Fundamentals ATI quiz 1 extra review

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his nameWhich of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings d. Administer a PRN antianxiety medication

Accompany the client back to his room

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautionsWhich of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? -A Shaking soiled linen before putting it in a hamper -Removing a face mask when standing 0.5 m (1.6 ft) from the client -Assigning another client with the same infection to share the room with the client -Allowing the client to visit a family member in the lobby of the facility

Assigning another client with the same infection to share the room with the client

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? -Attempt to increase the clients' self-motivation. -Keep detailed records of each client's progress. -Test client learning after each teaching session. -Avoid discussing areas that might cause client anxiety.

Attempt to increase the clients' self-motivation. Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of following action should the nurse? Withdraw the specimens from the drainage bag Cleanse the collection port soap and water Clamp the tubing below the collection port.

Clamp the tubing below the collection port

A nurse is caring for a client who has acute renal failure, which of the following assessment provides the most accurate measure of the clients fluid status? Daily weight Blood pressure Intake and output

Daily weight

A nurse planning care for a toddler who has acute gastroenteritis and was recently admitted. Which if the following should the nurse plan to provider for the child? -Oral rehydration solution -Bananas or applesauce -Chicken or beef broth -Hypertonic IV solution

Oral rehydration solution

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? -Auscultate for the blood pressure at the dorsalis pedis artery. -Measure the blood pressure with the client sitting on the side of the bed. -Place the cuff 7.6 cm (3 in) above the popliteal artery. -Place the bladder of the cuff over the posterior aspect of the thigh.

Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? •The client fully understands the provider's explanation of the procedure. •The client has been informed about the risks and benefits of the procedure. •The nurse witnessed the provider's explanation of the procedure. •The signature on the preoperative consent form is the client's.

The signature on the preoperative consent form is the client's. The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? -"Drink a minimum of 1,000 milliliters of fluid daily." -"Increase your intake of refined-fiber foods. -"Sit on the toilet 30 minutes after eating a meal." -"Take a laxative every day to maintain regularity."

"Sit on the toilet 30 minutes after eating a meal." Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? -Obtaining hydrogen peroxide for the tracheostomy care -Obtaining cotton balls for the tracheostomy care -Obtaining sterile gloves for the tracheostomy care -Obtaining a sterile brush for the tracheostomy care

-Ans: obtaining cotton balls for the tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch trayWhich of the following instructions should the nurse give to the dietary assistant? -Don a gown before entering the room and remove it before exiting B. Wear a mask while in the client's room C. Don gloves when entering the room and use hand sanitizer when exiting. D. Take no special precautions unless engaging in direct contact with the client .

Don gloves when entering the room and use hand sanitizer when exiting

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? -Evaluate pedal pulses. -Obtain a medical history. -Measure vital signs. -Assess for leg pain.

Evaluate pedal pulses. For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is planning an in-service training session about nutrition Which of the following statements should the nurse include in the teaching? -Fats provide energy -Carbohydrates repair body tissue -Data regulate fluid balance -Carbohydrates prevent instersitial edema

Fats provide energy

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.

Inspect, Auscultate, Percuss, Palpate

A nurse is caring for an older adult client 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? -Tie the restraints to the side rails. -Perform range-of-motion exercises to the wrists every 3 hr. -Remove the restraints one at a time. -Obtain a PRN prescription for the restaints.

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

A nurse is planning for care for a client who is confusing, requires a prescription for wrist restraints which of the following intervention should the nurse include in the plan of care? -Renew the prescription for the use of restaurants within 24 hours -Secure the restraints with the buckle side next to the clients skin -ensure 4 fingers can be inserted under the secured restraint

Renew the prescription for the use of restraints within 24 hours

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? •Holding a community clinic to administer influenza immunizations. •Screening groups of older adults in nursing care facilities for early influenza manifestations. •Educating parents of young children about dangers of influenza. •Finding rehabilitation programs for older adults who have complications from influenza

Screening groups of older adults in nursing care facilities for early influenza manifestations Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention.

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? -Fifth intercostal space just medial to the midclavicular line -Second intercostal space to the left of the sternum -Fifth intercostal space to the left of the sternum -Second intercostal space to the right of the sternum

Second intercostal space to the right of the sternum. The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is providing teaching to an older adult client who has constipationWhich of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000 of fluid daily." B. "Increase your intake of refined-fiber foods." C."Sit on the toilet 30 min after eating a meal. D. "Take a laxative every day to maintain regularity"

Sit on the toilet 30 min after eating a meal

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extra cellular fluid volume? Sodium Calcium Potassium Magnesium

Sodium Sodium regulates extra cellular fluid balance, nerve impulse transmission, acid base 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 each part of her hands with 5 strokes. -The nurse washes from the elbows down to the hands. -The nurse washes with her hands held higher than her elbows. -The nurse uses minimal friction when washing her hands.

The nurse washes with her hands held higher than her elbows. The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.