ATI Nursing Fundamentals Set A

A nurse is calculating the intake and output for a client over the last 8hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many ml Of Luis should the nurse document as the clients intake for the last 8 hours?

1820 mL 1. Calculate the intake separate for continuous IV infusion, juice, and the water, converting to mL as needed: IV: 150 mL x 8 hr = 1200 mL Juice: 1oz = 30mL 4oz x 30mL = 120 mL Water: 1L = 1,000 mL 0.5L x 1000 mL= 500 mL of water Add them all together 1200+ 120+ 500 = 1,820 mL

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife wit them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? A) "Tell me what the afterlife means to you" B) "You should discuss the afterlife with your priest" C) "keep praying. A miracle could happen" D) "Maybe your condition will lead you closer to god"

A) " Tell me what the afterlife means tot you."; uses open ended therapeutic communication to assist the client to talk about their concerns

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicated an understanding of the teaching? A) " i will be sure to keep the crutch tips dry" B) "I will hold a crutch n each hand when sitting down" C) "I will place my weight on my underarms." D) "I will lead with my right leg when going up the stairs."

A) "I will be sure to keep the crutch tips dry" ; the nurse should instruct the client to inspect the crutch tips frequently and keep them dry at all time to decrease the risk for slipping.

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? A) "The living will directs my medical care when I am unable to make decisions." B) "I should have a nurse cosign my lIving will." C) "After signing the living will, I will not be able to make any changes." D) "I am required by Medicare to have a living will when I am admitted to the hospital."

A) "The living will directs my medical care when I am unable to make decisions."

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? A) "the reduces muscle tone has relaxed the jaw muscles" B) "that hapens when a person gets close to death" C) " i can apply a chin strap to help hold the mouth closed' D) "you shouldn't worry about that at this time"

A) "the reduced muscle tone has relaxed the jaw muscle" ; prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? A) Check the pH of the gastric aspirate. B) Observe the color of the gastric aspirate after adding blue dye to the formula. C) Auscultate over the epigastrium D) Measure the length of the inserted NG tube.

A) Check the pH of the gastric aspirate.

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention. A) a stage 3 pressure injury on the coccyx B) a contaminated wound that is closed after 72 hours C) a puncture wound that's sutured D) an abdominal surgical wound intact with staples

A) a stage 3 pressure injury on the coccyx; a nurse should identify a pressure injury and other wounds with edge that are not approximated as healing by secondary intention

A nurse is assisting with the plan of care who has a bacterial infection and a persistent oral temperature of 38.9C (102F). Which if the following interventions should the nurse include in the plan of care to treat the fever? A) administer acetaminophen B) apply ice packs to the client Axillary C) maintain the room temp at 18.3C (64.9F) D) assist the client to ambulate 4 time a day

A) administer acetaminophen ; reduces body temp. Acetaminophen inhibits the synthesis of prostaglandins resulting in a reduced fever.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? A) administer an analgesic 30 minutes before starting the procedure B) hold the syringe 5cm (2in) above the upper end of the wound C) place the irrigation solution in a basin of cool water D) perform the wound irrigation with a 10-mL syringe with an angiocatheter.

A) administer an analgesic 30 minutes before starting the procedure; the nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation.

What can the nurse delegate to Assistant Personnel? A) apply thromboembolic stockings. B) monitor the circulation in all four extremities C) record the condition of the client's skin D) reinforce teaching about performing ROM exercises

A) apply thromboembolic stockings

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? A) clamp the infusion tubing B) remove the dressing C) withdraw the catheter from the vein D) ensure the catheter is intact

A) clamp the infusion tubing; this action stops the flow of the IV fluid and prevents it from leaking out during the IV removal.

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply) A) ensure that the client os wearing nonskid slippers B) move he bedside table away from the bedside C) place the client in a room near the nurses' station D) keep the bed's full side rails in the up position E) reinforce teaching about how to use the call bell

A) ensure that the client is wearing nonskid slippers C) place the client in a room near the nurses' station E) reinforce teaching about how to use the call bell.

A nurse is reinforcing teaching a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? A) precontemplation B) preparation C) maintenance D) action

A) precontemplation; in this stage the client avoids discussing the behavior and doesn't intent to make a change in behavior. The ages of health behavior change are precontemplation, contemplation, preparation, action, and maintenance stage.

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? A) provide privacy for the client B) keep the lights at a dim level C) expose half of the body at a time D) encourage the client's friend to remain in the room

A) provide privacy for the client. ;promotes a therapeutic environment by providing privacy while data is being collected for a health assessment

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? A) young adults should receive a dental assessment every 6 months B) young adult males should have a a testicular examination every 5 years. C) young adult females should have a routine physical exam every 4 years D) young adults should receive a TB skin test every 3 years

A) young adult should receive a dental assessment every 6 months

A nurse is reinforcing preposition teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicate an understanding of the teaching? A) "this can help prevent nausea" B) "this can help prevent pneumonia" C) "i should do this q4h" D) "i should do this to keep my heart from beating too fast"

B) "this can help prevent pneumonia" ; it reduces the risk of respiratory complication such ad atelectasis which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions.

A nurse is caring for a client who is postop and is experiencing Nashua and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? select all that apply. A) full bounding pulse B) cool extremities C) moist crackles in the lungs D) orthostatic hypotension E) flat neck veins

B) Cool extremities D) orthostatic hypotension E) Flat neck veins A and C indicate fluid volume excess, nurse should expect a weak peripheral pulse in a client with fluid volume deficit, the nurse should expect clear lungs in a client w volume deficit.

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? A) Stand facing the center of the bed at the client's side. B) Place feet apart with the foot nearest the head of the client's bed in front of the other foot. C) Keep knees and hips straight while bending at the waist toward the client. D) Encourage the client to keep their legs straight and remain still.

B) Place feet apart with the foot nearest the head of the client's bed in front of the other foot.

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? A) Heart rate 62/min B) Urine output of 200 mL over 8 hr C) Pulse oximetry 95% on room air D) BP 112/76 mm Hg

B) Urine output of 200 mL over 8 hr; A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider.

A nurse is assisting with the admission of a client who has active TB. Which of the following actions should the nurse plan to take? A) restrict the client's visitors to the immediate family B) assign the client to a negative-pressure airflow room C) discard personal protective equipment outside the client's room D) have the client wear a HEPA mask during transportation throughout the facility

B) assign the client to a negative-pressure airflow room

A nurse is using Maslow's hierarchy of needs in assisting with discharge panning for a client. Which of the following activities should the nurse recommend as the priority for this client? A) volunteer at the local food pantry B) attend an exercise program C) find an enjoyable hobby D) support environmental conservation

B) attended an exercise program ; fulfills physiological needs for activity

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? A) autonomy B) beneficence C) justice D) nonmaleficence

B) beneficence; The nurse is demonstrating beneficence by acting in the client's best interest to make it possible for the client to swallow the medication.

A nurse is assisting with a presentation to a group of older adult at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? A) body regulation of heat and cold increases with age B) circulation becomes less effective with age C) increased metabolic rate occurs with age, increasing body temperature D) sweat gland activity is increased with age

B) circulation becomes less effective with age

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the care plan? A) check for capillary refill proximally o the elastic bandage every 12 hours B) compare the clients pedal pulses bilaterally q4h C) place the client's legs in a dependent position for 30 minutes before applying the elastic bandages D) remove the elastic bandages every other day to inspect the skin

B) compare the client's pedal pulses bilaterally q4h. ; to check for adequate circulation for a client who has elastic bandages on their lower extremities.

A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the the top of the client's foot? A) posterior tibial B) dorsalis pedis C) popliteal D) brachial

B) dorsalis pedis

A nurse is caring for a client who has an in dwelling urinary catheter. Which of the following actions should the nurse take to prevent UTIs? A) empty the urine drainage bag every 12 hours B) drain urine from the tubing before amputation C) use clean technique for urine specimen collection D) hand the urine drainage bag at the level of the bladder

B) drain urine from the tubing before amputation; it will prevent back flow of urine into the bladder

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommended to be included in the plan of care? A) place the client in a room with another client who has pharyngitis B) ensure that the client wears a surgical mask during transportation throughout the facility C) limit the client's visitations to 30 minutes D) provide the client a room with negative-pressure airflow of six air exchanged per hour.

B) ensure that the client wears a surgical mask during transportation throughout the facility ; S. Pharyngitis requires droplet precautions. Staff should make every attempt to limit the clients movements outside of the room.

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is. A priority modification that the nurse should include? A) alarm clock that shakes the bed B) flashing smoke alarm C) low-pitched buzzer doorbell D) telephone with an amplified receiver

B) flashing smoke alarm

A client who has advanced cancer tells the nurse they have a difficult time talking to anyone about the illness. Hitch of the following actions should the nurse take to encourage therapeutic communication? A) keep the conversation moving by asking about the client's family B) let the client know that, as their nurse , they are available and willing to listen C) ask if the client understand what to expect in the advanced stages of the illness D) ask the client's visitors not to say anything about the advanced disease

B) let the client know that, as their nurse , they are available and willing to listen

A nurse is caring for a client who has Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? A) isopropyl alcohol B) mild soap C) chlorhexidine D) triclosan

B) mild soap

A nurse is contributing to a panic of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? A) check that the restraint is tied to a fixed frame of the bed B) pad bony prominences on the wrist C) remove the restraint every 4hr to allow movement D) tie the restraint with a knot that will tighten when pulled

B) pad bony prominences on the wrist; to prevent skin breakdown caused by the restraint rubbing against the client's skin

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? Why? A) Discontinued medications B) resolved health conditions C) frequency of vital signs D) completed nursing interventions

B) resolved health conditions ;the nurse should report both unresolved and resolved health conditions to promote continuity of care.

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicated an understanding of the teaching? A) the client leans on the crutches for supports while standing still. B) the client advances the unaffected leg first while climbing the stairs C) the client stands 5 cm (2in) form the front of a chair before sitting D) the client bears weight on their axilla while standing in the tripod position

B) the client advances the unaffected leg first while climbing the stairs

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? A) " why are you angry about taking insulin" B) "don't worry . Diabetes runs in my family as well." C) " I see that you are angry. Let's sit down and talk" D) "You should take insulin, because it reduces the risk for complications."

C) "I see that you are angry. Let's sit down and talk"

A nurse is reinforcing teaching about hospice care measure with the family of a client who is dying. Why of the following statement by a member of the client's family indicates an understanding of the teaching? A) "we will make sure she eats three meals a day" B) "we will decrease her pain medication if she gets too drowsy" C) "we will keep her room cool to help her breathe better" D) "we will make sure to provide oral care twice a day"

C) "we will keep her room cool to help her breathe better"

A nurse is caring for four clients who are required to provide information consent for TX. The nurse should identify that which of the following client is able to provide informed consent? A) a client who is receiving opioid medications via a PCA pump B) a client who has moderate Alzheimer's disease C) an 18 year-old client who has acute appendicitis D) a 16 year-old client who has a fractured tibia

C) an 18 year-old client who has acute appendicitis

A nurse is assisting with the care of a recently deceased client. Which of the following action should the nurse complete prior to the family viewing the body? A)remove dentures B) apply a shroud around the body with a visible ID tag C) clean soiled areas of the body D) place the client's head in a dependent position

C) clean soiled areas of the body

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take? A) allow the client to continue taking the mediation as they did at home. B) take the medications from the client and discard them C) compare the medications the rover has prescribed with the client's medications from home D) place the medications in the education chart and administer them as the client took them at home.

C) compare the medications the rover has prescribed with the client's medications from home

A nurse is caring for a client who is refusing medical tx. Which of the following actions should the nurse take? A) explain the negative consequences of the refusal B) discuss with the client's partner why the tx is necessary C) document the clients refusal of the tx D) try to convince the client that the tx is needed

C) document the client's refusal of the treatment; nurse is responsible for notifying the provider when client refuses a tx or procedure

A charge nurse is reinforcing teaching with and assistive personnel about performing pulse oximetry. Which of the following information should the nurse include in the teaching. A) select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B) use an adhesive oximetry probe for a client who has a latex allergy C) remove polish from the client's fingernail before applying the oximetry probe D) lubricate the tip of the oximetry probe

C) remove polish from the client's fingernail before applying the oximetry probe. ;the sensor needs t detect a pulsating vascular nail bed to produce a reading

A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? A) obscure the client's name with a marker prior to disposal B) place the paper in a trash Cana t the nurses' station C) shred the paper in a secure container D) secure the paper in the nurse's personal locker

C) shred the paper in a secure container

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? A) place the client;s medication record on the bedside table while ambulating the client B) give report about the client's status while tending at the nurses' station C) speak with the client about their condition after visitors have left D) place a message board in the client's room to post dietary information.

C) speak with the client about their condition after visitors have left.

A nurse is collecting data from an older adult client. Which of the following finding should the nurse report to the provider? A) the client has smooth, brown, irregular lesion on the back of each hand B) the client has glossy, white circles around the periphery of the corneas C) the client report urinary incontinence D) the client reports a decreased sense of taste

C) the client report urinary incontinence

A nurse is caring who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? A) the client' body should be placed on the floor B) the client's oldest child will bathe the body C) the client's face should be turned toward Mecca D) the client's body will be adorned with amulets

C) the client's face should be turned toward Mecca

A nurse i caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statement by the client requires immediate action but the nurse? A) "I don't understand why everyone is so worried about me" B) " I don't know if I'll ever find someone who wants to marry me" C) " when I look a myself in the mirror, I don't know if i can go on" d) " I feel like the doctor pressure me into have the mastectomy"

C) when i look at myself in the mirror, I don't know if i can go on"; this statement shows sadness and a decreased initiative. The greatest risk to this client is injury from suicidal ideation. Therefore the priority action is for the nurse to immediately contact the client's provider regarding this statement.

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? A) "keep the knees in a locked position when standing for prolonged periods" B) "bend at the waist when lifting a heavy object" C) "keep your feet close together when lifting a heavy object" D) "when lifting a heavy object, keep it close to your body"

D) "when lifting a heavy object, keep it close to your body." ; the nurse should instruct the client to keep the object as close to their body as possible to increase stability and decrease back strain when lifting a heavy object.

A nurse is reinforcing dietary teaching with a client who has a harmonic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the client? A) 1 cup of cantaloupe B) 1 large bakes potato C) 4oz of banana chips D) 1 cup of applesauce

D) 1 cup of applesauce

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? A) provide an artificial voice box B) avoid using facial gestures C) speak to the client in a louder voice D) ask the client close-ended questions

D) Ask the client close-ended questions

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? A) urine specific gravity 1.015 B) hematocrit 42% C) urine pH 6.5 D) BUN 8mg/dL

D) BUN 8 mg/dL; below the expected reference range of 10-20 mg/dL. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution.

A nurse is reinforcing preoperative teaching with a client who speaks a different language that the nurse. Which of the following action should the nurse take? A) ask a family member who speaks the client's primary language to interpret. B) plan a long teaching session initially to introduce the necessary material C) Provide the least important information first. D) Provide handouts written in the client's primary language.

D) Provide handouts written in the client's primary language

A nurse is reviewing the vital signs of four adult client. Which of the following findings requires further data collection by the nurse? A) a client who has respiratory rate of 12/min B) client with a BP of 110/74 mmHg C) client who has a temperature of 39.3C (99.2F) D) a client who has a pulse rate of 110/min

D) a client who has a pulse rate of 110/min; above range of 60-100/min, the nurse should collect further data to determine the cause of tachycardia

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to the assistive personnel? A) ensure a client can use crutches before discharge B) check a client's ability to swallow following a stroke C) obtain a client's pain rating prior to physical therapy D) assist a client to get out of bed after a breathing treatment

D) assist a client to get out of bed after a breathing treatment; the nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's scope

A nurse is explaining ethic and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision bout a treatment is an example of which of the following ethical principles? A) confidentiality B) nonmaleficence C) accountability D) autonomy

D) autonomy

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? A) show the AP where to apply the medication B) ask the client when the previous nurse last applied the education C) identify the client by comparing the MAR with the client's room number D) compare the label of the medication obtained with the MAR three times

D) compare the label of the medication obtained with the MAR three times

A nurse has delegated various client tasks to the assistive personnel on the care team which of the following actions by the AP should the nurse identify as correct? A) using hand sanitizer to cleanse their hands of spilled food from a clients meal tray B) setting aside their grown for future use in the room of a client who has a wound infection C) removing their gloves after exiting a client's room D) donning a mask to measure the vital signs of a client who has pertussis.

D) donning a mask to measure the vital signs of a client who has pertussis; caring for cliens who have pertussis requires droplet precautions. Therefore the AP should wear a mask when within 1m (3.3 feet) of the client.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? Why? A) support the clients head on a pillow that maintains cervical flex ions B) position the clients shoulders off the pillow for internal rotation. C) place the client's arms at their sides to keep their elbows extended D) internally rotate the client's hips by using a trochanter roll

D) internally rotate the client's hips by using a trochanter roll; the nurse should place trochanter rolls at the proximal end of each of the clients legs to maintain a neural or internal rotation of the client's hips and to prevent external rotation of the hips, which can cause injury when the client is supine.

A nurse is preparing to administer o2 to a client who has heart failure and is having sever difficulty breathing. Which of the following o2 delivery equipment should the nurse elect to provide the highest concentration of o2 to the client? A) nasal cannula B) simple face mask C) Venturi mask D) nonrebreather mask

D) nonrebreather mask ; provides the highest % of o2 concentration without intubation and mechanical ventilation

A nurse is collecting data from a. Client who has an NG tube set to low suction. Which of the following findings indicates hypomagnesia? A) bone pain B) drowsiness C) bowel hypomotility D) positive Chyvostek's sign

D) positive Chyvostek's sign; to elicit this sound the nurse should tap the clients facial nerve near the ear, if the client's facial muscles contract, the sign is positive, indicating low serum Mg or Ca levels

Decrease the rate of feeding on a client with continuous NG tube feedings if?

You hear hypermotility (greater than 40 bowel sounds/min), you should hear bowel sounds every 5-35