ATI Fundamentals Leadership Final Exam Prep

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A. Pernicious anemia B. Dehydration C. Prostate enlargement D. Bladder infection - d. Bladder infection A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should nurse take when obtaining the specimen? A. Use sterile swab to obtain the specimen B. Place specimen in sterile container C. Label the paper bag in which specimen container is placed D. Send specimen container immediately to the lab - d. Send specimen immediately to lab A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? A. One nurse lifting as the client pushes with his feet B. Two nurses lifting the client under the shoulders C. One nurse lifting the client's legs as the client uses a trapeze bar D. Two nurses using a friction reducing device - d. Two nurses using a friction reducing device A nurse is planning care for an older adult client who is at risk for developing pressure ulcer. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed B. Apply cornstarch to keep sensitive skin areas dry C. Massage the skin over the client's body prominences D. Elevate the head of the bed no more than 45 degrees - a. Use a transfer device to lift the client up in bed A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to inability to swallow. Which of the following is the priority action by the nurse? A. Observe client's respiratory status B. Elevate the head of client's bed from 30 to 45 C. Monitor intake and output every 8 hours D. Check residual volume every 4-6 hours - b. Elevate head of bed from 30 to 45 degrees to reduce risk of aspiration A home heath nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (select all that apply) A. Bathtub with rails B. Electric cords behind furniture C. Raised toilet seats D. Water heater temp 130 f E. Throw rugs - d. Water heater E. Throw rugs A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick release tie B. Ensure four fingers fit under restraints to prevent constriction C. Secure the restraints to the lowest bar on the side rail D. Anticipate removing the restraints every 4 horus - a. Secure the restraints using a quick release tie A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (select all that apply) A. Report of feeling pressure B. Tenderness over symphysis pubis C. Distended badder D. Voiding 30 ml frequently E. Dysuria - a. Report of feeling pressure B. Tenderness over symphysis pubis C. Distended bladder d. Voiding 30ml frequently A nurse is caring for a client who has fallen while getting out of bed and states "i'm okay. I guess i should have called for help to the bathroom." after assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. There were no injuries sustained B. An incident report was completed C. An incident report was forwarded to risk management D. The provider was notified - d. The provider was notified A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (tpn) solution is not infusing. The nurse should monitor the client for which of the following conditions? A. Excessive thirst and urination B. Shakiness and diaphoresis C. Fever and chills D. Hypertension and crackles - b. Shakiness and diaphoresis A nurse is caring for a client who receives intermittent enteral feedings through an ng tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? A. Confirm placement B. Remove gastric acid that might cause dyspepsia C. Determine the client's electrolyte balance D. Identify delayed gastric emptying - d. Identify delayed gastric emptying- if delayed should avoid feeding and causing distention A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust water temp to feel hot B. Apply 4-5 ml of liquid soap to hands C. Hold hands higher than elbows D. Rub hands and arms to dry - b. Apply 4-5 ml of liquid soap to hands A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for: A. Steoatorrhea B. Blood C. Bacteria D. Parasites - b. Blood A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. Vital signs measurement B. The client's self report of pain C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure - b. Client's self report A nurse is receiving change of ship report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? A. Critically analyze client data to determine priorities B. Collect and organize client data C. Set client centered, measurable and realistic goals D. Determine effectiveness of interventions - b. Collect and organize client data