NU 101: ATI Practice Assessment 1
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
"Are you able to help with your hygiene care?"
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
"I'll check the wires and cables on my TV to make sure they are in good working order." Additinal Safety Info: >visitors must smoke outside the house >use cotton materials, not woolen or synthetic materials (they can create sparks) >ensure any electrical equipment in the room is functioning properly to avoid electrical sparks >keep the tank upright and secure in its holder at all times
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?
"This is a difficult time, but we are helping each other through this."
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
"Use the complete name of the medication magnesium sulfate."
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
"What could I have done to deserve this illness?"
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3 mg
A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
Allow extra time for the client to respond to questions.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
Ask another nurse to observe the medication wastage. (locking the remaining controlled substance in the cabinet would be a violation of the Controlled Substances Act, page 760-Taylor)
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take FIRST?
Check the client for injuries
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse the wound from the center outward.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? a. Erythema on pressure points b. Lower-extremity pulse strength of 2+ c. Fluid intake of 3,000 mL per day d. A bowel movement every other day
Erythema on pressure points -2+ is an expected finding -Clients should drink between 2,000-3,000mL of fluids a day -bowel movements less frequent than 3/wk indicate constipation and should be further evaluated
nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 mL of sterile water -Each medication should be dissolved in at least 30 mL of warm, sterile water -medications should be drawn up separately - if the nurse encounters resistance when adm. meds, he should stop and contact the provider
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?
Gently shake the container of medication prior to administration. DO: Place P in high-fowlers position prior to med admin. DO NOT" a. transfer pre-packaged liquid med into a cup due to risk of altered dosing
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with her arms at her side and her feet together. (Assesses balance) Romberg Test Skill p680 (Taylor)
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position (veins will dilate due to gravity) >catheters must be inserted at a 10° to 30° angle >excess hair should be clipped NOT shaved because shaving can cause breaks and cuts in the skin that could place the client @ risk for infection > the nurse should avoid using fragile veins of an older adults hands because the loss of subcutaneous tissue makes those veins roll away from the needle. Also, having an IV catheter in the clients hands interferes with ADL performance and can diminish the older adult's sense of independence and mobility
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take FIRST? a. Rinse the feeding bag with water between findings b. Tell the client to keep the head of the bed elevated at least 30 degrees. c. Make sure the enteral formula is at room temperature d. Wipe the top of the formula with alcohol
Tell the client to keep the head of the bed elevated at least 30 degrees. *all other steps should be followed but the height of the bed is most important Administration Skill is onp1247 (Taylor)
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?
Use a clock pattern to describe food on the client's plate. (allows for greater independence during meals)
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend?
Use progressive relaxation techniques at bedtime.
*A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly b. riding a bike c. performing isometric exercises d. engaging in high-impact aerobics
a. walking briskly -- this is a weight bearing activity that is essential for maintaining bone mass, preventing osteoporosis. >riding a bike and preforming isometric exercises have no weight bearing advantages so they do not help osteoporosis >high-impact aerobics can injur bones that have decreased density- these INCREASE RISK OF INJURY
nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? Airborne
airborne precautions are used for Pts whom have infections that spread via droplet nuclei, that are smaller than 5 microns (includes varicella, TB, and measles) >Droplet nuclei larger than 5 microns require DROPLET precautions (include rubella, meningococcal pneuomia, and streptococcal pharyngitis) >Contact precautions are used for infections spread via direct contact or contact with the environment (incl. vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies) > Protective Equiptment: Clients with a compromised immune system
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse b. a nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care c. a nurse asks a nurse from another unit to assist with her documentation d. a nurse discussed a client's status with the PT that's caring for the clients at their bedside
c. A nurse asks a nurse from another unit to assist with her documentation.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? a. Biofeedback b. Aloe c. Feverfew d. Acupuncture
d. Acupuncture it is contradicted for herpes zoster or any other skin infection to prevent an open portal on the skins surgace which could increase further risk for infection >Feverfew should be avoided for Pts on blood thinners >aloe can have wound healing effects >biofeedback is a complimentary and alternative therapy used by clients for disease processes such as stroke, recovery, smoking cessation, and headache d/o
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. Insert an implanted port b. close a laceration with sutures c. Place an endotracheal tube d. Initiate an enteral feeding through a gastrostomy tube
d. Initiate an enteral feeding through a gastrostomy tube (this is within the RN scope of practice, along with feeding through nasogastric, gastrostomy, and jejunostomy tubes) physicians and clinicians are required to preform the rest of the skills
A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? a. Smoothie b. Banannas c. Pancakes d. Fried Egg
fried egg eggs that are poached or scrambled are an acceptable replacement for this item
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
"I can concentrate best in the morning."
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
"I flushed what I urinated at 7:00 a.m. and have saved all the urine since" for a 24h urine collection, the client should discard the first voiding and save all the subsequent voidings
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? a. suction the client's airway b. administer a bronchodilator c. increase the humidity in the client's room d. assist the client to an upright position
Assist the client to an upright position.
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting. See page 546 (Taylor)
**A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. position the client with the head of the bed elevated to 30° prior to insertion of the NG tube b. Remove the NG tube if the client begins to gag or choke c. apply suction to the NG tube prior to insertion d. Have the client take sips of water to promote insertion of the NG tube into the esophagus
Have the client take sips of water to promote insertion of the NG tube into the esophagus >taking sips of water as the NG tube passes down through, the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea >the bed must be elevated to 90° to reduce aspiration risk > if choking or gaging occur, the nurse should withdraw the NG tube slightly, not remove it > the nurse should NOT apply suction until the NG tube is in place and has been verified for position to reduce risk of injury to the client
A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?
