ATI NCLEX Fundamentals Assessment 1

A nurse in an assisted living facility observes that an older adult client who was previously socially interactive appears withdrawn and avoids the other residents. Which of the following actions should the nurse take first A. Assess the client for a loss of hearing B. Arrange transportation for the client to an outside senior activity program C. Encourage visits from family members and friends D. Plan a recreational activity for the client with a small group of residents

A

A nurse is supervising an assistive personnel (AP) who is using standard precautions. Which of the following actions by the AP indicates an understanding of how to implement these precautions A. Cleaning hands with an alcohol based antiseptic agent after helping to pull a client up in bed B. Applying clean gloves when delivering food trays to a group of clients in the dining room C. Donning a face shield when caring for a client who requires contact precautions D. Rinsing their gloved hands in the sink and patting them dry

A

A nurse is providing discharge instructions to a client who has a new gastrostomy tube. Which of the following statements by the client indicates an understanding of the instructions? A. "I can sit up in a chair during the feeding" B. "I'll replace the bag and tubing every week" C. "I'll keep the formula cold until I begin the feeding" D. "I don't have to worry about the placement of the tube, because my nurses have already checked that"

A The clients head should be elevated at 30-45 degrees during the feeding. They can be in bed with their head raised, sitting in a chair, or ambulating as long as their head is at 30-45 degrees. Never be supine, causes aspiration! -- B, the tubing and bag should be replaced every 24 hours to prevent bacterial growth. Other things to do: clean top of formula can before opening, avoid touching the opening of the feeding container and other parts of tubing that come in contact with the formula C, enteral formula should be kept at room temperature! Cold causes gastric gramps, nausea,and vomiting. D, the caregiver should check the pH level of secretions before feedings

A nurse in the PACU is caring for a client following abdominal surgery. Which of the following actions should the nurse take first A. Monitor the client's oxygen saturation level B. Assess the client's pain level C. Reinforce the client's surgical dressing D. Check the client's urinary output

A The greatest risk to the client is injury from an obstructed airway

A nurse is assessing a client who is cognitively impaired and received morphine via IV bolus 1 hr ago for postoperative pain. Which of the following findings requires further action by the nurse A. Restless and clenched teeth B. Oxygen saturation of 96% on 2L/min oxygen C. Reports discomfort when repositioning in bed D. Uses diaphragmatic muscles to breathe

A This is indicative that the patient is experiencing pain and requires action -- B, expected finding C, mid to moderate discomfort is common when pt moves or ambulates after surgery D, this is an expected finding and indicates the pt has a normal breathing pattern

A nurse is providing teaching about measures to promote wellness to a group of older adults. Which of the following instructions should the nurse include? (select all that apply) A. Participate in blood pressure screenings B. Undergo a depression screening C. Obtain the herpes zoster immunization D. Get the tetanus booster every 5 years E. Develop a plan for walking three times per week

A, B, C A, an increase in systolic and diastolic BP is a common physiological change associated with aging B, depression is the most common cognitive impairment among older adults C, herpes zoster= shingles vaccine -- D, tetanus booster is given every 10 years E, older adults should engage in 30 min of moderate physical activity every day and more strenuous activity for 20 min three times per week

A nurse is preparing to administer medications to a client. Which of the following actions should the nurse take to confirm the client's identity? (Select all that apply) A. Ask the client to state their full name B. Compare the client to the photograph on their medical record C. Match the client's room number with the room number on the medication administration record (MAR) D. Scan the barcode on the client's identification band E. Compare the client's hospital identification number on the MAR with the number on their identification band

A, B, D, E -- C, do not use the client's room number to confirm the client's identity because the client might change rooms or leave to visit other rooms.

A nurse is preparing to teach a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take to promote health literacy (Select all that apply) A. Ensure that instructional material are sensitive to the client's cultural background B. Use simple pictures to reinforce the teaching C. Choose materials that are at an eight grade reading level D. Select materials that are in the clients spoken language E. Distribute materials to the client prior to the procedure

A, B, D, E -- C, material should be written at the 5th-6th grade reading level or below

A home health nurse is teaching the caregiver of a client who had a recent stroke about proper body mechanics when repositioning the client in bed. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A. Elevate the bed to the height of your waist B. Elevate the head of the bed before you move the client up in bed C. Stand with your feet wide apart D. Face toward the direction of movement E. Keep your knees bent

A, C, D ,E -- The patient should be flat to reduce the risk for injury for the caregiver

A nurse is caring for a client who has a prescription for PRN sedative medication at bedtime. The client tells the nurse "I am not ready to go to sleep. Please leave the medication at my bedside." Which of the following actions should the nurse take A. Notify the provider that the client refused to take the medication B. Return with the medication when the client is ready to take it C. Inform the client that the administration of a PRN sedative medication should not be delayed D. Leave the medication with the client and return after 30 min to check that the medication was taken

