ATI Funds Practice Test 3
A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further teaching is required? "I should not leave all 4 side rails up unless there is a prescription for restraints" "An alert client will be safest if I raise the 2 upper side rails at the head of the bed" "If a client seems confused, Ill raise 4 side rails so that he doesn't hurt himself" "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed"
"If a client seems confused, Ill raise 4 side rails so that he doesn't hurt himself" (this would put them at greater risk for injury)
A nurse is calculating the protein needs of a young adult client who weighs 132 lbs. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? Fill in the blank
48 g 132/2.2=60 kg 60 kg x 0.8 g= 48 g
A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference On the day prior to discharge
During the admission process
A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Placing an unused portion of the medication in a sharp box Asking another nurse to observe the disposal of an unused portion of the medication Counting the inventory of the available narcotic after administering the medication Ensuring that another nurse signs the control inventory form disposal of an unused portion of medication
Asking another nurse to observe the disposal of an unused portion of the medication (they should witness to maintain safe control of the narcotic) INCORRECT: Placing an unused portion of the medication in a sharp box--> NO Counting the inventory of the available narcotic after administering the medication--> count before Ensuring that another nurse signs the control inventory form disposal of an unused portion of medication--> 2 nurses should sign
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? Wash the gloved hand and then throw the gloves away Prepare an incident report to document the event Carefully remove the gloves and proceed with hand hygiene Ask the provider to order a blood culture to determine the risk of infection
Carefully remove the gloves and proceed with hand hygiene
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? Trauma Severe infection Iron-deficiency anemia Chronic hypoxemia
Chronic hypoxemia (low oxygen supply)
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? Drop the eye medication into the lower conjunctival sac Apply gently pressure to the out opening of the eye for 2 min Hold the eyedropper 0.5 cm (0.2 in) from the cornea Instruct the client to close the eyes tightly after administration
Drop the eye medication into the lower conjunctival sac (to avoid placing the drops on the cornea causing damage)
A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? Crackles in the lung fields Flat neck veins Postural hypotension Dark yellow urine
Crackles in the lung fields (manifestations of the fluid-volume excess include--> crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain)
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight Blood pressure Specific gravity Intake and output
Daily weight
A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? Lactose Sucrose Maltose Fructose
Lactose
A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse which of the following statements by the newly licensed nurse indicates an understanding of the teaching? People who practice the Islamic faith pray over the deceased for a period of 5 days before burial People who practice the Hindu faith bury the deceased with their head facing north People who practice Judaism stay with the body of the deceased until burial People who practice the Buddhist faith have the female family members prepare the body following death
People who practice Judaism stay with the body of the deceased until burial
A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? Sanguineous Purulent Serous Hyperemia
Sanguineous (contains large amounts of red blood cells indicating that damaged capillaries are escaping from the plasma) INCORRECT: Purulent= thicker than other drainages (pus) Serous= serum; clear portion of the blood Hyperemia= not drainage
A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? The client fully understands the provider's explanation of the procedure The client has been informed about the risks and benefits of the procedure The nurse witness the provider's explanation of the procedure The signature on the preoperative consent form is the client's
The signature on the preoperative consent form is the client's (It is the responsibility of the provider who will perform the surgery to inform the client about the risk and benefits)
A nurse is teaching that parent of a child who is to take 30mL of liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give the child?
