Fundamentals ATI Exam

A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take?

Allow 2 mins in between suctioning to reoxygenate the lungs

What is the correct order to assess an abdomen?

Inspect Auscultate Percuss Palpate

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take?

Leave a space between the penis and sheath portion tip.

A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions?

Left lateral with right leg flexed

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the new nurse demonstrates understanding of the teaching?

"People who practice Judaism stay with the body of the deceased until burial"

What dressings help promote hemostasis?

Algeinate

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen upon rising in the morning.

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 inclue?

Cough deeply after each use - To loosen secretions -inhale to make the balls go up

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe.

A nurse is planning to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first?

Develop a plan of care.

A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the determine that the client has impaired gas exchanged?

Diagnosis

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices that the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 minutes. - Malfunctioning equipment is a safety risk for the patient, so it must be tagged and removed.

A nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at -40cm of water. Which of the following closed-chest drainage systems should the nurse prepare for the client?

Dry suction-control system

A nurse is preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation?

Make sure the air vent is open. - never clamp a chest tube during transportation

A nurse is changing dressings for a client who has two penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

During a pain assessment, a nurse asks questions about the quality of an adult client's pain. Which of the following statements by the client refers to pain quality?

My pain feels like I'm being stabbed by a knife

What feeding tube should the patient get if they need the tube for about two weeks with a high risk for aspirations?

Nasointestinal tube - NG tubes are contraindicated for aspirating clients - NJ tubes are for 4+ weeks

What is cranial nerve I responsible for?

Olfactory (smell)

A nurse is planning care for a client who is confused and require a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restraints within 24 hours

A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions should the nurse plan to take?

Reuse the catheter repeatedly. (hyper-oxygenation is not needed with inline suctioning)

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations. (administering vaccines is a primary intervention)

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum. (not the clients right)

A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed-chest drainage system?

Submerge the end of the chest tube in 1 in of sterile water. - this creates a water seal and prevents air from entering the pleural space through the open end of the chest tube.

What medications delay wound healing?

corticosteroids

A nurse is caring for a client who has acute renal failure. Which of the following asessments provides the most accurate measure of the client's fluid status?

daily weight

which of the laboratory findings should the nurse suspect with a client who tested positive for Chostek's sign?

decreased calcium

A nurse is administering an enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

insert the tip of the tubing 8 cm (3.1in) - insert 7-10cm

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

lower abdomen

How far in is an nasointestinal tub placed?

nose to the earlobe to the xiphoid process and 20-30cm more

A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include?

place the oxygen tank in a clutter-free environment

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

pull suction catheter back 1cm (0.5in) if the client starts coughing (or when resistance is met)

A nurse is caring for a client who has a stage 4 sacral pressure wound unjury for which provider has prescribed mechanical debridment. Which of the following is a form of mechanical debridement that the nurse should expect the client to recieve?

pulsating lavage (irrigations)

A home health nurse is teaching a client who has just started receiving oxygen therapy mask. The nurse should emphasize that the client must

repositioning the elastic band frequently

A nurse is administering an enema medicated with sodium polystyrene to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube?

3-4 in

When does NPH insulin peak?

6-14 hours

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

A brief thump felt near the fourth or fifth intercostal space near the left of the midclavicular line.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to received a prescription for urinary catheterization?

A client who is in the ICU for a gastrointestinal bleed

A nurse is caring for a client who has a chest tube in place that is attached to a water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema?

A dry, crackling sound at the insertion site when palpated. (A result of leaking air into the subq tissue surrounding the chest tube insertion site)

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin - redness around may indicate infection

A nurse is assisting a client 5 h after the insertion of a chest tube that is attached to a water seal drainage system, Which of the following observations about the drainage should the nurse report to the provider?

About 150mL/hour drainage over the past 2h - the first few hours the drainage should be 70mL/hr

Which of the following actions should the nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing?

Auscultate the client's lungs - silent aspirations are a common complication of swallowing impairment

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?

Bear weight on both of your legs (three points on the ground at all times)

A charge nurse is observing a newly liscensed nurse perform tracheostomy care for a client. Which of the following actions by the newly liscensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy care. - Cotton ball particles can be aspirated into the tracheostomy opeaning, possibly causing tracheal abscess. The charge nurse should interviene for the this action.

What is a wet popping sound when inspiring?

Crackles

A nurse is caring for a client who was admitted with community-aquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy?

Cracks in the oral mucosa

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 example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults - disease prevention

What enteral feeding formula should you administer to someone who has a dysfunctional GI tract?

Elemental - They contain predigested nutrients that are easy for a partially functional GI tract to absorb

oxygen therapy is prescribed for a client who brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings?

Elevated blood pressure - late stages is hypotension

A nurse who is preparing to provide chest physiotherapy for a client who has lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position. - To promote drainage

A nurse is performing eye irriagation on a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open. - Holding the eye open on cheekbone and eyebrow

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking - They can lip read

A nurse is planning to administer a dose of morphine sulfate IV for a client who is postoperative. Which of the following pain management protocols should the nurse use when caring for this client?

Have an opioid antagonist available during the administration - an equipment for respiratory support

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 client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?

I am going to listen to your abdomen - make sure there are bowel sounds present first

A nurse is planning to insert a NG tube for a client after explaining the procedure the client states, "you are not going to put that hose down my throat". Which of the following statements should the nurse make?

I can see that this is upsetting you. - Do not ask why questions

A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforced with the client that they are scheduled for which of the following type of ostomy procedure?

Illeostomy

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?

LRQ

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take?

Lift the penis perpendicular to the body

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?

Observe the rate, depth, and character of the client's respirations

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first - It stimulates saliva production

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube - To decrease the risk of aspirating any gastric contents

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh.

A nurse on a rehab floor 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?

Place the wheelchair at a 45 degree angle. - Positioning the wheelchair this way allows the client to pivot, lessoning the amount of rotation required.

What is the difference between systolic and diastolic pressure called?

Pulse pressure

A nurse is planning to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed. - The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk for self injury

A nurse is caring for an older adult who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time. - The nurse should remove the restraints one at a time for a client who is violent or noncompliant.

What is the Romberg test?

Test is for balance

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?

The nurse washes with her hands held higher than her elbows. - So that the water and soap suds can drain away from the clean area toward the dirty area

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for three days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation - To keep the client's balance midline - wait 60s before getting up, non-slip socks, stand beside and support patient

A nurse observes an assistive personnel preparing to obtain a blood pressure with a regular sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

Using a cuff that is too small will result in an inaccurately high reading.

A nurse is performing chest physiotherapy for a client who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the client exhales, the nurse should use which of the following techniques?

Vibration - to loosen secretions

A client 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?

Wear cotton clothing to avoid static electricity. - to avoid combustion

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

a 10 month old infant can pull up to a standing position.

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

cold extremities

A nurse is planning to obtain the vital signs of a two year old child who experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temprature?

temporal - place behind the ear that is not experiencing an infection (oral not recommended for those under three)

A nurse is teaching a client who has type 1 diabetes mellitus about the use of an insulin pump. Which of the following information should the nurse include in the teaching?

the risk of developing DKA can be increased with the use of an insulin pump

in initial wound healing put client on O2 2 L to increase tissue perforation to aide healing.

true