01 Oct A nurse is assessing a client’s personal hygiene. Which of the following findings indicates that the client might have difficulty with routinely bruising their teeth?
ATI Fundamentals 2019 Exam _ Proctored
A nurse is assessing a client’s personal hygiene. Which of the following findings indicates that the client might have difficulty with routinely bruising their teeth?
The clients mucosa is moist B. The client gums feel spongy
C. The client has a missing tooth
D. The Client’s tongue is a dull red color
A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first?
Make a copy of the medication reconciliation form for the client
Provide the client with the contact number for a diabetes education specialist C. Determine whether the client can afford the insulin administration supplies
D. Obtain printed about insulin self administration
A community health nurse is teaching a group of clients about kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include?
Contact your pelvic muscle when performing the exercises
Expect improvement after 2 weeks of performing the exercises
Hold your breath when performing the exercises
Tighten your buttocks when performing the exercises
A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse’s priority?
Skin tags noted in the neck region
A change in appearance of a mole on the shoulder
A flat, nonpalpable, discovered area of skin on the trunk
Atrophic wart on the left index finger
A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?
A cover the client with heavy blankets after shivering subsides B place ice packs on the clients neck and behind the knees
C apply a bath blanket between the client and a cooling blanket
D give the client a sponge bath using alcohol water solution
A nurse is caring for an infant who is to undergo surgery. The nurse should identifywhich of the following individuals should sign the consent form?
The infants 17 year old mother
The infants provider
The infants grandmother
The mother’s 21 year old sibling
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use?
Encourage the client to try to defecate for 20 min while on the fracture pan.
Keep the bed flat while the client is on the fracture pan.
Hyperextend the clients back while the fracture pan is in place.
Place the shallow end of the fracture pan under the clients buttocks.
A nurse is reviewing the medical record of a client who asks about the use of a magnet therapy for pain relief. The nurse should identify which of the following findingsis a contraindication for receiving this type of therapy?
The client is allergic to penicillin
The client has a prescription for metoprolol
The client has a history of alcohol use disorder
The client has an implanted defibrillator
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the clients room following a dressing change. Which of the followingpieces of personal protective equipment should the nurse remove first?
Gloves
Eyewear
Gown
Mask
A nurse is teaching a newly licensed nurse about the care of a client who has methicillin resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
I will wear an N95 respirator mask when caring for the client
I will tell the clients visitors to wear a mask when they are within 3 feet of theclient.
I will place the client in a private room
I will remove my gown before my gloves after providing client care.
A charge nurse in a long term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should thenurse plan to include?
Delirium has an abrupt onset
A nurse is preparing to insert an IV catheter for an adult client. Which of thefollowing actions should the nurse take?
choose the most proximal site on the extremity selected
apply a cool compress for several minutes before insertion of the IV catheter
place the tourniquet below the proposed insertion site
place the extremity in a dependent position
A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in theteaching?
Your partner must be present when you sign the advance directives
You will receive written information about advance directives prior to signing
You are required to sign advance directives prior to surgery
Your provider must sign the advance directives before surgery
A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Remove one restraint at a time
A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
Dilute each crushed medication with sterile water
Mix the medication together in a single syringe
Flush the NG tube with 5 mL of sterile water prior to administration
Combine the medication with the formula in the feeding bag
A nurse is planning care for a client who has urinary incontinence. Which of thefollowing interventions should the nurse include in the client’s plan of care?
Toilet the client every 4 hr while the client is awake
Apply a moisture barrier in a thick layer to vulnerable skin areas
Cleanse the skin with antibacterial soap and hot water after each incontinence episode
Reduce the clients daily fluid intake
A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. Thenurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?
Complete an incident report
Obtain the client’s vital signs
Document the fluid infusion in the client’s chart
Report the incident in to the unit manager
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA)
A nurse is caring for a client who is scheduled for surgery. While the nurse is
witnessing the client’s signature, the client states, I trust my doctor, but I don’t understand what is meant by resecting my intestine. Which of the following actionsshould the nurse take?
A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestationsoccurs during the alarm reaction stage?
Dilated pupils
Physical exhaustion
Bradycardia
Depression
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A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? – –
–
Unplug the pump
obtain a replacement pump
Notify the biomedical department to fix the pump
Label the pump with a defective equipment sticker
A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective?
The client’s skin on the lower back is intact without redness
The client’s laughing at a television show
The client states that he is able to concentrate while eating
The clients’s vital signs are within the expected reference range
A nurse is preparing a sterile field to assist with suturing a clients laceration. Whichof the following actions should the nurse plan to take?
Pour the sterile solution with the bottle 20 cm (8 in) above the sterile bowl
Hold the bottle of sterile solution so that the label is facing the palm of the hand
Place the lid of the sterile solution bottle face down on the sterile drape
Apply sterile gloves before opening the bottle of sterile solution
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24 a nurse receives a new prescription over the telephone from a client’s provider.
Which of the following actions should the nurse take first?
Ensure that the provider signs the prescription
Write down the complete prescription
Read back the prescription to the provider
Document the prescription as a telephone prescription in the medical record
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A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
This test will determine if your heart is performing properly
This test will indicate if you are at risk for developing blood clots
This test is used to check how your kidneys are working
This test will provide information about the function of your liver
A nurse is caring for a client who is on bed rest following abdominal surgery. Whichof the following findings indicates the need to increase the frequency of position changes?
Petechiae on the client’s right anterior thigh
Flat rash on the client’s ankle
nonpalpable macule on the client’s left shoulder
Non Blanching darkened area over the client’s trochanter
A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?
After I insert the hearing aid, i will turn it up as high as it will go
I should leave the battery in the hearing aid when i take it out to sleep
I will need to get a new hearing aid every year
I should gradually increase the time that i wear the hearing aid
A nurse is preparing to collect a specimen from a client. Which of the followingactions should the nurse take?
