ATI foundations study guide
A nurse is preparing to insert a new IV catheter for a client. Which of the following actions should the nurse plan to take?
Choose a vein that is palpable
the nurse is assessing the client. which of the following actions should the nurse take in a pt. who has IV infiltration - stop IV infusion - elevate the pt. arm - apply heat to pt. arm - place a pressure dressing over pt. arm - start a new IV in the pt. arm
- stop IV infusion - elevate the pt. arm - apply heat to pt. arm
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
Advocacy ensures clients' safety, health, and rights.
A charge nurse is delegating tasks for four clients. Which of the following tasks should the nurse delegate to the assistive personnel (AP)?
Prepare the room for a client who requires seizure precautions
a nurse is providing teaching to a pt. with self administering heparin. which of the following instructions should the nurse tell the pt.
administer heparin into the abd.
a nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation
compare the pt. home medications with the providers prescriptions
a nurse is caring for a child who has a prescription for a blood transfusion. the Childs parents have refused the tx due to their religious beliefs. which of the following actions should the nurse take
examine personal values about the issue
a nurse is applying a dressing for a pt. who has a stage 2 pressure injury. which of the following types of dressing should the nurse use
hydrocolloid
A nurse is teaching a client who has a new hearing aid. Which of the following statements by the client indicates to the nurse an understanding of the teaching?
i will reinsert my hearing aid if i hear a whistling sound
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?
the client holds the cane on the stronger side of the body
A nurse is performing medication reconcillation with a cllent. Which of the following actions should the nurse take first
Ask the client if she takes any over-the-counter medications.
A nurse is completing an informed consent document for a 16-year-old adolescent who is married and is scheduled for an emergency appendectory. Which of the following actions should the nurse take?
Ask the client if they understand the provider's plan for the appendectomy.
A nurse is teaching a client how to perform active range of-motion exercises of the lower extremities to Improve mobility. Which of the followin Instructions should the nurse include in the teaching?
Complete each session two times per day
The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. Increase intake of high-calcium foods. Eat probiotic foods, such as yogurt. Avoid alcohol while experiencing diarrhea Eat raw vegetables Eat three large meals a day. Avoid caffeine while experiencing diarrhea. Drink hot liquids several times a day. Drink carbonated beverages to replace lost fluids. Follow a low-fiber diet.
Eat probiotic foods, such as yogurt Avoid alcohol while experiencing diarrhea Avoid caffeine while experiencing diarrhea Follow a low fiber diet
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?
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
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 made by the pt. partner indicates effective coping
I am relying on support from our family during this time
A nurse is completing dietary teaching with a cllent who has heart fallure and has a prescription for 2g sodium diet. Which of the following statements made by the client Indicates an understanding of the teaching?
I can have nonfat yogurt as a desert
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?
Pad the client's wrist before applying the restraints.
A nurse is admitting a client to an acute care facility. Which of the following actions by the nurse promotes client self-determination?
Providing the client with information about end-of-life decision-making
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 client's urine output.
A nurse is planning to perform postmortem care for a client. Which of the following actions should the nurse plan to take?
Verify whether the client requires an autopsy.
a nurse is administering 1 L of NS to a pt. who is postop and has fluid volume deficit. which of the following changed should the nurse identify as an indication the tx of NS is successful
a decrease in HR
a nurse is caring for a pt. who has herpes zoster and asks the nurse about the use of complementary and alternative tx therapies for pain control. the nurse should inform the pt. that this condition is contraindicated who which of the following therapies
acupuncture
a nurse is preparing to administer enoxaparin SUBQ to a pt. which of the following actions should the nurse take
administer the med with needle at 45 angle
a nurse is preparing to administer an injecting of an opioid med. the nurse draws up 1ml from a 2m vial. which of the following actions should the nurse take
ask another nurse to observe the medication wastage
a nurse is responding to a call light and finds a pt. lying on the bathroom floor. which of the following actions should the nurse take first - check client for injuries - move hazardous objects away from pt. - notify provider - ask the client to describe how they fell
check the client for injuries
A nurse is preparing to administer an Intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should nurse take first?
check the pH of the client's stomach contents
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 is caring for a pt. who is postop and refuses to use an incentive spirometer following major abd. surgery. which of the following actions is the nurses priority
determine the reasons why the pt. is refusing to use the incentive spirometer
a nurse is caring for a pt. with pharyngeal diphtheria. what type of precautions should the nurse take
droplet precautions
a nurse is admitting a pt. who is having an exacerbation of heart failure. in planning pt. care when should he nurse initiate discharge planning
during the admission process
a nurse is assessing four adult pt. which of the following physical assessment techniques should the nurse use - ensure the bladder of the blood pressure cuff surrounds 80% of the pt. arm - use FLACC for pain assessment - obtain apical pulse in third intercostal space - palpate the stomach before auscultating bowel sounds
ensure the bladder of the blood pressure cuff surrounds 80% of the pt. arm
A nurse is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin. Which of the following actions should the nurse take first when mixing the insulin?
