ATI Funds Practice Test 6
A nurse in a long=term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? Assist the client to the floor Perform an abdominal thrust Open the airway with a head-chin tilt Observe the client closely
Observe the client closely (as long as they are able to cough strongly the nurse should not intervene)
A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrive to drive the client home. Which of the following actions should the nurse take? Ask the client's neighbor to call a family member to interpret Ask the client's neighbor to translate the information Obtain the services of an interpreter Document the inability to provide discharge instructions
Obtain the services of an interpreter
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Auscultate the blood pressure at the dorsalis pedis artery Measure the blood pressure with the client sitting on the side of the bed Place the cuff 7.6 cm (3in) above the popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh
Place the bladder of the cuff over the posterior aspect of the thigh (lower extremity blood pressure)
A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? Select all that apply Allowing the client to speak Stabilizing the position of the tube Preventing aspirations of secretions Preventing air leaks Preventing tracheal injury
Stabilizing the position of the tube Preventing aspirations of secretions Preventing air leaks
A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Pain level Hydration status Airway Urinary output
Airway
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Blow into the spirometer to elevate the balls in the device Cough deeply after each use Clean the mouthpiece with an alcohol swab after each use Use the spirometer every 8 hours
Cough deeply after each use (proper use of the device loosens secretions in the client's lungs--> client should cough out that excess)
A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? Warm the feeding tube in a microwave oven Elevate the head of the client's bed Flush the tube with 0.9% sodium chloride for irrigation Verify that the client's gastric pH is above 4
Elevate the head of the client's bed INCORRECT: Warm the feeding tube in a microwave oven--> ROOM TEMP Flush the tube with 0.9% sodium chloride for irrigation--> FLUSH WITH WATER PRIOR Verify that the client's gastric pH is above 4--> should be BELOW 4
A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nurse process, which of the following actions should the nurse take? Establish client outcomes Collect information about past health problems Determine whether the client has met specific goals Identify the client's specific health problems
Establish client outcomes
A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Decreased urine specific gravity Increased heart rate Decreased hematocrit Increased skin turgor
Increased heart rate (fluid volume deficit)
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may 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 share with the client? "Ask you provider to prescribe epoetin before the surgery" "You should ask your provider about taking iron supplements prior to the surgery" "Ask a family member to donate blood for you" "Donate autologous blood before the surgery"
"Donate autologous blood before the surgery" (the collection and reinfusion of the client's blood for the time of surgery)
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "A lot of clients who are cared for at home have the same problem" "Dont worry about it. He will get a bath and that will take care of the odor" "It must be difficult to care for someone who is confined to a bed" "When was the last time that he had a bath?
"It must be difficult to care for someone who is confined to a bed"
A nurse is providing teaching to an older adult client who has constipation. Which of the following statement should the nurse include in the teaching? "Drink a minimum of 1,000 mL of fluid daily" "Increase your intake of refined-fiber foods "Sit on the toilet 30 mins after eating a meal" "Take a laxative every day to maintain regularity"
"Sit on the toilet 30 mins after eating a meal" INCORRECT: Should be 1,500mL
A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? "The home health dietician will visit and help you learn to cook all over again" "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control" "The dietitian will help you choose foods you are used to that also meet your health needs" "It may be difficult, but I know you can change your eating and cooking habits with help from the dietitian"
"The dietitian will help you choose foods you are used to that also meet your health needs"
A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? "When did you start to believe in your faith?" "How often do you perform religious rituals?" "Which church do you regularly attend?" "What is your source of strength and hope?"
"What is your source of strength and hope?"
After assessing a client, the nurse documents "1+ pedal edema bilaterally". This indicates that the nurse observed an indentation of which of the following depths after applying pressure? 2mm 4mm 6mm 8mm
2mm INCORRECT: 4mm=2+ 6mm=3+ 8mm=4+
A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse?
8 1L=1000mL volume(ml)/time(hr)= X 1000ml/X hr= 125ml/hr x=8hr
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 is receiving 100% oxygen via partial rebreather mask A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula A client who has an old trachestomy and is receiving 40% humidified oxygen via tracheostomy collar A client who has COPD and is receiving oxygen at 2L/min via nasal cannula
A client who has heart failure and is receiving 100% oxygen via partial rebreather mask
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis
Absent bowel sounds with distention (paralytic ileus=immobile bowel)
A nurse is caring for a group of clients in a long-term care facility. One of the client is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? Offer the client a nutritious snack Accompany the client back to his room Reorient the client to his surroundings Administer a PRN anti anxiety med
Accompany the client back to his room
A nurse is assisting a client who has dysphagia at meal times. Which of the following actions should the nurse take? Assist the client into a semi-sitting position Have the client lean slightly backward Advise the client to tuck his chin downward Instruct the client to tilt his head slightly backward
Advise the client to tuck his chin downward
A nurse is caring for a client who has a terminal illness. The client is restless and reports sever pain but refused the prescribed opioid pain medication. Which of the following actions should the nurse take first? Ask why the client is refusing the pain medication Administer a PRN anti-anxiety medication Help the client change positions Offer the client a heat or cold pack to place on the painful area
Ask why the client is refusing the pain medication (assess the reason for refusal of meds)
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? Withdraw the specimen from the drainage bag Cleanse the collection port with soap and water Place the specimen in a clean specimen cup Clamp the tubing below the collection port
Clamp the tubing below the collection port (to allow FRESH, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile cup)
A nurse is planning care for a client who has a prescription for collection of 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 Force fluids during the day and collect the specimen in the evening Collect the specimen after antibiotics have been started Collect 2ml of sputum before sending the specimen to the lab
Collect the specimen when the client rises in the morning
A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? Sugar Coffee Cotton wisps Snellen chart
Cotton wisps (sensory and motor function) INCORRECT: Sugar= facial nerve VII Coffee= olfactory nerve 1 Snellen chart= optic nerve II
