Fundamentals ATI Practice B

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. use resuscitation bag with 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170 mmHg

b. select a suction catheter that is half the size of the lumen

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this with you?"

a. "we can talk about advance directives, and I can also give you some brochures about them"

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day

a. erythema on pressure points

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the client reports relief of nausea

b. an x-ray shows the end of the tube above the pylorus

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. ensure sterilization of non-disposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place c. cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. wear hypoallergenic latex gloves that contain powder.

b. wrap monitoring cords with stockinette and tape them in place

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore

c. evacuate the client

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg

c. rapid heart rate

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years"

d. "You should receive a pneumococcal immunization every 10 years"

A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic

a. ambulating a client who is postop

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as priority? a. auscultate lung sounds b. measure urine output c. monitor blood pressure readings d. monitor electrolyte levels

a. auscultate lung sounds

A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week

b. a client who smokes one pack of cigarettes each day

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of the steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

c,a,d,b

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it

a. gently shake the container of medication prior to administration

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number

8 mL/hr

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions

d. practice sessions

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? a. "most people are happy when their children grow up and leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the client's ability to self-administer medications c. report an identified discrepancy to The Joint Commission. d. compare prescriptions with medications the client received while at the facility

d. compare prescriptions with medications the client received while at the facility

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. place the client in high-Fowler's position. b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position

d. have the client use a trapeze bar when changing position