inject 25 units of air into the NPH vial of insulin
a charge nurse is teaching a newly hired nurse about the facility computerized documentation system. which of the following actions should he nurse take
instruct the new nurse to use direct quotes when recording pt. statements
a nurse is assessing a pt. who reports increased pain following PT. which of the following questions should the nurse ask when asking the pt. about the quality of their pain
is your pain dull or sharp
a pt. who is postop is verbalizing pain as a 2 on a 0-10 scale. which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management
it might help me to listen to music while I am lying in bed
a nurse is talking with an older adult pt. who is contemplating retirement. the pt. states they keep thinking about how much they enjoy their job. which of the following responses should the nurse make
lets talk about how the change in your job status will affect you
a nurse is caring for a pt. who is postop following a knee arthroplasty and requires the use of thigh length SCDs. which of the following actions should the nurse take
make sure at least two fingers can fit under the sleeves
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 pt. wears a mask when outside her room if there is construction in the area
a nurse is caring for a pt. who is postop and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon who says to continue to measure the pts. VS every 15 min and report back in 1 hr. which of the following actions should the nurse take
notify the nursing manager
identify sequence in which the nurse should perform the following steps remove all tubes and drains obtain the pronouncement of death from the provider ask the pt. family is they would like to view the pt. body wash the pt. body place a name tag on pt.
obtain the pronouncement of death from the provider remove all tubes and drains wash the pt. body ask the pt. family is they would like to view the pt. body place a name tag on pt.
in a pt. with a seizure disorder the nurse should assess the pts _____________ followed by the pts. _______
physical safety; incontinence
a nurse is planning to insert a peripheral IV cath for an older adult pt. which of the following actions should the nurse plan to take place the pt. arm in a dependent position insert cath at 45 degree angle shave excess hair from insertion site initiate IV therapy in the veins of the hand
place the pt. arm in a dependent position
a nurse is assessing an older adult pt. risk for falls. which of the following assessments should the nurse use to identify the clients safety needs?
pupil clarity visual fields visual acuity
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
reassure the pt. that this is an expected response to grief
a nurse is reviewing EBP principles about the administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include
regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
a nurse is performing a home safety assessment for a pt. who is receiving supplemental O2 therapy. which of the following observations should the nurse identify as proper safety protocol
the pt. identifies the location of the fire extinguisher
a nurse is caring for a pt. who asks about the purpose of advance directives. which of the following responses should the nurse make
they indicate the form of tx a pt. is willing to accept in the event of a serious illness
a nurse is caring for a pt. who has a terminal illness and is approaching death. the pt. is SOB and has noisy respirations from secretions in the airway. which of the following actions should the nurse take
turn the pt. every 2 hr
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?
use a bed exit alarm system
a nurse manager is preparing to review med documentation with a group of new nurses. which of the following statements should the nurse manager make in the teaching
use the complete name of the medication magnesium sulfate
a nurse is planning strategies to manage time effectively for pt. care which of the following strategies should the nurse implement
use the planning step of the nursing process to prioritize pt. care delivery
a nurse is teaching a pt. to care for trach at home. which of the following instructions should the nurse include
use trach covers when outdoors
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."
a nurse is evaluating teaching for a pt. who has heart failure. which of the following 3 statements by the client indicates understanding of teaching - I have been weighing myself every other morning - I am trying to decrease my intake of foods with K - I am limiting my Na intake to 2g daily - I am eating fewer potato chips and more fresh fruit - I lie down and rest after meals - I know to call my doctor if I gain three pounds or more in 2 days
- I am limiting my Na intake to 2g daily - I am eating fewer potato chips and more fresh fruit - I know to call my doctor if I gain three pounds or more in 2 days
what can the nurse delegate from the list below - doc. VS - measure intake and output - transfer pt. to wheelchair - insert NGT - collect data about pain level
- doc. VS - measure intake and output - transfer pt. to wheelchair
the nurse is placing the pt. on isolation precautions. which of the following interventions should the nurse take - wear an N95 mask when caring for pt - place a container for soiled linens in the pt. room - place the pt. in a negative airflow room - remove mask after exiting the pt. room - wear a sterile water resistant gown if within 3 ft of pt.
-wear an N95 mask when caring for the pt. - place a container for soiled linens in the pt. room - place the pt. in a negative airflow room - remove mask after exiting the pt. room