B

A nurse is preparing to teach a client who speaks a different language than the nurse about how to perform a dressing change. Which of the following actions should the nurse plan to take A. Speak loudly during the teaching session B. Request the services of an interpreter C. Ask a family member to translate for the client D. Simply communicate by asking "yes" or "no" questions

B

A nurse is teaching an older adult about sleep hygiene habits. Which of the following statements by the client indicates an understanding of the teaching A. "I will exercise for 30 minutes before bedtime" B. "I will avoid drinking caffeine in the evening" C. "I will drink plenty of fluids immediately before bed D. "I will limit my nap to 1 hour per day"

B

A nurse is assessing a client who has dark-toned skin. Which of the following findings should the nurse report to the provider? A. Light yellow colored sclera B. Blue undertones in palms and soles of feet C. Plum tinted lips D. Fingernails are transparent and convex

B Blue undertones is a possible indication of cyanosis. This change in skin tint can also be detected in the conjunctiva and might be visible on the nail beds and buccal mucosa -- A, this is an expected finding for a client who has dark-toned skin. Overt yellow or green pigmentation can be an indication of liver disease C, Plum colored lips are an expected finding for dark toned skin. Pallor of the lips can indicate anemia, and blush undertones can indicate possible cyanosis D, Transparent and convex shaped nails is an expected finding. Spoon shaped, brittle, or rigid nails can indicate malnutrition

A nurse is planning care for an older adult client who is receiving long-term antibiotic therapy for respiratory infection and has watery diarrhea. Which of the following interventions is the nurse's priority? A. Administer antidiarrheal medication B. Initiate fluid replacement therapy C. Obtain a stool specimen for cuture D. Apply a disposable waterproof pad to the client's bed

B The greatest risk to this pt is injury from dehydration, which is common in older adults, so the priority intervention is to increase the pt fluid intake with oral rehydration solutions

A nurse is preparing to remove a client's intermittent abdominal sutures. Which of the following actions should the nurse plan to take? A. Pull the visible part of the sutures through the client's skin when removing them B. Cut the sutures close to the skin edge on either side C. Use clean bandage scissors for the procedure D. Lift the sutures from the skin with a sterile needle

B The nurse should grasp and gently life the surgical knot with forceps and cut the sutures close to the skin. The nurse should cleanse the incision and the external portion of the suture prior to suture removal. This helps soften and moisten the sutures for easy removal -- A, do not pull the visible portion of suture through the skin because this drags external bacteria and debris through the underlying skin layers C, the nurse should use special scissors with curved cutting tips that slide between the suture and skin. Using bandage scissors jeopardizes skin integrity and places the client at risk for infection D, the needle could puncture the skin. A sterile suture kit contains forceps to lift sutures from the skin

A charge nurse is observing another nurse perform a sterile dressing change on a client. Which of the following actions should the charge nurse identify as a contaminant to the sterile field A. Placing a surgical mask on a client who is coughing B. Placing sterile supplies within a 1cm (0.4in) border of the sterile field C. Using sterile forceps to move the items on the sterile field D. Positioning the sterile tray on the beside table 1cm (0.4in) above waist level

B The nurse should place objects toward the center of the sterile field and away from the 2.5cm (1 in) border around the drap

A nurse is providing discharge teaching to a client who has asthma and will be using a dry-powder inhaler at home. Which of the following client statements indicates an understanding of the teaching? A. "I will shake the inhaler before using it" B. "I will exhale away from the inhaler before inhalation" C. "After inhaling a dose of medication, I should hold my breath for 3 seconds before exhaling" D. "I should bend my head slightly forward as I release the medication into my lungs"

B This prevents the loss of any powder -- A, do not shake the inhaler before using C, hold their breath for 5-10 sec before exhaling to make sure the medication reaches the airway D, tilt their head slightly back and inhale slowly while releasing the medication. This opens the airway and allows more medication to enter

A nurse in an acute care facility is caring for a client who has confusion and continually pulls at her medical tubes and devices. Which of the following actions should the nurse take first A. Obtain a written prescription to apply wrist restraints to the client B. Apply a stockinette dressing to conceal the client's IV C. Administer the lowest possible dose of an IV sedative to the client D. Telephone family members to advise them that the client might require restraints

B Use least restrictive intervention first!

