Fundamentals ATI Review
A nurse is caring for an older client who is violent and attempting to disconnect your IV lines. The provider prescribes soft wrist restraints. Which of the following action should the nurse take while the client is in restraints?
Remove the restraints one at a time. Explanation Restraint should be removed one at a time for clients who are violent or noncompliant. "Performs range of motion exercises every 3 hrs" - INCORRECT bc it should be every 2 hrs .
A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental tasks for this age group?
independepent moral development (NOT DEVELOPMENT OF CONCRETE REASONING)
A nurse is caring for a group of clients in a long-term care facility. One client is walking in the hallway and bumping into walls and does not responf to his name. Which of the following actions should the nurse take first?
Accompany the client back to his room (to reduce risk of injury)
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?
Apply intermittent suction when withdrawing the catheter.
A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the clients record first?
Assessment
A nurse is caring for a middle aged adult client. The nurse should evaluate the client for progress toward which of the following developmental task?
Ceasing to compare personal identity with others. (YOUNG ADULTS : SHOULD FOCUS ON MANAGING A HOME , ESTABLISHING THEMSELVES, FORMING NEW FRIENDSHIPS)
A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site which of the following sites should the nurse select?
Choose a vein that is soft on palpation ( soft and "bouncy")
A charge nurse is teaching adult CPR to a group of newly licensed nurses. Which of the following action should the charge nurse teach as the first response in CPR?
Confirm unresponsiveness. Explanation : Call for assistance is incorrect
A nurse is caring for a client who has pharyngeal diphteria. Which of the following types of transmission precautions should the nurse initiate?
Droplet Explanation: Infections that spread via droplet nuclei that are larger than 5 microns in diameter. Nurse should wear a mask when within 3 ft of client. Examples rubella, menningococcal pneumonia, streptococcal pharyngitis.
A nurse is assesing a client. Which of the following findings should the nurse identify as protein calorie malnourishment ? Select all that apply.
Dry, brittle hair Edema Poor wound healing
A nurse is caring for a client who has diarrhea. See exhibit 1,2,3. The nurse is providing teaching. Select 4 instructions that the nurse should include.
Eat probiotic food such as yogurt. Avoid alcohol. Avoid caffeine. Follow a low-fiber diet.
PPE for pt that has AIDS and is incontinent of stool?
Gown and Gloves
The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?
Hearing aids ( because they can be removed)
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?
Limit drinking liquids with food. (bc drinking beverages with food leads to satiety and bloating which results in client eating fewer calories)
A nurse is caring for an adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at meal time?
Offer the client tart or sour foods first ( to stimulate saliva production)
A home health nurse is performing a follow-up visit for a client who has a gastronomy tube through which they receive intermittent feedings and medications. The cleint has recently developed diarrhea. Which of the following findings should the nurse identify as possible cause of the diarrhea?
The clients caregiver washes out the feeding bag with warm water every 24 hours . Explanation: Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
Use the planning step of the nursing process to prioritize client care delivery. Explanation: The priority to-do list is an efficient tool for optimal time management.
The nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?
Wrap the clients finger in a warm wash cloth.
Which of the following assessments provides the most accurate measure of the clients fluid status?
daily weight
A nurse is using a portable ultrasound bladder scanner to measure a clients post-voidal residual volume. Which of the following actions should the nurse take?
Apply light pressure to the scanner head once it is in position.
A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching.
Bear weight on both of your legs.
A nurse is performing a focused assessment of a clients peripheral vascular system . In which of the following locations should the nurse palpate the posterior tibial pulse?
Behind the medial malleoulus
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?
Contact precautions
A nurse in the ED is caring for an inmate who has lacerations and is bleeding. The client was brought to the facility by a guard who asks the nurse about the clients HIV status. Which of the following actions should the nurse take?
Instruct the guard to ask the inmate.
A nurse is preparing to administre a dose of ampicillin. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record?
The client threw the medication on the floor (The nurse should document exactly what took place for an accurate, factual account of the events.
A nurse is caring for a client who is post-op following abd surgery. See exhibit 1,2, and 3. Highligh the assessment that the nurse should report to the provider.
Urinary output- client with indwelling cath should produce 30-50 mL of urine per hour. Reported pain level Vital signs
A nurse is teaching middle-aged female client about disease prevention and health maintenance . Which of the following diagnostic test should the nurse recomment as part of this clients routine health screening?
eye exam every 2 yrs ( -women ages 30-65 should have a pap every 2 yrs not 1 yr -women 45 and older should have an annual mammogram not every 2 yrs -client should have a colonoscopy every 10 yrs not 1 yr)
Which of the following foods should the nurse include as an example of an incomplete protein?
lentils ( along with vegetables, nuts, grains, seeds)
A nurse is admiting a client to a healthcare facility. See exhibit 1,2 and 3. The nurse is placing the client on isolation precautions. Which interventions should the nurse include?