Semi-fowler's
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question?
The dose > the dose is not complete because the unit of measurement is not specified
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? *** a. "I'm having mild pain" b. "The pain is like a dull ache in my stomach" c. "I notice the pain gets worse after I eat" d. "The pain makes me feel nauseous"
"The pain is like a dull ache in my stomach" -"I'm having mild pain" (describes the sevarity of the pain. The nurse should use a pain scale to make this more accurate) -"I notice the pain gets worse after I eat" (this is a factor that aggravates the pain) -"The pain makes me feel nauseous" (manifestation of the pain)
**A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?
"You should have a fecal occult blood test every year." -avg risk starts at age 50 Additional Tips: >blood-contrast barium enema every 5yrs >Colorectal cancer screenings begin at age 50. One option is colonoscopy Q10yrs > flexible sigmoidoscopy Q5yrs (Starting on p419-Taylor. See Table 19-1 on p424)
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?
1. ask the client if he can bear weight 2. position the chair on the left side of the bed 3. have the client sit and dangle his feet at the bedside 4. Use the stand-and-pivot technique to move the client to the chair
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 steps for this procedure.
1. inject 10 units of air into the NPH insulin bottle 2. Inject 5 units of insulin into the bottle of regular insulin 3. Withdraw the correct dose of regular insulin 4. Withdraw the correct dose of NPH insulin Nancy Regan RN
A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (round to the nearest whole number. No trailing zero. Use a leading zero if it applies. )
8mL/hr a. 25,000units/250mL = 100units/mL b. divide 800 units by 100 to get 8mL/hr
A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds b. Measure urine output c. Monitor BP readings d. Monitor serum electrolyte levels
Auscultate lung sounds Why? This assessment is priority when using airway, breathing, and circulation (ABC) approach to monitor fluid-volume excess, which can be a complication of IV therapy. Moist crackles, dyspnea (difficult/labored breathing), and shortness of breath can be adverse effects.
A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention b. Decreased blood pressure c. Calf swelling d. Deminished bowel sounds
Calf swelling Calf swelling includes swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility -bladder distention can cause urinary retention, bladder distention, can be a complication of bed rest due to a loss of muscle tone in bladder and detrusor muscles -A pt on bed rest can develop postural hypotension manifested by a drop in BP when the client moves from lying to sitting. The nurse should also assess for a increase in pulse rate and dizziness -diminished bowel sounds reflect slowed peristalsis and constipation
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
Contact precautions
** 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 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
Have the client use a trapeze bar when changing position >reduced friction and shearing that result from sliding up and down in bed. Shearing is a risk factor in pressure-ulcer development >high-fowlers position places additional pressure on the sacrum and heels >Increased protein helps tissue repair. Prevention includes a balanced diet >massage can cause capillary breakdown in subQ tissues
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?
Narrowed arterial lumen (hearing bruits on the audiotape indicates that blood flowing through the occluded or narrowed arteries Heart Sounds https://www.youtube.com/watch?v=6YY3OOPmUDA
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4mEq/L
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the tragus of the client's ear
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?
Pupil clarity Visual fields Visual acuity Risk for Falls p692 (Taylor)
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
Rapid heart rate
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response to grief.
** A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
Remove the stockings at least once per shift. (This allows the nurse to check the client's circulation and skin integrity)
A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
Role overload
**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 a restriction bag w/ 80% O2 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 a water-soluble lubricant d. Adjust the wall suction apparatus to a pressure of 170 mm Hg
Select a suction catheter that is half the size of the lumen. (selecting a suction catheter 1/2 size prevents hypoxemia and trauma to the mucosa) Why? -100% O2 should be used - the nurse should lubricate with sterile water or 0.9% sodium irrigation to decrease trauma to the mucosa - 120 mm Hg, no higher than 150 mm hg should be used to prevent hypoxemia and trauma to the mucosa
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
Situation, background, assessment, and recommendation (SBAR)
**A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
Skin Blanching along with edema and coolness at the IV site
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
Stand close to the cabinet when lifting it. DO NOT bend at the waist, keep his feet close together, or use his back muscles for lifting Good Ergonomics p 1043-1044 (Taylor)
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of the body Proceeding with Ambulation: 1. the patient stands with weight evenly distributed between the feet and the cane 2. The cane is held on the patients stronger side and is advanced 4-12in (10-30cm) 3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane 4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane 5. The weaker leg is moved forward until even with the stronger leg along with advancement of the cane pg 1078 (Taylor)
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion.
A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Wrap monitoring cords with stockinette and tape them in place. a. Ensure sterilization of nondisposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place b. wrap monitoring cords with stockinette and tape them in place. c. cleanse latex ports on IV tubing with chlorahexadine before injecting medicaiton d. wear hypoalergenic latex gloves that contain powder
Wrap monitoring cords with stockinette and tape them in place. many cords contain latex > ethylene oxide can cause allergic rxns in clients who have a latex allergy (sterilize before use) > hypoallergenic can still cause an allergic response but is especially harmful because of the powder (see pages 548-549. Taylor)
**A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? a. Place the client in a room with negative-pressure airflow. b. Wear gloves when assisting the client with oral care. c. Limit each visitor to 2hr increments d. Wear a surgical mask when providing care e. Use antimicrobial sanitizer for hand hygiene.
a. Place the client in a room with negative-pressure airflow. b. Wear gloves when assisting the client with oral care. e. Use antimicrobial sanitizer for hand hygiene.