A nurse enters a client's room and sees the client on the floor next to the bed. Which of the following actions should the nurse take first? A. Assist the client back into bed B. Notify the risk manager C. Obtain the client's vital signs D. Complete an incident report about the client's fall

C

A nurse is preparing to administer medication to a client who has COPD. The client states "I don't want to take my medication today because it makes me feel weak." Which of the following responses should the nurse take? A. "You need to take this medication to feel better" B. "This is what your doctor prescribed for you, so it must be correct" C. "You have the right to refuse your medication" D. "I will come back later to give you your medication"

C

A nurse is providing discharge teaching to the caregiver of a client who has a tracheostomy tube. Which of the following instructions about tracheostomy care should the nurse provide the caregiver A. "Remove the outer cannula once monthly when caring for the tracheostomy" B. "Expect secretions in the tracheostomy to be thick and tenacious" C. "Plan to perform tracheostomy care daily" D. "Use sterile technique when performing tracheostomy care"

C -- A, the outer cannula should be in place at all times B, secretions should be thin enough to maintain a patent airway and easily removable with suctioning D, clean technique is sufficient

A nurse is teaching a group of parents about the play habits of toddlers. Which of the following activities should the nurse recommend for toddlers? A. Catching a ball B. Skipping C. Jumping D. Sharing toys with a friend

C -- A, this is appropriate for a school aged child B, this is appropriate for a preschooler D, toddlers engage in parallel play

A client is reviewing data for a group of clients at the beginning of the shift. For which of the following clients should the nurse initiate a dietary referral? A. A client whose BMI is 23 B. A client who gained 1.8kg (4lbs) overnight after receiving IV fluids C. A client whose pre-albumin level is 11 mg/dL D. A client who has a sodium level of 140 mEq/L after taking a thiazide diuretic

C Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of acute nutritional changes! -- A, expected range of BMI is 18.5-24.9 B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for fluid overload. However, this does not indicate a need for dietary referral. D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low sodium levels.

A nurse is administering a tuberculin test by the intradermal route to a client. Which of the following steps should the nurse take? A. Pinch the client's skin to elevate the tissue slightly before piercing the skin with the needle B. Hold the bevel of the needle pointing downward when piercing the skin C. Insert the needle at a 10 degree angle to the skin D. Massage the site for a few seconds after removing the needle to distribute the medication evenly

C Insert the needle at a 5-15 degree angle to deposit the medication in the dermis

A charge nurse in the CCU is reviewing prescriptions for a group of clients. The nurse should identify that which of the following procedures are outside the nurse's scope of practice A. Drawing blood from an arterial line B. Determining a Glasgow Coma Scale score C. Administering an antibiotic intrathecally D. Providing initial education for a client who has type 1 diabetes

C Intrathecal injections involve injecting medication directly into the intrathecal space of the spinal cord. A nurse's scope of practice allows injections that are intradermal, subcutaneous, intramuscular, and intravenous

A nurse is proving discharge teaching to a client who will be using crutches for the first time. Which of the following actions by the client should the nurse identify as a safety risk when walking with a three point gait? A. The client transfers their weight from the crutches to the unaffected leg B. The client assumes a tripod position when standing still C. The client holds both crutches in one hand when ascending stairs D. The client keeps their elbows in a flexed position

C This is a safety risk when walking up the stairs. The client must bear all weight either on both crutches or on the unaffected leg when performing a three point gait. This is non weight bearing. When ascending stairs, the patient should hold a crutch in each hand and place the unaffected foot on the next step while wearing all of their weight on the crutches. Then, they should move the crutches and the affected leg up to the next step at the same time.

A nurse is caring for a client who is 6hr postoperative and has voided 50mL of urine. Which of the following actions should the nurse take first? A. Review the client's intake and output during and after the surgical procedure B. Insert a straight urinary catheter and measure the client's urine output C. Palpate the client's lower abdomen for bladder distention D. Request a prescription for bethanechol from the provider

C This should be the first action to obtain information about the presence of residual urine -- A, reviewing the intake and output record obtains information about fluid balance and hydration status. However, this is not the first choice to assess the presence of residual urine B, the nurse will obtain a prescription for inserting a straight catheter both to confirm urinary retention and remove residual urine. However, this is not the first step d, bethanenchol is used to treat postoperative urinary retention. However, this is not the first step

A nurse is caring for a client who has died. Identify the sequence of steps the nurse should follow for postpartum care. A. Attach identification tags to the body B. Remove medical equipment from the body C. Cleanse the body while adhering to body-fluid precautions D. Verify the client's organ and tissue donation status E. Confirm that the provider certified and documented the death

Correct order: E. Confirm that the provider certified and documented the death D. Verify the client's organ and tissue donation status B. Remove medical equipment from the body C. Cleanse the body while adhering to body-fluid precautions A. Attach identification tags to the body

A nurse is performing blood glucose monitoring for a client. After identifying the client and performing hand hygiene, in what order should the nurse take the following steps? A. Apply clean gloves B. Hold the client's hand in a dependent position C. Clean the clients finger with an antiseptic D. Apply the blood to the test strip E. Have the client wash their hands F. Puncture the lateral side of the clients finger to obtain blood

Correct order: E. Have the client wash their hands A. Apply clean gloves B. Hold the client's hand in a dependent position C. Clean the clients finger with an antiseptic F. Puncture the lateral side of the clients finger to obtain blood D. Apply the blood to the test strip -- Wash hands first to reduce the presence of micro-organisms. Then apply gloves to prevent blood contamination. Then hold the clients hand in a dependent position to increase blood flow to the fingertips. Do not squeeze the finger! Then clean the site, allow it to try. Chose a lateral side to avoid many nerve endings. Puncture the site, wipe away the first drop of blood (has fewer RBC and may have serous fluid), then apply the second drop of blood to the strip.

