider.

Urinary output, reported pain level, vital signs

A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hrs. The nurse should set the infusion pump to deliver how many ml/hr? (round to nearest whole number)

107 ml/hr

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

A. Administer the medication with the needle at a 45 degree angle.

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

A. Advocacy ensures clients safety, health and rights.

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

A. Use a bed exit alarm system.

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.

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

B. Droplet

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

B. Place the clients are in a dependent position.

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 ED and I had difficulty breathing?" Which of the following responses should the nurse make?

B. We would give you oxygen through a tube in your nose.

A nurse in a providers office is assessing the deep tendon reflexes of a client. Which of the images should the nurse identify as indicating the correct technique for eliciting the clients patellar reflex?

B. the knee

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

C. Compare the clients home medications with the providers prescriptions.

A nurse is administering 1L of 0.9% sodium chloride to 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?

C. Decreased heart rate

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

C. Use the planning step of the nursing process to prioritize client care delivery.

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 injury

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?

A. Examine personal values about the issue.

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?

C. Administer the medication into the abdomen. (This is because it helps reduce pain and bruising at the injection site)

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?

D. Is your pain sharp or dull?

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates though the stethoscope and identify the type of breath sounds.

D. Normal breath sounds, brochovesicular.

A nurse is preparing to administer an injection of an opioid medication to the client. The nurse draws out 1 ml of the medication from a 2ml vial. Which of the following actions should the nurse take?

A. Ask another nurse to observe the medication wastage.

A nurse is caring for a patient who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel.

Document vital signs, measure I and O, transfer from wheelchair to bed

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 death announcement from the provider. 2. Remove tubes and indwelling lines. 3. Cleanse the body 4. Ask family if they would like to view the body. 5. Place name tag on body prior to transfer.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

B. Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements indicates an understanding of the teaching?

B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

B. Regulate oxygen via nasal cannula at a flow rate no more than 6L/min

A nurse is caring for a patient who asks about the purpose of advance directives. Which of the following statements should the nurse make?

B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.

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?

B. Use tracheostomy covers when outdoors. To protect air wait from cold air, dust and other airborne particles.

A nurse is caring for a patient with COPD. Select three findings that require follow-up.

Breath sounds (Crackles in the left upper lobe, decreased sounds in bilateral bases), O2 saturation (85% RA), Temperature (101.5f, 38.6c)

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?

C. A mole with asymmetric appearance.

A nurse is caring for a client 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 statements should the nurse make?

C. I am available to talk if you should change your mind.

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

C. Role overload

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

D. Acupuncture

A nurse is caring for a patient who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the patients VS every 15 minutes and to report back in one hour. Which of the following actions should the nurse take next?

D. Notify the nursing manager

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

D. Potassium 5.4 mEq/L (reference range 3.5-5mEq/L)

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?

D. Stand close to the cabinet when lifting it.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply)

Pupil clarity, visual fields, visual acuity

The nurse is caring for a client who is receiving a unit of packed RBCs. Complete the following sentence: The client has manifestations of (______) as evidenced by the clients (______).

Allergic Reaction, Itching

A nurse is admitting a client to a health care facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.

Wear a N95, Place a trash can for soiled linens inside clients room, place client in negative airflow room, remove mask when leaving the clients room.

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?

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

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?

D. Hydrocolloid

A nurse in a providers clinic is caring for a patient who has heart failure. The nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding by the teaching?

Limiting sodium intake to 2g/day, eating fewer potato chips and more fruit, call doctor if i gain 3 or more pounds in 2 days.

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?

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

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?

A. During the admission process.

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?

B. Make sure the client wears a mask when outside her room if there is construction in the area.

A client who is postoperative 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 that the client understands the preoperative teaching she received about pain management?

C. It might help me to listen to music while I am lying in bed.

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'm not sure I want to retire". Which of the following responses should the nurse make?

C. Let's talk about how the change in your job status will affect you.

A nurse is caring for a patient 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?

C. Make sure two fingers can fit under the sleeves.

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

D. Reassure the client that this is an expected response to grief.