ATI Fundamentals quiz
A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of client care is the client transferred to the surgical suite table before being transferred to PACU? A. Pre-operative. B. Postoperative C. Intraoperative. D. Admission
C. Intraoperative.
A nurse is caring for a patient who has fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A. Carminative. B. Hypertonic. C. Oil retention. D. Sodium polystyrene sulfate
C. Oil retention. The nurse should administer an oil retention enema prior to the removal of fecal impaction to soften the stool. This makes the procedure less painful
A nurse is performing in and abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. a..Inspection. b. Palpation. c. Percussion. d. Auscultation.
a d c b
Nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in a clients record first? a. Assessment b. Plan of care. c. Nursing interventions performed. d. Evaluation of progress
a. Assessment
Versus planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will provide the clients commitment to a long-term goal of weight loss? a. Attempt to increase the clients self motivation. b. Keep detailed records of each clients progress. c. Teach the client learning after each teaching session. d. Avoid discussing areas that might cause client anxiety
a. Attempt to increase the clients self motivation.
Nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? a. Evaluate pedal pulses. b. Obtain medical history. c. Measure vital signs. d. Assess for limping.
a. Evaluate pedal pulses.
A nurse on the medical surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? a. Identify goals for the client. b. Obtain client information. c. Document nursing needs. d. Evaluate the effectiveness of care.
a. Identify goals for the client.
This is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessment should the nurse expect? a. Frequent bowel sounds with flatus. b. Absent bowel sounds with distention. c. Hyperactive bowel sounds with diarrhea. d. Normal bowel sounds with increased peristalsis
b. Absent bowel sounds with distention.
A nurse is caring for a client who has terminal illness. The client asked several questions about the nurses religious beliefs related to dying and death. Which of the following actions should the nurse take? a. Change the topic because the client is trying to divert attention from the illness to the nurse. b. Encourage the client to express his thoughts about death and dying. c. Tell the client that religious beliefs are a personal matter d. Offered to contact the clients minister or facilities chaplain
b. Encourage the client to express his thoughts about death and dying.
Irish nurse is observing a newly license nurse perform tracheostomy care for a client. Which of the following actions by the newly license nurse requires intervention? a. Obtaining hydrogen peroxide for the tracheostomy care. b. Obtaining cotton balls for the tracheostomy care. c. Obtaining sterile gloves for the tracheostomy care. d. Obtaining a sterile brush for the tracheostomy care
b. Obtaining cotton balls for the tracheostomy care.
A nurse is collecting health history data from a client who is deaf and uses American Sign Language ASL to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with an interpreter? a. Face away from the client to avoid distraction. b. Pace speech to allow time for the interpreter to convey the words. c.Make eye Contact with the interpreter when explaining the procedure. d. Stand in the background while the interpreter translates the message
b. Pace speech to allow time for the interpreter to convey the words
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? a. Holding a community clinic to administer influenza immunizations. b. Screening groups of older adults in nursing care facilities for early influenza manifestations. c. Educating parents of young children about the dangers of influenza. d. Finding rehabilitation programs for older adults who have complications from influenza
b. Screening groups of older adults in nursing care facilities for early influenza manifestations.
A nurse is demonstrating Post operative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates the lack of readiness to learn by the client? a. The client asks the nurse to repeat the instructions before attempting the exercises. b. The client reports severe pain. c. The client asked the nurse how often deep breathing should be done after surgery. d. The client tells the nurse that this exercise will probably be painful after surgery
b. The client reports severe pain.
What is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? a. Encourage the child to cough frequently to clear congestion from anesthesia. b. Place heating pad on the child's neck for comfort. c. Administer analgesics to the child on routine schedule throughout day and night. d. Provide the child with ice cream when oral intake is initiated
c. Administer analgesics to the child on routine schedule throughout day and night.
A charge nurse is teaching adult cardio pulmonary resuscitation CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? a. Call for assistance. b. Begin chest compressions. c. Confirm unresponsiveness. d. Give rescue breaths
c. Confirm unresponsiveness.
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 that the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? a. Turn on the machine every 15 minutes to measure the clients blood pressure. b. Record only blood pressure readings needed for 15 minute interval. c. Obtain manual and automatic readings and compare them. d. Disconnect the machine, and measure the blood pressure manually every 15 minutes
d. Disconnect the machine, and measure the blood pressure manually every 15 minutes
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? a. Explain the x-ray procedure to the client. b. Help the client into the wheelchair before the transporter arrives. c. Ask the client if he has any questions. d. Identify the client using two identifiers.
d. Identify the client using two identifiers.
