ATI Fundamentals Study Set B

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

-Hold the sterile drape above the waist and away from the body

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feeding. Which pieces of information are critical to communicate to the next nurse who will be caring for this client?

-New Prescriptions -Arterial blood gas results -Tracheal secretion characteristics

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

-PC for after meals

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

-Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching?

-Place soiled linen in a single linen bag

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

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?

-Position the client for drainage of secretions by gravity

A nurse is evaluating a client's use of crutches. The nurse should identify that which of following actions by the client indicates safe usage of this equipment?

-The client has slightly flexed elbows when ambulating with the crutches

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. Which part of the nursing process?

-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 tasks?

-Ceasing to compare personal identity with others

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

-Check the client's capillary blood glucose level every 4 hr

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

-Check the client's perineum

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?

-Chronic hypoxemia

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

-Clamp the tubing below the collection port

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube?

-Coat the tip of the tube with a water-soluble lubricant -Ask the client to swallow water while the tube enters her throat -Tell the client to tilt her head backward as insertion begins

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

-Collect the specimen when the client rises in the morning

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?

-Collecting and trading game cards

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the med 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

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?

-"Can you explain the concerns you're having right now?"

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

-"Fats provide energy."

A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following statements should the nurse address first?

-"I can't sleep well because whenever I move in my sleep, the pain wakes me up."

A nurse is caring for an older adult client who has 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 new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?

-Explain that it is against policy to share access codes and refer the resident to his supervisor

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

-Fill the bag 2/3 full with ice

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

-Side hip between the iliac crest and anterior iliac spine

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postop. Which of the following clients should the nurse see first?

A client who is 2 days postop following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, blood drainage

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment?

-Dry, brittle hair -Edema -Poor wound healing

While admitting a client to the med unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make healthcare decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

-Durable Power of attorney document

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following PPE items should the nurse don prior to providing client care?

-Gown -Gloves

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of info should the nurse include in the teaching?

-Hold the breath for 5 sec after goal volume is reached

A nurse is caring for a client who has a temp of 101.7. Which of the following actions should the nurse take?

-Keep the client's bed linens dry

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data?

-Secondary-source data

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include?

-Sit with your back supported -Keep your knees at hip level -Use an ergonomically designed computer keyboard

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

-Support the client's decision

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration?

-The client's ID number -The client's name -ABO compatibility -Rh compatibility

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

-Upon the client's admission to the care facility

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

-Washing dishes

A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8g/kg. How many grams of protein per day should the nurse recommend for this client?

48g 132/2.2= 60 kg 60 kg x 0.8 g=48 g

A nurse is teaching a client who is postop 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?

-Antagonistic

A nurse ask 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 client's ability in which of the following functions?-

-Abstract reasoning

A nurse is caring for a child who is postop following a tonsillectomy. Which of the following actions should the nurse take?

-Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group?

-"I go home on the weekends to be with my family because I do not have any good friends here on campus."

A nurse is teaching a group of older adults about expected age-related changes. 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."

A nurse is talking with the parent of a pre-school-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

-"Keep a diary of the foods your child eats each day."

A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence?

-Hold the mouthpiece 1 to 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 breath -Hold your breath for 10 seconds

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

-"It modulates the transmission of the pain impulse."

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

-"Keep the rubber crutch tips securely in place."

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 min after eating a meal."

A middle-aged client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group?

-"We miss our daughter so much that we are going to move closer to her."

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The med is available in 80 mg tablets. How many tablets should the nurse administer per dose?

-2 tablets

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

-A client who has a prescription for a transfusion of packed red blood cells

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

-Ask the client about first aid performed at the scene

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?

-Bounding

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which interventions is the nurse's priority?

-Measure the client's apical pulse

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

-Instruct the client to perform foot and leg exercises ever 1-2 hr while awake to help prevent thrombophlebitis

A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching?

-Kosher diets have restrictions regarding how the food must be prepared

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit," Which of the following actions should the nurse take?

-Assist the client in finding local smoking-cessation assistance programs

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

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

-Brainstem

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?

-Carefully remove the gloves and proceed with hand hygiene

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

-"I'll wear nonsterile gloves"

A nurse is preparing to administer meds to client who is unconscious. The nurse should bring the med administration record to the client's bedside and perform which of the following verification procedures?

-Compare the medical record number and name on the MAR with the client's identification band

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

-A client who has heart failure and receiving 100 percent oxygen via partial rebreather mask

A nurse on a surgical unit is receiving a client who had abdominal surgery from the post anesthesia care unit. Which of the following assessments should the nurse make first?

-Airway

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep?

-Allow the client to maintain the same bedtime routine as at home

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

-Apply pressure to the puncta after instilling the medication

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

-Ask the client to identify the specific food allergies

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

-Ask why the client is refusing the pain medication

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

-Assigning another client with the same infection to share the room with the client

A nurse is caring for a client who is postop following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?

-Cover the incision with a moist sterile dressing

A nurse is changing the dressings for a client who is 3 days postop following a cholecystectomy. The nurse observes yellow, thick drainage on dressing. The nurse should document this finding as which of the following types of drainage?

-Purulent exudate

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

-Repeat each joint motion 5 times during each session

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?

-Romberg

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities?

-Scoliosis

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

-Supports self-determination

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an AP. The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

-Talk with the AP about the technique used

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temp of 102. 6 F, a HR 105/min, a soft nontender abdomen, menses overdue by 2 days. Which of the following findings should be the nurse's priority?

-Temperature

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

-Test for the presence of the client's gag reflex

An AP is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

-The AP hangs the collection bag at the level of the bladder

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

40 mL/20min x 15gtt/min= 30

A nurse is caring for a client who is postop and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?

Assessment

After inspection of abdomen which techniques is next?

Auscultation

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

Bear down

A nurse is reviewing the lab values of a client who has a positive Chvostek's sign. Which of the following lab findings should the nurse expect?

Decreased calcium, hypocalcemia

A nurse is teaching a middle-aged adult about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decreased estrogen and testosterone production

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the flight-or-flight response?

Increased blood pressure

A nurse is caring for an older adult who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first Rationale: Client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of meal to stimulate saliva production]

A nurse is initiating seizure precautions for a client who has seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside?

Oxygen Equipment

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side