ATI Fundamentals
How often should patients have their blood sugar checked?
starting at age 45, a minimum of every 3 years
a nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. which of the following actions should the nurse take to evaluate the client's learning? encourage the client to ask questions ask the client to explain how to select or prepare meals encourage the client to fill out an evaluation form about how the nurse presented the information ask whether the client has resources for further instruction on this topic
ask the client to explain how to select or prepare meals
a nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food". the nurse tells the client, "I will call the surgeon and ask for a change in diet. the surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? basic commitment complex integrity
basic
A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline
discipline
A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply) building models working with clay filling and emptying containers playing with blocks looking at books
filling and emptying containers playing with blocks looking at books
A newly licensed nurse is considering strategies to improve critical thinking. Which of the following action should the nurse take? (Select all that apply) find a mentor use a journal to write about the outcomes of clinical judgments review articles about evidence-based practice. limit consultation with other professionals involved in a client's care make quick decisions when unsure about a client's needs
find a mentor use a journal to write about the outcomes of clinical judgments review articles about evidence-based practice.
A nurse is teaching a client about health promotion and secondary prevention strategies. Which of the following recommendations should the nurse include? Influenza immunization rehabilitation therapy genetic screening Hypertension screening
hypertension screening
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? knowledge experience intuition competence
knowledge
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? sanguineous exudate serous exudate serosanguineous exudate purulent exudate
purulent exudate
A nurse is performing a focused assessment of a client's peripheral vascular system. Where should the nurse palpate the posterior tibial pulse?
Below the medial malleoulus
A nurse in a provider's office is reviewing the laboratory reports for a client who is at risk for heart disease. Which of the following results should the nurse report to the provider? LDL 170 mg/dL HDL 60 mg/dL Triglycerides 60 mg/dL Total cholesterol 197 mg/dL
LDL 170 mg/dL
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
Montgomery straps
A nurse is caring for an older adult client who has dysphagia following a CVA. Which of the following actions should the nurse take when assisting the client at mealtime? Encourage the client to drink fluids before swallowing food offer the client tart or sour foods first tilt the client's head backward when swallowing turn on the tv
Offer the client tart or sour foods first Explanation: A client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aids chewing and swallowing.
at what age should an infant be able to hold hands in an open position
2 months
at what age should an infant no longer have a grasp reflex?
3 months
at what age should an infant only have a slight head lag
3 months
birth weight should double by ____ to ____ months
4 and 6
at what age should an infant be able to grasp objects with both hands
4 months
at what age should an infant be able to place object in their mouth?
4 months
at what age should an infant be able to roll from back to side
4 months
at what age should an infant be able to rolls from front to back
5 months
at what age should an infant be able to use palmar grasp dominantly?
5 months
How often should patients get a routine physical examination?
generally every 1 to 3 years for females and every 5 years for males from age 20 to 40, more often after age 40
A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? give the client information about immunization against meningitis tell the client to have a TB skin test every 2 years determine the client's health risks teach the client about exercise recommendations
determine the client's health risks
A nurse is preparing to adminster 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? withdraw the regular insulin from the vial inject 15 units of air into the regular vial of insulin withdraw the NPH insulin from the vial. Inject 25 units of air into the NPH vial of insulin
Inject 25 units of air into the NPH vial of insulin
at what age should an infant be able to move objects from hand to hand
7 months
at what age should an infant be able to sit, leaning forward with both hands
7 months
at what age should an infant be able to sit unsupported
8 months
at what age should an infant be able to use pincer grasp
8 months
at what age should an infant be able to pull themselves to a standing position
9 months
at what age should an infant demonstrate head lag?
1 month
at what age should an infant have a strong grasp reflex?
1 month
at what age should an infant be able to change from a prone to a sitting position
10 months
at what age should an infant be able to cruise or walk while holding onto something
11 months
at what age should the grasp reflex be fading?