Chris is preparing a client who is scheduled for a hysterectomy to transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? a. Tell the client it is too late for her to change her mind because the surgery is already scheduled. b. Telephone the operating room and cancel the surgery. c. Inform the clients family about the situation. d. Notify the provider about the clients decision
d. Notify the provider about the clients decision
A nurse is obtaining the blood pressure of a client's lower extremity. Which of the following action should the nurse take? a. Auscultate for the blood pressure at the dorsal pedis artery. b. Measure the blood pressure with the client sitting on the side of the bed. c. Place the cuff 7.6 cm 3 inches above the popliteal artery. d. Place the bladder of the cuff over the posterior aspect of the thigh.
d. Place the bladder of the cuff over the posterior aspect of the thigh.
Nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? a. Open all sterile supplies and solutions. b. Stabilize the tracheostomy tube. c.Don sterile gloves. d. Preform hand hygiene
d. Preform hand hygiene
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? a. I should expect my heart rate to take longer to return to normal after I exercise as I get older. b. Urinary incontinence is some thing I will have to live with as they grow older. c. I can expect to have less wax in my ear as I get older. d. My stomach will be empty more quickly after meals as I grow older
a. I should expect my heart rate to take longer to return to normal after I exercise as I get older. There are adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise
A nurse receiving a client from PACU is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? a. Lock the wheels on the bed and stretcher. b. Instruct the client to raise his arms above his head. c. Elevate the stretcher 2.1 cm or 1 inch above the height of the bed. d. Logroll the client
a. Lock the wheels on the bed and stretcher.
A nurse is caring for a client who has dysrhythmia. To the following techniques should the nurse use to assess for a pulse deficit? a. Obtain the apical and radial rates simultaneously b. Check the blood pressure in the left and right arms c. Compare the pulse strength in the upper extremities d. Palpate the pulses in the lower extremities
a. Obtain the apical and radial rates simultaneously To assess for a pulse deficit, the nurse and the second person assess the clients radio and apical pulse is simultaneously and compare both rates to calculate subtract the difference between apical and radial pulse rates
This is caring for a client who has type one diabetes and is resistant to learning about self injection of insulin. Which of the following statements should the nurse make? a. Tell me what I can do to help you overcoming your fear of giving yourself injections. b. I am sure your provider will not be pleased that you refuse to give yourself insulin injections. c. It's OK. I am sure your partner will be able to learn how to give you the insulin injections. d. You won't be able to go home unless you learn to give yourself insulin injections
a. Tell me what I can do to help you overcoming your fear of giving yourself injections.
A nurse is teaching range of motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates the understanding of super nation of the hand? a. The client holds the hand with the palm up. b. The client holds the hand with the palm down. c. The client points the finger is towards the floor. d. The client points the fingers towards the ceiling
a. The client holds the hand with the palm up.
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? a. Wash the gloved hands then throw the gloves away. b. Prepare an incident report to document the event. c. Carefully remove the gloves and follow with hand hygiene. d. Ask the provider to order a blood culture to determine the risk of infection.
c. Carefully remove the gloves and follow with hand hygiene.
A nurse is measuring a clients vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? a. Measure the pulse using a Doppler ultrasound stethoscope. b. Check the clients pedal pulses. c. Count the atypical pulse for one full minute and describe the rhythm in the chart. d. Take the pulse at each peripheral site and count the rate for 30 seconds
c. Count the atypical pulse for one full minute and describe the rhythm in the chart.
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? a. My parents are retired, and they have to come out with our children. b. I am going to ask my husband to go to counseling with me. c. I keep having nightmares about my upcoming surgery. d. My girlfriends bought me a nice wig
c. I keep having nightmares about my upcoming surgery.
A nurse on rehabilitation unit is preparing to transfer a client who is unable to walk from a bad to a wheelchair. Which of the following technique should the nurse use? a. Stand towards the clients stronger side. b. Instruct the client to lean backwards from the hips. c. Place the wheelchair at a 45° angle to the bed. d. Assume a narrow stance with feet 15 cm 6 inches apart.
c. Place the wheelchair at a 45° angle to the bed.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make it to the client? a. Ask your provider to prescribe epoetin before the surgery. b. You should ask your provider about taking iron supplements prior to the surgery. c. Request a family member donate blood for you. d. Donate autologous blood before surgery
d. Donate autologous blood before surgery autologous blood transfusion is the collection and re-infusion of the clients blood. With preoperative autologous blood drawn from the client 3 to 5 weeks before elective surgical procedures and stored for transfusion at the time of surgery.