-Wear an N95 mask when caring for the client. -Place a container for soiled linens inside the clients room. -Place the client in a negative airflow room. -Remove mask after exiting the clients room. "Wear a sterile water-resistant gown within 3 ft of the client"- INCORRECT bc TB is airborne precautions, water resistant gowns are for contact precautions.
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 2 milliliter vial. Which of the following action should the nurse take?
Ask another nurse to observe the medication wastage. Explanation: A second nurse must witness the disposal of any portion of a dose of controlled substance.
A nurse is planning to insert a peripheral IV cath for an older adult client. Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position. Explanation: Because the veins will dilate due to gravity.
A nurse is assessing a clients peripheral pulses. Which description should the nurse use to document the findings?
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.
A nurse is planning care for a client who reports abd pain. Assessment reveals the pt has a temp of 102.6, heart rate of 105 bpm, a soft non tender abd, and menses due over by 2 days. Which of the following findings should be the nurses priority?
Temperature Explanation: Overdue menses is an important assessment because of clients abd pain but irregular menses is common when a person is stressed therefore not a priority. Elevated temperature is an emergent physiological need. Consider Maslow's hierarchy if needs.
A nurse is preparing to apply a dressing for a client who has a stage two pressure injury. Which of the following types of dressing should the nurse use?
Hydrocolloid Explanation: Hydrocolloid dressings promote healing and stage two pressure injuries by creating a moist wound bed.
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in long-term care. Using this scale, which of the following parameters should the nurse evaluate?
Nutrition ( Along with sensory perception, skin moisture, activity, mobility, friction and shear)
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 teaching?
Use tracheostomy covers when outdoors.
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?
Abdominal cramping Explanation: The client has hyponatremia which is low sodium levels. Manifestations include abd cramping, weakness, confusion, lethargy, head ache, and nausea.
During a physical examination of a client, the nurse suspects strabismus. Which of the following test should the nurse use to collect additional data?
Corneal light reflex
A nurse is caring for a client who is post operative and is exhibiting signs of hemorrhagic shock . The nurse notifies the surgeon who tells the nurse to continue to measure the cleints vital signs every 15 minutes and report back in 1 hr. Which of the following actions should the nurse take next ?
Notify the the nursing manager. Explanation: The greatest risk to the client is not receiving timely intervention therefore the next action should be to activate the chain of command.
A nurse in a long term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take
Observe the client closely (As long as the person can cough strongly, the nurse does not need to intervene)
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.
Obtain the pronouncement of death from the provider. Remove tubes and indwelling lines. Wash the client's body. Ask the client's family members if they would like to view the body. Place a name tag on the body.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to Aortic valve stenosis. Which of the following anatomical area should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
Sit on the toilet 30 minutes after eating a meal Explanation: Increase peristalsis occurs after the food enters the stomach. Sitting on the toilet 30 minutes after eating a meal regardless of feeling the urge to defecate is a recommended method of bowel retraining to treat constipation. "Drink 1000 mL of fluid a day" - INCORRECT bc it should be 1500 mL
A nurse is caring for a client who is hospt and has a new tracheostomy. Which of the following actions should the nurse take when performing thracheostomy care?
Soak the inner cannula of the tracheostomy tube in normal saline
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client's. Explanation : The nurse acts as a witness to attest that it is the client signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risk and benefits
After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client for a meter- dose inhaler?
- Hold the mouthpiece 1-2 inches in front of your mouth - Tilt your head back slightly and open your mouth wide -Depress the canister while taking a slow deep breathe -Hold your breathe for 10 seconds
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following action should the nurse take?
Disconnect the machine and measure the blood pressure manually every 15 minutes. Explanation: If the nurse questions the reliability of the monitoring equipment a manual process should be used. Also malfunctioning equipment poses a safety risk for the client so It must be tagged and removed. "Obtain manual and automatic readings and compare them" - INCORRECT
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?
Examine personal values about the issue. Explanation: Nurses must do so to provide care without bias. Parents MUST give consent.
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal after exercise as I get older" Explanation : Older adults experience decreased cardiac output, which causes increased pulse rate during exercise . The pulse rate also takes longer to return to normal "Urinary incontinence is something I will have to live with as I grow older" - bladder capacity decreases in older adults but it's not an expected finding and should be reported so it can be treated.