2 months
A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? Establish boundaries for the toddler place the toddler in a room with the door closed inform the toddler how you feel when he misbehaves use favorite snacks to reward the toddler
Establish boundaries for the toddler
a nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate the nurse an understanding of the teaching? I should keep feeding my son whole milk until he is 3 years old it's okay for me to give my son a cup of apple juice with each meal I'll give my son about 2 tablespoons of each food at mealtimes my son loves popcorn, and I know it is better for him than sweets
I'll give my son about 2 tablespoons of each food at mealtimes
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? supine semi-fowler's semi-prone trendelenburg
Semi-fowlers
a nurse is providing a preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? I don't want my spouse to see my incision will you give me pain medicine after the surgery? can you tell me about how long the surgery will take? my roommate listens to everything I say.
can you tell me about how long the surgery will take? asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. the client's new diagnosis of cancer can cause anxiety, fear, or depression, all of which can interfere with the learning process.
A nurse is observing a client drawing up and mixing insulin Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? the client is able to discuss the appropriate technique the client is able to demonstrate the appropriate technique the client states an understanding of the process the client is able to write the steps on a piece of paper
the client is able to demonstrate the appropriate technique
A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" every time the mother tries to help get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development? trying to increase her independence developing a sense of trust establishing a new identity attempting to master a skill
trying to increase her independence
A nurses planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? use the pain scale to determine the client's pain level discuss the adverse effects of pain medication with the client obtain the client's vital signs check the client's allergies
use the pain scale to determine the client's pain level
at what age should an infant be able to lift their head off mattress when prone?
2 months
at what age should an infant be able to have hands slightly open?
3 months
at what age should an infant be able to raise head and shoulder off mattress when prone?
3 months
at what age should an infant be able to place objects in a container
11 months
at what age should an infant be able to sit down without assistance
12 months
at what age should an infant be able to turn pages in a book
12 months
a nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. which of the following statements should the nurse identify as an indication that the client understands the instructions? I'll limit pushing the button so I don't get an overdose if I push the button and still have pain after 2 minutes, I'll push it again I'll ask my niece to push the button when I am sleeping I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button
I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in the trendelenburg position perform percussion directly over the client's bare skin use a flattened hand to perform percussions remind the client that chest percussions can cause mild pain
Place the client in the trendelenburg position
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority? A client who received crush injuries to the chest and abdomen and is expected to die a client who has a 4-inch laceration to the head a client who has partial-thickness and full-thickness burns to his face, neck and chest a client who has a fractured fibula and tibia
a client who has partial-thickness and full-thickness burns to his face, neck and chest
a nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. learning has occurred in which of the following domains? cognitive affective psychomotor kinesthetic
affective
How often should female patients have a breast cancer screening?
ages 20 to 39: every 3 years, then annually ages 40 to 54: annual mammogram ages 55 and older should have the choice to have a mammogram every 1 to 2 years
How often should females have a Pap smear?
ages 21 to 65 years: every 3 years age 30 can decrease pap screening to every 5 years if HPV screening performed well. after age 65 no testing is needed if previous testing was normal and not a high risk for cervical cancer.
an occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? irrigate the affected area with running water wash the affected area with antibacterial soap brush the chemical off the skin and clothing leave the clothing in place until emergency personnel arrive
brush the chemical off the skin and clothing
A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first? flush the client's tubing with 30 mL of water draw up 30 mL of air and instill into the tubing check the pH of the client's stomach contents check the gastric residual volume
check the pH of the client's stomach contents
A nurse is performing guaiac testing for a client to screen for colon cancer. The nurse should identify that ingestion of which of the following foods can cause a false negative result? dairy products citrus fruits soy products fish with omega-3 fats
citrus fruits
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. which of the following activities should the nurse include as an example of concrete operational thinking? playing in the sand playing dress-up with old clothes collecting and trading game cards describing interpersonal relationships
collecting and trading game cards
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? Hold the irrigator 1.25 cm (0.5 in) above the eye direct the irrigation solution up toward the upper eyelid exert pressure on the bony prominences when holding the eyelids open direct the irrigation from the outer canthus to the inner canthus of the eye
exert pressure on the bony prominences when holding the eyelids open
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? exhale slowly to reach the goal volume hold the breath for 5 sec after goal volume is reached continue to breathe deeply between each cycle limit the repeat pattern of breathing to 5 breaths
hold the breath for 5 sec after goal volume is reached
the mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding hi fruits and vegetables. which of the following responses should the nurse make? (Select all that apply) it might be good to add bananas, as they can help with loose stools let's make a list of the foods your baby is eating so we can spot any problems did the changes begin after you started a particular food? has your baby been vomiting since starting these new foods? most babies react with a little indigestion when you start new foods
let's make a list of the foods your baby is eating so we can spot any problems did the changes begin after you started a particular food? has your baby been vomiting since starting these new foods?