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 Increased tone of the large intestines Increased percentage of the body's muscle mass Decreased incidence of chronic illness
Decreased estrogen and testosterone production
A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? Liver size Pedel edema Skin texture Gait
Gait
A nurse is preparing to change the bed linens of a client who has AIDs and is incontinent of stool. Which of the following personal protective equipment items should the nurse don prior to providing client care? Select all that apply? Gown Gloves Mask Hair cover Goggles
Gown Gloves
A nurse is reviewing a client's 24 hour dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli , and a glass of milk for dinner. This client's diet is deficit in which of the following food groups? Dairy Vegetables Fruits Grains
Grains
A nurse is caring for a client who requires a chest xray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Explain the xray procedure to the client Help the client into a wheelchair before the transporter arrives Ask if the client has any questions Identify the client using 2 identifiers
Identify the client using 2 identifiers
A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? Inspect both breasts simultaneously Squeeze the nipples Palpate the breast and tail of Spence Palpate the axillary lymph
Inspect both breasts simultaneously
A nurse is caring for a client who has dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficit? Obtain the apical and radial rates simultaneously Check the blood pressure in the left and right arms Compare the pulse strength in the upper extremities Palpate the pulses in the lower extremities
Obtain the apical and radial rates simultaneously (then subtract the difference)
A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? Perform a Romberg test Check nails for Beau's lines Palpate for respiratory excursion Perform a blanch test
Perform a blanch test (cap refill) INCORRECT: Romberg test= balance/gross motor function
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 Trendelenburg position Perform percussions 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 Trendelenburg position (right sided to promote drainage to the client's left side)
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? Raise the enema bag if the client experiences cramping Lubricate 2.54cm (1in) of the tip of the rectal tube prior to insertion Place the client in a left Sim's position Don sterile gloves prior to the procedure
Place the client in a left Sim's position INCORRECT: Raise the enema bag if the client experiences cramping-->administer SLOWLY Lubricate 2.54cm (1in) of the tip of the rectal tube prior to insertion--> 2 IN Don sterile gloves prior to the procedure--> CLEAN not sterile
A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take? Recap the needle on the syringe Schedule a nurse to administer future injections for this client Explain to the client that the syringe should be disposed of in the bathroom trash can Place the syringe in a puncture-proof disposal container
Place the syringe in a puncture-proof disposal container
A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? Give the client a bronchodilator immediately after the procedure Position the client for drainage of secretions by gravity Schedule postural drainage following meals Instruct the client regrading the importance of fluid restrictions
Position the client for drainage of secretions by gravity
A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? Change the infusion tubing Flush the IV catheter Remove the IV catheter Apply a cool compress to the site
Remove the IV catheter
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 xray 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 xray of the client's abdomen (to determine the placement)
A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temp; however, the nurse wanted an oral temp. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? Right task Right circumstance Right person Right communication
Right communication
A nurse is caring for a client who has perisperhal edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? Sodium Calcium Potassium Magnesium
Sodium INCORRECT: Calcium= bone and tooth formation Potassium= smooth muscle contraction Magnesium= cardiac and skeletal muscles
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in that day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? Continue the teaching, but check afterward with the surgeon about the informed consent Stop the teaching and check with the surgeon about the informed consent Stop the teaching and ask the client to sign the informed consent Continue the teaching and check the client's medical record afterward for. signed consent form
Stop the teaching and check with the surgeon about the informed consent
A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an an assistive personnel. The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? Notify the charge nurse about the incident Insist that the AP attend an in-service training about standards precautions Talk with the AP about the technique used Observe the AP a second time and intervene if the technique remains the same
Talk with the AP about the technique used
A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? The client holds the cane on the unaffected side The client walks by stepping with the unaffected leg before the affected leg The client holds the cane directly next to the foot The client holds the cane with a straight elbow
The client holds the cane on the unaffected side
A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? The risk of eating disorders increases at this age The client's basal metabolic rate could decrease Daily vitamins will become necessary to meet nutritional needs Limiting the intake of fish to once per week reduces cardiovascular risks
The client's basal metabolic rate could decrease (adipose tissue replaces skeletal muscle mass)
A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? The deceased was a close friend The client lived far from the deceased The death was sudden The client has not visited the deceased in a long time
The death was sudden
A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? Use a gait belt during ambulation Ensure the client is wearing socks before ambulating Instruct the client to sit on the edge of the bed for 15 sec before ambulating Walk 2ft behind the client during ambulation
Use a gait belt during ambulation
A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? Use battery-operated equipment for personal care Apply mineral oil to protect the facial skin from irritation Remove the television set from the client's bedroom Wear cotton clothing to avoid static electricity
Wear cotton clothing to avoid static electricity
A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? Middle adulthood Adolescence Childhood Young adulthood
Young adulthood INCORRECT: Middle adulthood= generativity vs. self absorption and stagnation Adolescence= identity vs role confusion Childhood= industry vs inferiority
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 of instructions should the nurse give the client? Place in order "Depress the canister while taking a slow, deep breath" "Hold the mouthpiece 1-2 inches in front of your mouth" "Tilt your head back and slightly open your mouth wide" "Hold your breath for 10 mins"
"Hold the mouthpiece 1-2 inches in front of your mouth" "Tilt your head back and slightly open your mouth wide" "Depress the canister while taking a slow, deep breath" "Hold your breath for 10 mins"
A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? Tie a secure knot with the restraint straps Attach the restraints' straps to the bedside rails Make sure 3 fingers fit beneath the restraints Remove the restraint every 2 hour
Remove the restraint every 2 hour