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?
"We would give you oxygen through a tube in your nose." Explanation: Oxygen can provide comfort and is not considered resuscitative measure.
NCLEX Next Gen: A nurse is caring for a client who has a new diagnosis of seizure disrder. See A & Exhibit B Complete the following sentence: The nurse should first adress the clients ___________ , followed by ___________
1) Physical safety 2)Positioning Explanation: Greatest risk to pt is injury from seizure. Nurse should next turn client on their side with head tilted slightly forward. This will protect pt from aspiration
A nurse is planning care for a client that has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to AP?
-Assist the client with partial bath. -Measure BP after nurse administers antihypertensive medication. -Use a communication board to ask what the client wants for lunch. Explanation: AP CANNOT - test the clients swallowing abilities - irrigate the clients indwelling urinary cathether
A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence should the nurse plan to take?
-Turn off vaccum on the NPWT device and administer prescribes analgesic -Remove soiled dressing and perform hand hygiene -Apply sterile or clean gloves and irrigate the wound -Apply a skin protectant or a barrier film to skin around the wound -Placed prepared foam into the wound bed and cover with a transparent dressing -Connect tubing to transparent film and turn on the NPWT unit
A nurse is caring for a child who is post op following a tonsillectomy. Which of the following action should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day and night. Explanation: To serve the client stroke following tonsillectomy the nursery administer pain medication routinely around the clock the nurse can provide the medication rectally or intravenously to avoid the oral. " Provide a child with ice cream when oral intake is initiated"- INCORRECT Milk products such as ice cream and putting our avoided because it got the mouth and throat causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy
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 nurses priority action?
Administer pain medication 45 minutes before changing the clients dressing Explanation: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the clients physiological need for comfort and pain relief.
A nurse is providing a discharge teaching to a client about self administering heparin. Which of the following instructions should the nurse include in the teaching?
Administer the medication into the abdomen Explanation: Administer the medication into the abdomen at least 2 inches from the umbilicus. Client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue..
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the needle at a 45* angle. Explanation: This med is given subcutaneously so at 45 or 90 degree.
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients commitment to a long-term goal of weight loss?
Attempt to increase the clients self motivation. Explanation: Motivation to learn is important and improving and clients commitment to achievement of a health goal as well as increasing the amount in speed of learning. " keep detailed record of each clients progress" - INCORRECT bc this will help each client track individual progress but does not improve client progress toward individual goals.
A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which cranial nerve is the nurse testing?
Cranial nerve XII- Hypoglossal
A nurse is caring for client who has pancreatitis. See exhibit 1,2,3. Select the three tasks that the nurse can delegate to AP
Document the client's vitals Measure the clients intake and output. Transfer the client from wheelchair to bed "Collect data about the clients pain level"- INCORRECT bc outside of AP scope of practice
A nurse is caring for a client who has a methicillin-resistant staph (MRSA) infection. A dietary assistant asks what precautions are neccesary. Which instructions should the nurse give?
Don gloves when entering the room and use hand sanitizer when exiting
A nurse is providing preop teaching to a client who is scheduled for a arthroplasty in the next month that might require blood transfusion.Which of the following statements should the nurse make to the client?
Donate autologous blood before the surgery. Explanation: Autologous blood transfusion is the collection and reinfusion of the clients blood. The blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of surgery, it is the safest form of blood transfusion because it is the clients own blood, eliminating exposure to transfusion transmitted infections.
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which action should the nurse plan to take?
Hold the dropper 1 cm (0.5 in) above ear canal during admin.
A nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?
Hold the medication bottle with the label against the palm of the hand when pouring
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements made by the client indicates she is experiencing psychological distress?
I keep having nightmares about my upcoming surgery. Explanation: Night nightmares and sleep disturbances are manifestations of anxiety and PTSD. These indicate that the client is at risk for experiencing psychological distress.
A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an idication that the client has completed Erikson's developmental tasks for her age age group.
I think I have done a good job with my children since they are all independent now.
A nurse is instructing a client about collecting a 24 hr specimen for creatinine clearance . Which statement should the nurse identify as indication that the pt understands the procedure ?
I'll make sure to keep the collection bottle in the container of ice they gave me
A nurse is performing an abdominal assessment . Identify the correct sequence for this assessment.
Inspection Auscultation Percussion Palpation For any other adult assessment the sequence is Inspect, Palpate, Perscuss, and Auscultate
Which of the following questions should the nurse ask when assessing the quality of pain ?
Is your pain sharp or dull? Explanation: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, etc helps determine the quality of pain.
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?