A nurse is reviewing safety measures with the parent of an 8-month-old infant Which of the following statements by the parent indicates an understanding of safety for the infant? my baby loved to play with the crib gym, but I took it out of the crib I just bought a soft mattress so my baby will sleep better my baby really likes sleeping on the fluffy pillow we just got I put the baby's car seat out of the way on the table after I put him in it.
my baby loved to play with the crib gym, but I took it out of the crib
a nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) open doors to client rooms place blankets over clients who are confined to beds move beds away from the windows. draw shades and close drapes instruct ambulatory clients in the hallways to return to their room
place blankets over clients who are confined to beds move beds away from the windows. draw shades and close drapes
a nurse reviewing car seat safety with the parents of a 1-month-old infant. when reviewing car seat use, which of the following instructions should the nurse include? use a car seat that has a three-point harness system position the car seat so that the infant is rear-facing. secure the car seat in the front passenger seat of the vehicle convert to a booster seat after 12 months.
position the car seat so that the infant is rear-facing.
A nurse is caring for a client who is receiving continuous enteral feeding through an NG tube and develops diarrhea. Which of the following actions should the nurse take? Change the tube feeding bag every 48 hours chill the formula prior to administration increase the infusion rate request a prescription for an isotonic enteral nutrition formula
request a prescription for an isotonic enteral nutrition formula
a nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? auscultate over the stomach while injecting air request an x-ray of the client's abdomen place the head of the client's bed in a flat position administer the feeding if the pH of the aspirated contents is >6
request an x-ray of the client's abdomen
Is communicable disease screening programs classified as primary, secondary or tertiary prevention?
secondary
A nurse educator is reviewing proper body mechanics during employee orientation. which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply) my line of gravity should fall outside my base of support the lower my center of gravity, the more stability I have to broaden my base of support, I should spread my feet apart when I lift an object, I should hold it as close to my body as possible. When pulling an object I should move my front foot forward.
the lower my center of gravity, the more stability I have to broaden my base of support, I should spread my feet apart when I lift an object, I should hold it as close to my body as possible.
A nurse is assessing a client's peripheral pulses. How should the nurse document the findings?
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply) Request assistance when repositioning a client avoid twisting your spine or bending at the waist keep your knees slightly lower than your hips when sitting for long periods of time use smooth movements when lifting and moving clients take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.
Request assistance when repositioning a client avoid twisting your spine or bending at the waist use smooth movements when lifting and moving clients
A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? Lie on your back with your head and shoulders supported by a pillow have your head turned to the side while you lie on your stomach have a table beside your bed so you can sit on the bedside and rest your arms on the table lie on your side with your top arm resting on the bed and your weight on your hip.
have a table beside your bed so you can sit on the bedside and rest your arms on the table
Is child car seat programs classified as primary, secondary or tertiary prevention?
primary
Is heath education programs classified as primary, secondary or tertiary prevention?
primary
at what age should an infant be able to hold bottle
6 months
at what age should an infant be able to roll from back to front
6 months
at what age should an infant be able to bear full weight on feet
7 months
Piaget development: birth to 24 months is called what?
sensorimotor stage
A nurse is giving a presentation about accident prevention to a group of parents and toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply) store toxic agents in locked cabinets keep toilet seats up turn pot handles toward the back of the stove place safety gates across stairways make sure balloons are fully inflated
store toxic agents in locked cabinets turn pot handles toward the back of the stove place safety gates across stairways
Is immunization programs classified as primary, secondary or tertiary prevention?
primary
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse check the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? fairness responsibility risk-taking creativity
responsibility
a nurse is talking with the parents of a 6-month-old infant about gross motor development. which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply) rolls from back to front bears weight on legs walks holding onto furniture sits unsupported sits down from a standing position
rolls from back to front bears weight on legs sits unsupported
Is early detection of diabetes programs classified as primary, secondary or tertiary prevention?
secondary
what does the sensorimotor stage include?
separation is the sense of being distinct from other objects in the environment object permanence develops at about 9 months. this is the process of knowing that an object still exists when it is hidden from view mental representation is the recognition of symbols
A nurse is evaluating the developmental motor skills of a 4-month-old infant. Which of the following findings should the nurse expect? Uses a spoon to feed herself sits up with support uses a pincher grasp creeps on hands and knees
sits up with support
A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg's test, indication what alteration?
Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception) which results in positive Romberg's sign.
A nurse in a community health center is teaching a group of clients about the use of aromatherapy. The nurse should include in the teaching that which of the following essential oils is used to alleviate swollen joints?
Chamomille
A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?
Death is viewed as an interruption of what might have been
A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should identify that the client is in which of the following stages of dying?
Depression
Are prevention of pressure ulcers after spinal cord injury classified as primary, secondary, or tertiary prevention?
Tertiary
A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking? The client holds the cane on the affected side The client advances the unaffected leg followed by the cane The client supports his weight on the unaffected leg when moving the cane forward The client keeps 2 points of support on the ground
The client keeps 2 points of support on the ground
How often should patients have their visual acuity checked?
age 40 and under: every 3 to 5 years every 2 years aged 40 to 64 annually over age 40
A nurse is teaching a client how to perform active range-of-motion exercises of the lower extremities to improve mobility. Which of the following instructions should the nurse include in the teaching? Move each joint just beyond the point of resistance perform each exercise six time each session complete each session two times per day start with a different set of joints each session
complete each session two times per day
a nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? encourage the client to participate actively in learning select instructional materials identify goals the nurse and the client agree are reasonable determine what the client knows about stress incontinence
determine what the client knows about stress incontinence
a nurse is teaching a middle-aged female client about disease prevention and health maintenance.Which of the following diagnostic test should the nurse recommend as part of the client's routine? annual papanicolaou (pap) testing mammogram every 2 years eye examination every 2 years annual colonoscopy
eye examination every 2 years
A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. the nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? coronary artery stents aneurysm clip hearing aids automated internal defibrillator
hearing aids
a nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? help the client see the benefits of their actions identify the client's support systems suggest and recommend community resources devise and set goals for the client teach stress management strategies
help the client see the benefits of their actions identify the client's support systems suggest and recommend community resources teach stress management strategies
A nurse is preparing the room for a client who is transferring from the emergency department and is on seizure precautions. Which of the following items should the nurse place in the client's room? oral-nasal suction tongue blade sterile gloves wire cutters
oral-nasal suction
A nurse is performing medication reconciliation with a client. Which of the following actions should the nurse take first? Contact the provider about discrepancies in medication dosages. Provide the client with a new list of prescribed medications. Compare the provider's admission prescriptions to the client's list of home medications. Ask the client if she takes any over-the-counter medications.
Ask the client if she takes any over-the-counter medications.
How often should patients have a colorectal screening?
Every year between the age of 50 and 75 for high-sensititivity fecal occult blood testing, or flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years
A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound?
Excessive wax in the ear canal
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? obtain a walker for the client to use to transfer back to bed. call for additional staff to assist with the transfer use a transfer belt and assist the client back into bed. Determine the client's ability to help with the transfer.
Determine the client's ability to help with the transfer.
How often should patients get a TB test?
Every 2 years if at risk of infection. health care workers should be screened annually
How often should patients have their blood pressure checked?
Every 2 years; annually if previously elevated.
How often should patients have their skin checked?
Every 3 years by a skin specialist for age 20 to 40; annually over age 40 years
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take? Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube position the client on the right side insert the tip of the tubing 8 cm (3.1 in) hold the enema container 61 cm (24 in) above the rectum
Insert the tip of the tubing 8 cm (3.1 in)
A nurse is caring for a client who had human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV?
Standard precautions
A nurse teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. which of the following muscle groups is responsible for movement at the knee joint? antigravity antagonistic synergistic skeletal
antagonistic
Is exercise programs classified as primary, secondary or tertiary prevention?
secondary
a nurse is assessing a 2-week-old newborn during a routine checkup. which of the following findings should the nurse expect? sleeps 14 to 16 hour each day posterior fontanel is closed pincer grasp present hands remain in a closed position current weight same as brith weight
sleeps 14 to 16 hour each day hands remain in a closed position current weight same as brith weight
How often should patients have their cholesterol checked?
starting at age 20, a minimum of every 5 years
