Fundamentals ATI Practice

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? A. "I think I should take my pain medication more often, since it is not controlling my pain." B. "Breathing faster will help me keep my mind off of the pain." C. "It might help me to 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 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 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? A. Protective environment B. Airborne precautions C. Droplet precautions D. Contact precautions

D

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 client's pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 0 to 10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?"

D

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television." B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." C. "I will place my alarm clock on my bedroom dresser across the room." D. "I will replace the old throw rug in my kitchen with a new one."

B

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A. Insert the suction catheter while the client is swallowing B. Apply intermittent suction when withdrawing the catheter C. Place the catheter in a location that is clean and dry for later use D. Hold the suction catheter with her clean, nondominant hand

B

A nurse is assessing an older adult client's risk for falls. Which of the following assessments would the nurse use to identify the client's safety needs? (Select all that apply) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity

B, D, E

A nurse receives report about a client who has 09% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions should the nurse take first? A. Reposition the client B. Document the client's IV intake in the medical record C. Request a new IV fluid prescription D. Check the IV tubing for obstruction

D

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. Use the face, legs, activity, cry, and consolability (FLACC) pain rating scale for a client who is experiencing pain. B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum D. Palpate the client's abdomen before auscultating bowel sounds

B

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. "They allow the court to overrule an adult client's refusal of medication treatment." B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." C. "They permit a client to withhold medical information from health care personnel." D. "They allow health care personnel in the emergency department to stabilize a client's condition."

B

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 client's partner indicates effective coping? A. "I am not worried because I still have hope that he will be okay." B. "I am relying on support from our family during this time." C. "We can plan our family reunion once he recovers and comes home." D. "We don't see any reason to start discussing funeral arrangements right now."

B

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. B. Determine the reasons why the client is refusing to use the incentive spirometer. C. Document the client's refusal to participate in health restorative activities. D. Administer a pain medication to the client.

B

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag. B. Place a client who has tuberculosis in a room with negative-pressure airflow. C. Provide disposable plates and utensils for a client who is HIV-positive D. Dispose of a client's blood saturated dressing in a trash bag inside a second trash bag.

B

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 emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your heath care proxy to make decisions" B. "We would give you oxygen 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 nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least six 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 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? A. The client uses a wool blanket on their bed B. The client uses nonacetone nail polish remover. C. The client stores an extra oxygen tank on its side under their bed D. The client has a weekly inspection checklist for oxygen equipment

B

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? A. Insert the catheter at a 45 degree angle B. Place the client's arm in a dependent position C. Shave excess hair from the insertion site D. Initiate IV therapy in the veins of the hand

B

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? A. Critical pathway B. Situation, background, assessment, and recommendation (SBAR) C. Transfer report D. Medication administration record (MAR)

B

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? A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min C. Make sure the reservoir bag of a partial rebreathing mask remains deflated D. Use petroleum jelly to lubricate the client's nares, face, and lips?

B

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning B. Use tracheostomy covers when outdoors. C. Use sterile technique when performing tracheostomy care at home D. Cleanse irritated skin with full-strength hydrogen peroxide.

B

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer B. Focus teaching on what the client will need to do in the future to manage his illness C. Provide the client with written information about the phases of loss and grief D. Reassure the client that this is an expected response to grief

D

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manger 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 is preparing to administer 0.9% sodium chloride 750mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

107 mL/hr (divide given mL by hours of infusion)

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. Advocacy ensures client's safety, health, and rights B. Advocacy ensures that the nurses are able to explain their own actions C. Advocacy ensures that nurses follow through on their promises to clients D. Advocacy ensures fairness in client care delivery and use of resources

A

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A. Numbness of the extremeties B. Bradycardia C. Positive Chvostek's sign D. Abdominal cramping

D

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record B. Complete an incident report C. Consult the facility's risk manager D. Notify the nurse manager

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

D

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? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube. B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

D

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 the 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 a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body

2, 3, 4, 5, 1

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that 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 min

A

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care,. when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family

A

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 B. Tell the parents that this is a necessary procedure C. Inform the parents that the staff does not require their consent D. Contact a spiritual support person to explain the importance of the procedure

A

A nurse is preparing to administer an injection of an opioid medication to a 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 B. Notify the pharmacy when wasting mediation C. Lock the remaining medication in the controlled substances cabinet D. Dispose of the vial with the remaining medication in a sharps container

A

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 B. Administer the medication into the client's nondominant arm C. Pull the client's skin laterally or downward prior to administration D. Massage the 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 the fall

A

A nurse in a providers office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A. Hit the back of foot (heel) B. Hit the knee cap C. Hit the front elbow D. Hit the back of elbow

B

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 46cm (18in) 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 planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. Combine client care tasks when caring for multiple clients B. Wait until the end of the shift to document client care C. Use the planning step of the nursing process to prioritize client care delivery D. Allow for interruptions in tasks to discuss client care issues with colleagues

C

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? A. Role ambiguity B. Sick role C. Role overload D. Role conflict

C

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 through the stethoscope and identify the type of breath sounds. A. Crackles B. Rhonchi C. Friction rub D. Normal breath sounds

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 receiving visitors. B. Limit the client's time with visitors to no more than 30 min per day. C. Assign the client to a room with negative-pressure airflow exchange. D. Wear a gown when caring for the client.

D

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 reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D

A nurse is assessing a client's readiness to 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. "I'm 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 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 client every 2 hr. B. Administer an antiemetic every 6 hr. C. Hold oral care D. Increase the room's temperature

A

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 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 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 client's wrist before applying the restraints. B. Evaluate the client's circulation every 8 hr after application. C. Remove the restraints every 4 hr to evaluate the client's status. D. Secure the restraint ties to the bed's side rails

A

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply) A. Assist the client with a partial bed bath. B. Measure the client's BP after the nurse administers an antihypertensive medication. C. Test the client's swallowing ability by providing thickened liquids. D. Use a communication board to ask what the client wants for lunch. E. Irrigate the client's indwelling urinary catheter.

A, B, D

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A. The client is receiving formula at room temperature B. The feedings infuse at a slow, continuous drip over 8 hr each night C. The client's caregiver washes out the feeding bag with warm water once every 24 hr D. The client's caregiver flushes the tubing with water before and after administering medications

C

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Increase in hematocrit B. Increase in respiratory rate C. Decrease in heart rate D. Decrease in capillary refill time

C

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 identification bracelet with the medication administration record B. Call the pharmacy to determine whether the client's medications are available C. Compare the client's home medications with the provider's prescriptions D. Place the client's home medication bottles in a secure location

C

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment 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 for you."

C

A nurse is caring for a client 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? 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 the ankle pressure at 65 mmHg

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 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? A. "You would have so much more time to spend with your family." B. "You should consider getting a part-time job or 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 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 irrigant used from the client's urine output D. Perform the irrigation using a 20-mL syringe

C