ATI Nursing Fundamentals

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

770mL

A nurse implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? a. Apply a cold pack to the edematous area b. Check capillary refill before applying an ice pack to the affected area c. Half-fill an ice pack with crushed ice d. Apply an ice pack for 60 min intervals

B

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? a. Palpation of both carotid arteries simultaneously b. Auscultation of the arteries for bruits with the bell of the stethoscope c. Palpation of the arteries for murmurs bilaterally d. Auscultation of the arteries for thrills with the diaphragm of the stethoscope

B

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? a. The client places a crutch on each side when assuming a sitting position b. The client moves the unaffected leg onto a step first when descending stairs c. The client places weight on the axillae when walking. d. The client has slightly flexed elbows when ambulating with the crutches

D

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? a. Perform a Romberg test b. Check nails for Beau's lines c. Palpate for respiratory excursion d. Perform a blanch test

D

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? a. Skeletal muscle relaxants b. Beta-adrenergic blockers c. Broad spectrum anti-infective agents d. Plasma volume expanders

D

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? a. Move the client from supine to a low Fowler's position every 2-3 hours to help prevent orthostatic hypotension b. Limit fluid intake to 1L (33.8 oz) in 24 hr to help prevent dependent edema c. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications d. Instruct the client to perform foot and leg exercises every 1-2 hr while away to help prevent thrombophlebitis

D

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Using clean technique to perform the procedure b. applying suction while inserting the catheter c. lubricating the suction catheter with an oil-based lubricating jelly d. administer high-flow oxygen prior to the procedure

D

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should then nurse use first to help the client make a commitment to these lifestyle changes? a. Identify the risks of nonadherance b. Schedule learning sessions to demonstrate the psychomotor skills the client will need c. Provide clearly written and easy to understand materials d. Help the client identify ways that these changes will result in positive personal outcomes

D

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) a. Carefully reinsert the intestine through the opening in the wound b. Place the client in a supine position with the hips and knees flexed c. Leave the room to call the surgeon d. Cover the wound and intestine with a sterile, moistened dressing e. Monitor the client for manifestations of shock

b, d, e

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit? a. Obtain the apical and radial rates simultaneously b. Check the blood pressure in the left and right arms c. Compare the pulse strength in the upper extremities d. Palpate the pulses in the lower extremities

A

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? a. The client holds the cane on the unaffected side b. The client walks by stepping with the unaffected leg before the affected leg c. The client holds the cane directly next to the foot d. The client holds the cane with a straight elbow

A

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? a. Check to determine if the catheter tubing is kinked b. Palpate the bladder c. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride d. Encourage the client to drink more fluids

A

A nurse is teaching a client about how to remove a solid dressing. Which of the following statements by the client indicates an understanding of the teaching? a. "I'll wear non sterile gloves." b. "I'll use adhesive remover each time." c. "I'll take my pain pill after I change the dressing." d. "I'll fold the dressing with the soiled surface facing outward."

A

A nurse is teaching an AP how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? a. Elevating the finger above the heart level b. Rubbing the fingertip with an alcohol pad c. Puncturing the side of the fingertip d. Wrapping the finger in a warm cloth

A

A hospice nurse is visiting with a family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? a. The client watches television in her bed during the day b. The client drinks warm milk before bedtime. c. The client goes to bed at 2200 every night d. The client gets up to use the bathroom once during the night

A

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? a. Air conduction is less than bone conduction in the left ear b. Air conduction is greater than bone conduction in the left ear c. Sound is materializing to the right ear d. Sound is materializing to the left ear

A

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. As which of the following times should the nurse begin discharge planning? a. One week prior to the client's discharge b. Upon the client's admission to care facility c. Once the discharge date is identified d. When then client addresses the topic with the nurse

B

A nurse is caring for a middle aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? a. "I am comfortable with my decision to choose a lifelong partner." b. "I think I have done a good job with my children since they are all independent now." c. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." d. "I love my work so much that it is difficulty to think about retirement."

B

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? a. document the finding b. measure the client's apical pulse rate c. talk with the client about factors that can affect the pulse rate d. notify the provider about the client's radial pulse rate

B

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts oof the client's body? a. heart b. lungs c. thyroid gland d. skin

B

A nurse is administering an IM injection to a 5-month old infant. Which of the following injection sites should the nurse use? a. Deltoid b. Ventrogluteal c. Vastus lateralis d. Dorsogluteal

C

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? a. Assist the client into a semi-sitting position b. Have the client lean slightly backward c. Advise the client to tuck his chin downward d. Instruct the client to tilt his head slightly backward

C

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? a. Carminative b. hypertonic c. oil retention d. sodium polystyrene sulfate

C

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply.) a. canned peaches b. white rice c. black beans d. whole grain bread e. tomato juice

C, D

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? a. rectal b. tympanic c. oral d. temporal

D

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? a. Document the administration of the medication b. Count the amount of available medication on hand and sign for it c. Measure the client's respiratory rate d. Check the medication dose and the client's identification

D

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? a. complete a medication error report b. notify the prescribing provider c. assess the client d. notify the charge nurse

c

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? a. hyperglycemia b. hypotension c. heightened immune response d. bleeding tendencies

A

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? a. Daily weight b. Blood pressure c. Specific gravity d. Intake and output

A

A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for injection? a. Lower medical quadrant of the buttock near coccyx b. Side hip between the iliac crest and anterior iliac spine c. tissue of the posterior upper arm d. lower inner thigh 4 finger-widths above the patella

B

A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? a. Frequent bowel sounds with flatus b. Absent bowel sounds with distention c. Hyperactive bowel sounds with diarrhea d. Normal bowel sounds with increased peristalsis

B

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? a. Gustation b. Stereognosis c. Proprioception d. Kinesthesia

B

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. Te 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? a. Change the infusion tubing b. Flush the IV catheter c. Remove the IV catheter d. Apply a cool compress to the site

C

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? a. palpitation b. bradycardia c. tachycardia d. dysrhythmia

C

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? a. Hold the irrigator 1.25 cm (0.5 in) above the eye b. Direct the irrigation solution up toward the upper eyelid c. Exert pressure on the bony prominences when holding the eyelids open d. Direct the irrigation from the outer cantos to the inner cantos of the eye

C

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? a. Stand toward the client's stronger side b. Instruct the client to lean backward from the hips c. Place the wheelchair at a 45-degree angle to the bed d. Assume a narrow stance with the feet 15 cm (6in) apart

C

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "If I do this often, I won't experience muscle wasting." b. "If I do this often, I won't get pneumonia." c. "If I do this often, I won't get constipation." d. "If I do this often, I won't have a fast heartbeat."

B

A nurse is working with the facility's language interpreter to explain a wound care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client? a. Make eye contact with the interpreter b. Break sentences into shorter segments to allow time for interpretation c. Ensure the interpreter and the client speak the same dialect d. Speak in a loud tone of voice

C

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? a. Increased blood pressure b. Decreased blood glucose level c. Decreased oxygen use d. Increased GI motility

A

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? a. Redness at the infusion site b. Edema the infusion site c. Warmth at the infusion site d. Oozing of blood at the infusion site

B

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique? a. The nurse washes each part of her hands with 5 strokes b. The nurse washes from the elbows down to the hands c. The nurse holds her hands higher than her elbows while washing d. The nurse uses minimal friction when washing her hands

C