2 tbsp 15mL/1 tbsp = 30 ml/X tbsp 15X=30 X=2
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? 2-pont discrimination test Glasgow coma scale Babinski reflex Romberg test
Romberg test (stand with feet together and arms at the sides, first with eyes open and then with them closed to test balance)
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? Anger Bargaining Depression Acceptance
Depression (they have realized the full impact of the loss and might express hopelessness and despair) INCORRECT: Anger--> resistance, blaming other or a higher power Bargaining-->stall awareness of the loss by trying to keep it from occuring Acceptance--> integrate the loss by making arrangements
A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? Retention Oliguria Diuresis Dysuria
Diuresis (aka polyuria excretion of high volume of urine) INCORRECT: Oliguria= diminishing urine output despite an acceptable fluid intake Dysuria= painful/difficult urination: result of a UTI
A nurse is employing a through, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? Health history Physical exam Review of systems Interview
Physical exam (physical findings are objective and the nurse should collect this info in a systematic way)
A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? Use isopropyl alcohol to clean blood spills Discard empty blood bags in a bedside trash can Break used needles before discarding them Place soiled linen in a single linen bag
Place soiled linen in a single linen bag INCORRECT: Use isopropyl alcohol to clean blood spills--> use chlorine bleach
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? Skeletal muscle relaxants Beta-adrenergic blockers Broad-spectrum anti-infective agents Plasma volume expanders
Plasma volume expanders (dextran and albumin help correct hypovolemia in emergency situations such as hemorrhage or burns) INCORRECT: Skeletal muscle relaxants=cyclobenzaprine and metaxalone Beta-adrenergic blockers= propranolol and carvedilol Broad-spectrum anti-infective agents = ampicillin and ceftixime
A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following? Leukoplakia Leukemia Leukocytosis Leukopenia
Leukopenia (occurs when there is a DECREASE in WBCs-->makes the client at risk of infection) INCORRECT: Leukoplakia= involves thick white patches in the mucosa of the mouth Leukemia= uncontrolled production of blast cells or immature WBC in the bone marrow Leukocytosis= increase in WBC
A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting which of the following functions? Regulation of acid-base balance Reabsorption of nutrients for cellular growth Regulation of body temp Secretion of hormones needed for growth
Regulation of acid-base balance (by retaining biocarbondate as they excrete hydrogen ions) INCORRECT: Small intestine--> absorbs nutrients for cellular growth Integumentary system--> regulates body temp Anterior pituitary gland--> secretes hormones
A nurse is 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
A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? Inform the guard that the warden must request this information Ask the guard to sign a release of information form Instruct the guard to ask the inmate Complete an incident report
Instruct the guard to ask the inmate (the client must offer the information freely--> therefore the guard must ask the client)
A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? Apply an alcohol-water solution to the client's skin Keep the client's bed linens dry Apply ice packs to the groin Limit the client's fluid intake to 1183 mL (40oz) pf fluid per day
Keep the client's bed linens dry (maximize the client's heat loss by keeping linens and clothes dry)
A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? Confirm that the client performed the procedure correctly Instruct the client to look at the floor while instilling the eye drop Remind the client to avoid using a facial tissue after instillation Instruct the client apply pressure to the inside corner of the eye after instillation
Instruct the client apply pressure to the inside corner of the eye after instillation (apply pressure over the nasolacrimal duct to prevent medication from flowing into the nasal passages)
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 smoke-cessation assistance programs Tell the client that she will be all right after receiving medical care Inform the client that she must stop smoking or the provider will not be able to care for you Advocate for the client by supporting her statement about not quitting
Assist the client in finding local smoke-cessation assistance programs
A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? Refer to client to a nutritionist Discuss eating strategies with the client Determine the client's intention to change current eating habits Instruct the client to perform 30 mins of vigorous exercise daily
Determine the client's intention to change current eating habits FIRST
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? Don clean gloves to remove the old dressing Loosen the dressing by pulling the tape away from the wound Remove the entire old dressing at once Open sterile supplies after applying sterile gloves
Don clean gloves to remove the old dressing (sterile gloves are not necessary) INCORRECT: Loosen the dressing by pulling the tape away from the wound (pull TOWARDS the wound to decrease tension or stress on the wound edges) Remove the entire old dressing at once (remove layer by layer to prevent removal of drains and allow assessment of the drainage) Open sterile supplies after applying sterile gloves (open sterile supplies AFTER removing the old dressings and washing the hands and before donning sterile gloves to apply the dressing)
A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? The motivation for communication is evident Feedback is provided A message is communication to the group of clients Multiple channels are used by the sender
Feedback is provided
A nurse is caring for a client who is having difficult breathing. The nurse should assist the client into which of the following positions? Supine Lateral Fowler's Trendelenburg
Fowler's INCORRECT: Trendelenburg= lowering the head of the bed with the foot of the bed raised into a straight incline can promote venous circulation
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Cream of rice Cottage cheese Gelatin Ice cream
Gelatin
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink Grasp a skin fold on the chest under the clavicle, release it and note whether it springs back Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers
Grasp a skin fold on the chest under the clavicle, release it and note whether it springs back
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? Hold the dropper 1cm (0.5 in) above the ear canal Apply pressure to the nasolacrimal duct following administration Place a cotton ball into the inner ear canal for 30 mins following administration Straighten the ear canal by pulling the auricle down and back prior to administration