A nurse is caring for a client in a rehabilitation facility. The client says, "I am upset about not being able to attend my church while living here." Which of the following responses should the nurse make A. "Have you attended services at this facility?" B. "You will be going home soon and can get back to church" C. "Perhaps your friend will pick you up for a church service" D. "I would like to hear more about your church"

D

A nurse is providing teaching about foot care to a client who has diabetes and peripheral neuropathy. Which of the following statements by the client indicates an understanding of the teaching A. "I will make sure the temperature of the water I use to wash my feet is 115 degrees" B. "I will rub my feet with the towel to dry them thoroughly" C. "I will soak my feet in soapy water for 30 minutes at least once per week" D. "I will apply lotion to the tops and soles of my feet, but will avoid getting it between my toes"

D -- A, temp should be between 105 and 110 degrees B, pat their feet dry with a towel C, feet should be washed daily but avoid soaking them, because this can dry the skin and cause cracking and potential infection

A nurse is teaching a client about ways to prevent infection. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands with soap and water for 10 seconds" B. "I should replace my toothbrush every 6 months" C. "I can eat leftovers for up to 4 days as long as they have been refrigerated" D. "I should wash visibly soiled linens separately from other laundry"

D -- A, wash hands with soap and water for at least 15 seconds B, change toothbrush every 3 months or following respiratory infection C, avoid eating leftovers after they have been stored in the refrigerator for more than 2 days

A nurse is planning discharge for a client who has an abdominal wound that is healing by secondary intention. Which of the following actions should the nurse take? A. Instruct the client on how to keep sutures clean and dry B. Demonstrate to the client how to cleanse the wound with hydrogen peroxide C. Arrange an appointment for the application of adhesive skin closures D. Schedule home health services for dressing changes

D A wound healing by secondary intention remains open and edges do not mesh, which increases the risk of infection. The wound bed should be moist to facilitate epithelialization. A home health nurse needs to assess the wound site and notify provider if an infection or other complication occurs -- A, wounds with surgical incisions and sutures are "primary intention" B, hydrogen peroxide can damage healing tissue. A secondary intention wound requires cleansing with a noncytotoxic cleanser, like 0.9% NaCl irrigation C, wounds by "tertiary intention" remain open for several days to allow edema to resolve or infection to heal. The provider then closes it with staples, sutures, or adhesive skin closures. This would is " secondary intention", so it remains open

A nurse is assessing a client who has a calcium level of 11.2 mg/dL. Which of the following findings should the nurse expect A. Positive Chvostek's sign B. Positive Trousseau's sign C. Diarrhea D. Hyporeflexia

D Expected calcium range: 9.0-10.5. This pt has hypercalcemia. Manifestations include hyporeflexia, lethargy, fatigue, anorexia, confusion, nausea, vomiting, and constipation. -- A,positive chvostek sign is a sign of hypocalcemia. Seen as a facial muscle contracture when the nurse taps the client's cheek in front of the ear B, positive trousseau sign is a sign of hypocalcemia and hypomagnesia. Seen as a spasm of the hand that occurs when the nurse decreases the patients blood supply by inflating the blood pressure cuff C, diarrhea is a sign of hypocalcemia and constipation is a sign of hypercalcemia

A nurse is assessing a client who reports difficulty falling asleep at night and wants to use essential oil therapy to promote relaxation. Which of the following conditions in the client's medical history should the nurse identify asa reason to consult the provider? A. Gastroesophageal reflux (GERD) B. Egg allergy C. Blood clots D. Asthma

D The use of essential oils can cause bronchospasms -- A, the patient does not ingest most essential oils, they will not worsen the reflux of stomach contents B, Oils can irritate sensitive skin and often are diluted by a carrier oil, such as soybean or coconut oil. Use caution with soy or tree nut allergies, but an egg allergy is not contraindicated. C, oils do not affect coagulation. However, clients on anticoagulants should avoid some herbal preparations such as ginger, garlic, and feverfew

A nurse is preparing to remove a client's NG tube. Which of the following instructions should the nurse give to the client before removing the tube A. "Inhale and exhale several times as I remove the tube" B. "As I remove the tube, bear down and push until I tell you to stop" C. "Breathe as usual while I remove the tube" D. "Take in a deep breath and then hold it as I remove the tube"

D This prevents aspirating gastric contents as the glottis is temporarily closed