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 areas should the nurse place the stethoscope to auscultate the aortic valve? a. Fifth intercostal space just medial to the mid clavicular line. b. Second intercostal space left of the sternum. c. Fifth intercostal space left of the sternum. d. Second intercostal space right of the sternum
d. Second intercostal space right of the sternum The aortic valve is located in the second intercostal space right of the sternum. Aortic stenosis precedes a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward
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? a. The client fully understands the providers explanation of the procedure. b. The client has been informed about the risks and benefits of the procedure. c. The nurse witnessed the providers explanation of the procedure. d. The signature on the perioperative consent form is the clients
d. The signature on the perioperative consent form is the clients
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery. Which of the following responses should the nurse make? a. It's for your safety. Dentures can slip and block your airway during surgery. b. You wouldn't want your teeth to be lost or broken during surgery would you. c. The anesthesiologist requires everyone to remove their dentures. d. What worries you about being without your teeth?
d. What worries you about being without your teeth?
A nurse asks a client to explain the statement, "a bird in the hand is worth two in the bush" Through this question, the nurse is evaluating the clients ability in which of the following intellectual functions? a. judgment b. short term memory c. attention span d. abstract reasoning
d. abstract reasoning
A nurse is planning to obtain the vital signs of a two year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? a. rectal b. tympanic c. oral d. temporal
d. temporal
this is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the clients ability to learn new dietary habits? a. The involvement of the client planning the change. b. The emphasis the provider places on dietary changes. c. The learning theory the nurses used to teach the dietary changes. d. The extent of dietary changes planned for the client
a. The involvement of the client planning the change.
A nurse is teaching an assistive personnel AP about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? a. There are many times I should use soap and water rather than alcohol-based hand rub to clean my hands. b. I will use cold water when washing my hands to protect my skin from becoming too dry. c. I will apply friction for at least 10 seconds while washing my hands. After washing my hands d. I will dry them from the the elbows down
a. There are many times I should use soap and water rather than alcohol-based hand rub to clean my hands.
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse take? a. Place the client in supine. b. Keep both side rails up. c. Raise the level of the bed. d. Inspect the clients mouth using a finger sweep.
c. Raise the level of the bed.
Where is in the emergency department is assessing a client who reports diarrhea and decreased urination for four days. Which of the following action should the nurse take to assess the clients skin turgor? a. Put on the fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. b. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. c. Press the skin above the ankle for five seconds, release it, and note the depths of impression. d. Measure the skinfold thickness at the upper arm using a pair of calibrated skin fold calipers
b. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IVs. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Tyler restraints to the side rails. Performed range of motion exercises to the rest every three hours. Remove the restraints one at a time. Obtain a PRN prescription for the restraints
c. Remove the restraints one at a time.
A nurse is caring for a client who is in the terminal stage of cancer which of the following actions should the nurse take when she observes the client crying? a. contact the family and ask them to stay with the client. b. Offer to call the clients minister. c. Sit and hold the clients hand. d. Leave the room and out allow the client to cry privately
c. Sit and hold the clients hand.
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? a. Drink a minimum of 1000 mL of fluid today. b. Increase your intake of refined fiber foods. c. Sit on the toilet 30 minutes after eating every meal. d. Take a laxative every day to maintain regularity
c. Sit on the toilet 30 minutes after eating every meal. Increased peristalsis occurs after 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 retaining to treat constipation
First is planning care for a client who reports abdominal pain. The assessment by the nurse reveals the client has a temperature of 39.2°C or 102.6°F, heart rate of 105 over a minute, a non-tender abdomen, and menses over due by two days. Which of the following findings should be the nurse is priority? a. Heart rate of 105 per minute b. Soft, non-tender abdomen c. Temperature d. Overdue Menzies
c. Temperature
A nurse on a medical surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique? a. The nurse washes each part of her hands with five strokes. b. The nurse washes from the elbows down to the hands. c. The nurse washes with her hands held higher than her elbows. d. The nurse uses minimal friction when washing her hands.
c. The nurse washes with her hands held higher than her elbows.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and die systole with the diaphragm of her stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? a. Audible click. b. Murmur. c. Third heart sound. d. Pericardial friction rub
d. Pericardial friction rub
A nurse observes an AP preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give me AP? a. The reading will be in audible if the cuff is too small for the client. b. The width of the cuff bladder should be 75% the circumference of the clients arm. c. As long as the cuff will circle the arm the reading will be accurate d. Using a cuff that is too small will result in an accurately high reading.
d. Using a cuff that is too small will result in an accurately high reading.
