ATI Proctored Fundamentals Exam

ATI Proctored Fundamentals Exam 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? - CORRECT ANSWER-"I flushed what I urinated at 7:00 a.m. and have saved all urine since." 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? - CORRECT ANSWER-Calf Swelling 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? - CORRECT ANSWER-A nurse asks a nurse from another unit to assist with her documentation. 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? - CORRECT ANSWER-Remove the stockings at least once per shift. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? - CORRECT ANSWER-Auscultate Lung Sounds 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? - CORRECT ANSWER-Walking Briskly 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? - CORRECT ANSWER-Erythema on pressure points 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? - CORRECT ANSWER-Check the client for injuries 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? - CORRECT ANSWER-"You should have a fecal occult blood test every year." 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? - CORRECT ANSWER-"Use the complete name of the medication magnesium sulfate." A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? - CORRECT ANSWER-Place the client in a room with negativepressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene. 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. - CORRECT ANSWER-Air into NPH Air into Regular Draw up Regular Draw up NPH 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? - CORRECT ANSWER-Initiate an enteral feeding through a gastrostomy tube. 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? - CORRECT ANSWER-Have the client take sips of water to promote insertion of the NG tube into the esophagus. 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? - CORRECT ANSWER-Pupil Clarity Visual Fields Visual Acuity 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? - CORRECT ANSWER-The client holds the cane on the stronger side of her body. 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? - CORRECT ANSWER-Narrowed Arterial Lumen A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? - CORRECT ANSWER-Airborne A 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? - CORRECT ANSWER-Flush the tube with 15 mL of sterile water. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? - CORRECT ANSWER-Cleanse the wound from the center outward. A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report? - CORRECT ANSWER-A client who has an IV infusion pump receives an additional 250 mL of IV fluid. 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? - CORRECT ANSWER-Skin Blanching 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? - CORRECT ANSWERSituation, Background, Assessment, and Recommendation (SBAR) 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? - CORRECT ANSWER-Contact Precautions 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? - CORRECT ANSWER-Assist the client to an upright position. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? - CORRECT ANSWER-Potassium 5.4 meq/L 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? - CORRECT ANSWER-Stand close to the cabinet when lifting it. 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? - CORRECT ANSWER-Withhold the blood transfusion. 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? - CORRECT ANSWER-Select a suction catheter that is half the size of the lumen. 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? - CORRECT ANSWER-"Are you able to help with your hygiene care?"