Hold the dropper 1cm (0.5 in) above the ear canal INCORRECT: Apply pressure to the nasolacrimal duct following administration--> eye drops Place a cotton ball into the inner ear canal for 30 mins following administration--> in the outermost for 15 mins Straighten the ear canal by pulling the auricle down and back prior to administration--> for a child 3 or younger
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? Serve foods at warm or hot temps Offer the client low-density foods Make sure the client lies supine after meals Limit drinking liquids with food
Limit drinking liquids with food (leads to early satiety and bloating, which results in the client consuming fewer calories) INCORRECT: Serve foods at warm or hot temps--> should be COLD or room temp food Offer the client low-density foods--> high protein, high caloric, nutrient dense foods Make sure the client lies supine after meals--> to reduce nausea client should sit upright for 1 hour after meals
A nurse is collecting health history data from a client who is deaf and uses ALS to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? Face away from the client to avoid distraction Pace speech to allow time for the interpreter to convey the words Make eye contact with the interpreter when explaining the procedure Stand in the background while the interpreter translates the message
Pace speech to allow time for the interpreter to convey the words
A nurse is preparing to administer a cleaning enema to a patient. Which of the following actions should the nurse plan to take? Insert the rectal tuber 15.2 cm (6in) Wear sterile gloves to insert the tubing Position the client on his left side Hold the solution bag 91 cm (36in) above the client's rectum
Position the client on his left side INCORRECT: --> insert 7-10cm (3-4in) Clean gloves Hold the bag 30cm (12 in) above
A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? Rehabilitation Assisted living facility Respite care Adult day care facility
Respite care (service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance) INCORRECT: Adult day care facility--> for clients who need minimal assistance
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? Applying the sterile gloves to open catheter package Wiping the labia minora in an anteroposterior direction Spreading of the labia with the dominant hand Using a cotton ball to wipe the right and left labia majora
Wiping the labia minora in an anteroposterior direction
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 provides a distraction from the pain" "It modulates the transmission of the pain impulse" "It promotes increased circulation to the painful area" "It elicits a relaxation response"
"It modulates the transmission of the pain impulse" (applies low-voltage electrical stimulation directly over a location of pain at an acupressure point; it modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief) INCORRECT: Distraction methods= visual, auditory, tactile, and intellectual distraction Massage= relaxation but wont relieve pain like a TENS unit
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? "You look just fine to me" "Nobody expects you to look beautiful in the hospital" "I understand how you feel. I would feel the same way" "Would you like to talk about how you feel?"
"Would you like to talk about how you feel?"
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? "tell me what I can do to help you overcome your fear of giving yourself injections" "your provider will not be pleased that you refuse to give the insulin injection to yourself" "its ok, im sure your partner will be able to learn how to give the insulin injections" "You wont be able to go home unless you learn to give yourself insulin injections"
"tell me what I can do to help you overcome your fear of giving yourself injections"
A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? "I will have the steps to my house painted a dark color" "I will put a night-light in the hallway" "I will put on socks when I get out of bed" "I will secure any wires in my home under rugs"
"I will put a night-light in the hallway"
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 of the following interventions in the nurse's priority? Measure the client's apical pulse Administer the allopurinol to the client Inform the nurse manager Complete an accident report
Measure the client's apical pulse (Atenolol is a beta blocker and can decrease the client's heart rate)
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? Select all that apply Room temp New prescriptions Number of visitors Arterial blood gas results Tracheal secretion characteristics
New prescriptions Arterial blood gas results Tracheal secretion characteristics
A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Encourage the client to take deep breaths Observe the rate, depth, and character of the client's respirations Prepare to administer oxygen Give the client a back rub to promote relaxation
Observe the rate, depth, and character of the client's respirations (nurse must collect data)
A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the clients urine is 1.035. Which of the following actions should the nurse take? Deliver the formula at a slower rate Request a lower-fat formula Provide more water with feedings Instill a lactose-free formula
Provide more water with feedings
A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? "Inhale forcefully during the insertion" "Raise your index finger if you need to pause during the insertion" "Bear down during the insertion" "Avoid making any swallowing motions during the insertion"
"Raise your index finger if you need to pause during the insertion" (tell them it is uncomfortable and the gag reflex will be activated during the procedure so establishing a communication technique is vital)
An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plan because his friends discourage him. Which of the following statements should the nurse make? "Dont worry; teenagers often have friends who give bad advice" "I think you should stop seeing those friends since they discourage you from following your treatment plan" "Tell me more about how your friends discourage you" "Where did you meet these friends?"
"Tell me more about how your friends discourage you"
A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? Fat breaks down into amino acids Protein serves as an energy source when other sources are inadequate Glucose breaks down into ammonia Carbohydrates provide 9cal/g of energy
Protein serves as an energy source when other sources are inadequate INCORRECT: Fat breaks down into amino acids-->PROTEIN does Glucose breaks down into ammonia --> PROTEIN does Carbohydrates provide 9cal/g of energy --> carbs= 4 cal/g of energy fat= 9 cal/g of energy