A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?
Thirst
Confusion
Cool skin
Shakiness
A nurse is assessing an older adult client. Which of the following findings should the nurse expect?
– Decreased sense of balance
A nurse is preparing to administer a controlled substance to a client for painmanagement. Which of the following actions should the nurse take?
Report any discrepancy in the court total of the controlled substance after administration
Place the assisted portion of the controlled substance in the sharps container
Verify the count total of the controlled substance after removing the amountneeded
Ask a second nurse to report her signature when wasting any unused portion of the controlled substance
A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, im worried about the bag. Which of the following is an appropriate response by the nurse?
You are worried about having to wear a colostomy bag?
Have you ever known someone who has a colostomy
Let’s wait until after the surgery to discuss your concerns about your colostomy
The surgeon will only place the colostomy if it is necessary
A nurse is preparing to administer medication to a client. Which of the followingshould the nurse use as a client identifier?
Age
Room number
Photograph
Bed number
A nurse is preparing to administer an injection to a client. Which of the followingactions should the nurse plan to take after administering the injection?
Discard the needle in a puncture proof container
Place the needle on the bedside table
Remove the needle from the syringe
Recap the needle before disposal
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?
Assist the client in setting goals to make the change
Develop a plan for the client to integrate the change into her lifestyle C. Present information about the benefits of quitting smoking
D. Recommend small changes for the client to make to change her behavior overtime
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A nurse is providing teaching to a client who is at risk for thrombus formation. Whichof the following statements made by the client indicates an understanding of the teaching?
I will keep my legs crossed while sitting
I will perform exercises once every 4 hours while i am awake
I should massage my legs when they hurt
I should limit the time that i spend sitting in a chair
A nurse is documenting client care. Which of the following abbreviations should thenurse use?
A nurse who is documenting information in a clients electronic medical record is asked to assist with an emergency. Which of the following actions should the nurse take?
Ask another nurse to monitor the computer
Turn the computer off
Move the computer to a secure place
Print out the current notes to finish later
A nurse is caring for a client who is receiving continuous enteral feeding via NG
tube. Which of the following is an unexpected finding?’
Diarrhea one time in a 24 hour period
A weight gain of 0.91 kg (2 Ib) in 2 days
A gastric residual of 300 mL at the end of the shift
A blood glucose level of 110 mg/dL
A nurse is planning care for a female client who has an indwelling urinary catheter.Which of the following actions should the nurse include in the plan?
Tape the catheter to the lower abdomen
Attach the drainage bag to the side rails of the bed
Keep the drainage bag below the level of the bladder
Empty the drainage bag when it is three quarters full
A nurse is reviewing the medical record for a newly admitted client. Which of thefollowing laboratory values should the nurse report to the provider?
Sodium 140 B. Potassium 1.8
C. Magnesium 1.9
D. Calcium 6.5
A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220Ib. How many mg should the nurse administer? (Round to the nearest whole number.
Use a leading zero if it applies. Do not use trailing zero).
– 200 mg
A nurse is caring for a client who tells the nurse, since I retired, I have a lot of time on my hands and nothing to do. I guess nobody needs me. Which of the following responses should the nurse make?
If i were you, i would volunteer my time
Do you have family members you can visit
You need to realize that you have valuable skills to offer others D. Tell me about some hobbies you enjoy
A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The nurse should identify that which of the following findings indicates a need forrestraints?
The client’s family is unable to stay with the client
The client becomes confused at night
The client gets of bed to use the bathroom frequently D. The client is assigned a room near the nurses station
A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation?
No changes noted to the wound from previous nursing notes B. Client premedicated with MSO4 sunq prior to dressing change
C. The wound seems clean and does not appear to be infected
D. New dressing applied as prescribed, no drainage on old dressing
nurse is preparing to reposition a client who has a lower back injury. Which of thefollowing actions should the nurse take?
Place the clients arms at their sides
Flex the client’s knees
Place the client at the side of the bed nearest the direction they will be turned D. Roll the client as one unit in a smooth continuous motion.
A nurse is caring for a client who has TB. which of the following precautions should the nurse plan to implement when working with the client?
A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client’s bedside?
Oral suction equipment and oral airway.
A nurse is providing teaching to the family of a client who is at the end stage of life. Which of the following client manifestations should the nurse instruct the family to expect?
A. Increased periods of wakefulnessB. Altered breathing patterns
C. Increased salivation
D. Warm and dry extremities
A nurse is preparing to obtain informed consent from a client who speaks a differentlanguage than the nurse and is scheduled for surgery. Which of the following actions should the nurse take?
A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?
A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating Ivtherapy?
A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer theclient as a part of a full liquid diet?
A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client’s plan ofcare?
Type 2 diabetes mellitus patient with corns and calluses.
A nurse is caring for a male client who has a prescription for intermittent catheterization with a coude catheter. Which of the following images show the type of catheter the nurse should use?
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should thenurse take first?
Provide the client with a mirror to look at her mastectomy incisions
refer the client to a breast cancer support group
identify the impact of the mastectomy on the client’s body image
encourage the client to assist with her dressing change
A nurse is preparing to perform a physical assessment of a client’s abdomen. Identify the sequence in which the nurse should perform the following steps. (Place them in order of performance. Use all steps)
3. Percuss all four quadrants of the abdomen to measure sound quality
1. Provide adequate lighting to inspect the abdomen
4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the abdomen
2. Listen to the abdomen arteries using the bell of a stethoscope
5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen
60.a nurse working on a medical surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel?
A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should thenurse take first?
A
nurse is caring for a client who has a new diagnosis of terminal cancer. Which ofthe following interventions is the priority?