Make sure the client wears a mask when outside her room if there is contruction in the area. Explanation: An ASCT compromises the client's immune system, and greatly increases the risk for infection. The client will need protection from breathing in any pathogens in the environment.
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?
Make sure two fingers can fit under the sleeves.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining cotton balls for the tracheostomy care Explanation : Cotton ball particles can be aspirated into the tracheostomy opening possibly causing a tracheal abscess. " obtaining hydrogen peroxide for the tracheostomy care" - INCORRECT bc half-strength peroxide solution is used to clean the inner cannula.
A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?
Oil retention ( CARMINATIVE ENEMA IS TO ASSIST PT TO EXPEL FLATUS HYPERTONIC FLUID SOLUTION IS TO CLEANSE BOWELS IN (PREP FOR SURGERY) SODIUM POLYSTERENE ENEMA IS FOR PT WITH HIGH POTASSIUM LEVELS)
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultate a high pitch scratching sound during both Systole and diastole with the diaphragm of the stethoscope position at the left sternal boarder . Which of the following Heart sounds should the nurse document?
Pericardial friction rub Explanation: A pericardial friction rub has a high pitch scratching grading or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. It is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction following cardiac surgery or trauma and with some autoimmune problems such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward
A nurse is obtaining the blood pressure in a clients lower extremity which of the following action should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh. Explanation: This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. Placing the cuff 3 inches above the popliteal is incorrect it should be 1 inch above the popliteal.
A nurse on a rehabilitation unit is preparing to transfer a client who is an unable to walk from a bed to a wheelchair. Which of the following techniques should nurse use?
Place the wheelchair at a 45° angle to the bed. Explanation: Positioning the wheelchair at a 45° angle allows the client to pivot lessening the amount of rotation required "Assume a narrow stance with feet 6 in apart" - INCORRECT bc your feet should have a wide stance
A nurse is preparing to perform oral hygiene on an unresponsive client. Which of the following actions should the nurse plan to take?
Raise the level of the bed Explanation: To allow the proper body mechanics and reduce the risk of self injury
A home health nurse is visiting an older client with severe dementia. The clients son who serves as her primary caregiver reports being exhausted from working part time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver?
Respite care (bc it is a service for caregivers who need time to rest from multiple responsibilties related to the care of a family member who needs assistance) NOT ASSISTED LIVING BC THIS IS FOR PTS THAT NEED LIMITED CARE AND SEVERE DEMENTIA IS TOTAL CARE. NOT ADULT DAY CARE BC THIS IS FOR PTS THAT NEED MINIMAL ASSISTANCE NOT TOTAL CARE SUCH AS SEVERE DEMENTIA PT.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans to the nurse include as a secondary prevention?
Screening groups of older adults in the nursing care facilities for early influenza manifestations. Explanation: secondary prevention is focus on preventing complications of an illness or providing care to prevent illness from becoming severe.
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. On day 2 the IV site is edematous and cath is blanched and cool to touch and IV fluid is not infusing. The nurse is assesing the client Which action should the nurse take?
Stop the IV infusion Elevate the clients left arm Apply heat to the clients left hand "Start a new IV in the clients left hand"-INCORRECT bc this could cause tissue damage
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?
Subtract the amount of irrigant used from the clients urinary output. Explanation: the nurse should calculate the fluid used for irrigation and subrtract it from the clients urinary output.
A nurse is planning to obtain vital signs of a 2 yr old child who is experiencing diarrhea and who migh have a right ear infection. Which of the following routes should the nurse use to obtain temperature?
Temporal Explanation: Oral route is not appropiate for kids under 3. Temporal artery route is noninvasive and could be used. IF the child is diaphoretic(sweaty) place probe behind the ear, avoid an area covered with hair.
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?
The client identifies the location of a fire extinguisher. Explanation: " The client has a weekly inspection checklist for oxygen equipment." - INCORRECT bc the caregiver should inspect oxygen equipment daily.
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who have emergency surgery for appendicitis. Which of the following statement indicates a lack of readiness to learn by the client?
The client reports severe pain Explanation: A client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity. " The client asked the nurse to repeat the instructions before attempting the exercise" - INCORRECT bc while the client might not totally understand the mechanics of performing the exercise he does have a readiness to learn the activity
Practice Test A: A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation ?
The nurse should compare the clients home medications with the providers prescriptions when performing medication reconciliation.
A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in what position for evaluation?
sitting
A nurse is caring for a client who is dehydrated. The murse should expect insensible fluid loss of approx 500-600 mL each day through which organ?
skin
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?
wear a gown when caring for the client Explanation: the nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. the nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces)