ATI Standard Quiz- Fundamentals Final
A nurse in a provider's office is reviewing the lab findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? A. WBC 15,000 mm3 B. Erythrocyte Sedimentation rate 15 mm/hr C. Urine pH 7.2 d. Urine specific gravity 1.0063
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 clients fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. intake and output
A
A nurse is caring for a client who has a fecal impaction. Before 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 is caring for a client who has c-diff and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the clients gown B. Use alcohol based sanitizer cleanse the hands C. Wear a mask when assisting the client with his meal tray D. Place the client on complete bed rest
A
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse first? A. Inspection B. Auscultation C. Percussion D. Palpation
A
A nurse is teaching a client who has lower extremity weakness how to use a four point crutch gait. Which of the following instructions should the nurse include in the teaching? A. Support the majority of your weight on the axillae B. Keep elbows extended C. Bear weight on both of your legs D. Move both crutches forward at the same time
C
An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. don't worry, teenagers often have friends who give them bad advice B. I think you should stop seeing those friends since they discourage you from following your treatment plan C. Tell me more about how your friends discourage you D. Tell me where you met these friends
C
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish brown urine in the clients urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis
A
A nurse is planning to perform passive range of motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion five times during each session B. Move the joint to the point of considerable resistance C. Sit approximately 2 feet from the side of the bed closest to the joint being exercised D. Exercise the smaller joints first
A
A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation
A
A nurse on a mental health unit is preparing to terminate the nurse client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. Loss B. Trust C. Self disclosure D. Risk taking
A
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the clients wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the clients surgeon D. Reassure the client
A Rationale: The nurse should apply the safety and risk reduction priority setting framework when caring for this client.
A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form that has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiography of the kidneys, ureters, and bladder C. A client who has a prescription for a TB test D. A client who has a distended bladder and needs urinary catherization
A
A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the clients respirations C. Prepare to administer oxygen D. Give the client a back rub to help her relax
B
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice
B
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? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouth piece with an alcohol swab after each use D. Use the spirometer every 8 hours
C
A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? A. Sunken eye balls B. Hypotension C. Poor skin turgor D. Bounding pulse
D
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? A. Two point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test
D
A nurse is caring for a client who, while sitting a chair, starts to experience a seizure. Which of the following actions should the nurse take? A. Place the padded tongue blade in the clients mouth B. Lower the client to the floor and place a pad under the clients head C. Seek the help of a coworker and left the client back into bed D. Use an oropharyngeal airway to keep upper airway passages open
B
A nurse is responding to a parents question about his infants expected physical development during the first year of life. Which of the following information should the nurse include? A. A 2 month old infant can turn from his abdomen to his back B. A 10 month old infant can pull up to a standing position C. A 4 month old infant can sit up without support D. A 6month old infant can crawl on his hands and knees
B
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increase urinary output C. Tachycardia D. Bradypnea
C Rationale: Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.
A nurse on a surgical unit is receiving a client who has abdominal surgery from the postanesthetic care unit. Which of the following assessments should the nurse make first? A. Pain level B. Hydration status C. Airway D. Urinary output
A
A nurse is providing oral for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the clients mouth open C. Rinse the clients mouth with an alcohol based mouth wash following the procedure D. Cleanse the clients mucous membranes with lemon glycerin sponges
A
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 minutes B. Fill the bag two-thirds with ice C. Place the ice bag uncovered on the clients ankle D. Tell the client that it is expected to feel numbness when the ice bag is in place
B Rationale: the nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the clients ankle
A nurse is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? A. Use battery operated equipment for personal care B. Apply mineral oil to protect the facial skin from irritation C. Remove the TV set from the clients bedroom D. Wear cotton clothing to avoid static electricity
D
A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan of care based on which of the following factors contributing to this postoperative complication? A. Blood loss B. NPO status after surgery C. NG suctioning D. Impaired peristalsis of the intestines
D
A nurse is preparing to administer an IM injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal
D Rationale: According to evidence based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels
A nurse is reviewing the lab values for a client who has a positive Chvostek's sign. Which of the following lab findings should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium
A
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the clients provider and verify the prescription D. Ask the client if she takes this medication at home
A Rationale: A nurse must have knowledge about medications to administer them safely. The nurse should become familial with the medication by looking it up it in the medication reference on the unit
A nurse on a telemtry unit is caring for a client who had a myocardial infarction. The client states "all this equipment is making me nervous". Which of the following responses should the nurse make? A. You wont need the equipment very long B. All of this equipment can be frightening C. Why dose this equipment bother you? D. Let me tell you about what each machine does
B
A nurse is caring for a client who has terminal illness. Which of the following findings indicates that the clients death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia
B Rationale: Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a clients death is imminent.
A nurse is planning care for a client who has a single-lumen NG tube for gastric decompression. Which of the following actions should the nurse include in the plan of care (SATA) A. Set the suction machine at 120 mmhg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the clients gown E. Apply petroleum jelly to the clients nares
B C D
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. A lot of clients who are cared for at home have the same problem B. Dont worry about it. He will get a bath, and that will take care of the odor C. It must be difficult to care for someone who is confined to bed D. When was the last time that he had a bath
C
A nurse is planning to insert a NG tube for a client after explaining the procedure. The client states, "you are not putting that hose down my throat". Which of the following statements should the nurse make? A. I would try to get it over with because you won't get better without this tube B. You should talk to your provider about it C. Why dont you want the tube inserted? D. I can see that this is upsetting you
D
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 at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site
B
A nurse in a providers office is collecting information from an older adult client who reports that he has been taking tylenol 500mg/day for severe joint pain. The nurse should instruct the client that large doses of tylenol could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. Liver damage D. Respiratory depression
C Rationale: Tylenol in large doses can be toxic to the liver. Daily intake should be limited to less than 3-4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of livery impairment.
An assistive personnel is assisting a nurse with the care of a female client who has a indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area B. The AP tapes the catheter to the clients inner thigh C. The AP hangs the collection bag at the level of the bladder D. The AP ensures that there are no kinks in the drainage tubing
C
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500mg/day of vitamin E C. Limit fluid intake to 20mL/kg of body weight per day D. Provide a protein intake of 1.5g/kg of body weight per day
D
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed B. Tie the restraint with a quick release knot C. Allow one finger beneath between the restraint and the clients chest D. Place the restraint under the clients clothing
B
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an exmaple of the nurse promoting primary prevention? A. Teaching clients to perform self-examination of breasts and testicles B. Educating clients about the recommended immunizations schedule for adults C. Teaching clients who hae type 1 DM about the care of their feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually
B Rationale: Primary prevention includes health education about disease prevention
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside while feeding the client B. Ordered pureed foods C. Make sure feedings are at room temperature D. Offer the client a drink of fluid after every bite
A Rationale: The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurses full attention during the feeding
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? A. Place the client in Trendenlenburgs position B. Perform percussions directly over the clients bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain
A Rationale: The nurse should place the client in right lying position in Trendelenburg position to promote drainage from the clients left lower lobe
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? A. People who practice this Islamic faith pray over the decreased for a period of of 5 days before B. People who practice the hindu faith busy the decreased with their head facing north C. People who practicies judaism stay with the body of the decreased until burial D. People who are practicing the Buddhist faith have the female family memebers prepare the body following death
C
A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half-strength
C
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert rectal tube 15.2cm (6in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36in) above the clients rectum
C
A nurse is providing a 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? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream
C
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pain from the extinguisher D. Sweep the hose from side to side to dispense material
C
A nurse is teaching a client how to self administer insulin. Which of the following actions should the nurse take to evaluate the clients understanding of the process within the psychomotor domain of learning? A. Ask the client if he wants to self-administer his insulin B. Have the client list the steps of the procedure C. Have the client demonstrates the procedure D. Ask the client if he understands the purpose of insulin
C
A nurse is providing discharge to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes
D
A nurse is reviewing measures to prevent back injuries with assistive personnel. Which of the following instructions should the nurse include? A. Stand 3 feet from the client when assisting with lifting? B. Lock your knees when standing for long periods C. Lift up to 22.6kg without the use of assistive devices D. When lifting an object, spread your feet apart to provide a wide base of support
D
