Fundamentals ATI

Fundamentals ATI 1. A nurse is providing teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? a. The RDA defines the level of nutrient intake that meets the needs of healthy people 2. A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? a. Sodium 3. A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? a. Insert the tip of the tubing 8cm (3.1in) 4. A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routs of infection should the manager identify as an iatrogenic HAI? a. Infection acquired from a diagnostic procedure 5. A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? a. Request a prescription for an isotonic enteral nutrition formula 6. A nurse is caring for a client who had a mastectomy and has a self-suctioning drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? a. Collapse the device to remove air after emptying 7. A nurse if providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? a. Stop the teaching and check with the surgeon about informed consent. 8. A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? a. Regulation of acid-base balance 9. A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests. a. Romberg 10. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2C (102.6 F), a heart rate of 105/min, a soft non-tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority? a. Temperature 11. A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? a. Keep the rubber crutch tips securely in place 12. A nurse is reviewing a client’s laboratory report. The client’s ABG levels are pH: 7.5 PaCO2: 32 mmHg, HCO3: 24 mEq/mL. The nurse should determine that the client has which of the following acid-base imbalances? a. Respiratory Alkalosis Expected Ranges: b. pH: 7.35 – 7.45 (Alkalosis) c. Paco2: 35 – 45 mmHg (Respiratory Alkalosis) d. HCO3: 22 – 26 mEq/mL (Bicarbonate) 13. A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? a. Young children Erikson’s Developmental Tasks b. Infant (2 days – 1 year): trust vs mistrust c. Toddlers (1-3): autonomy vs. shame and doubt d. Preschooler (3-6): initiative vs. guilt e. School-Age Children (6-12): industry vs. inferiority f. Adolescents (12-20): identity vs. role confusion g. Young Adulthood (20-35): intimacy vs. isolation h. Middle Adulthood (35-65): generativity vs. self-absorption and stagnation i. Older Adulthood (65 and older): integrity vs despair 14. A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personal (AP). The nurse later observes the AP emptying the bag without wearing gloves. Whish of the following actions should the nurse take? a. Talk with the AP about the technique used 15. A nurse is caring for a semiconscious who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? a. Verify the initial X-ray examination b. Measure the length of exposed tube c. Determine the pH of aspirated fluid 16. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? a. Raise the level of the bed 17. A nurse if performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? a. Pull suction catheter back 1 cm (0.5in) if the client starts coughing 18. A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration? a. Elevate the head of the bed to 30-40 degrees 19. A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the clients wound has eviscerated. Which of the following actions should the nurse take? a. Place the client in a supine position with the hips and knees flexed b. Cover the wound and intestine with a sterile, moistened dressing c. Monitor the client for manifestations of shock 20. A nurse delegates the collection of a client’s temperature to an assistive personal (AP). The nurse notes in the documentation that the AP obtained the client’s axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? a. Right communication 21. A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? a. Place the client in a left Sims’ position 22. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of day living. Which of the following activities should the nurse recommend to the client? a. Washing dishes 23. A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? a. Soak the inner cannula of the tracheostomy tube in normal saline 24. A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client’s HIV infection status. Which of the following actions should the nurse take? a. Instruct the guard to ask the inmate 25. 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? a. Obtaining cotton balls for tracheostomy care 26. A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? a. Check the patient’s pain level 27. A client who has glaucoma of the right eye self-administers timolol eye drops onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? a. Instruct the client to apply pressure to the inside corner of the eye after instillation 28. A nurse is caring for a client who has temperature of 38.7C (101.7F). Which of the following actions should the nurse take? a. Keep the client’s linens dry 29. A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? a. Increased heart rate 30. A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking? a. The client keeps 2 points of support on the ground 31. A nurse in a providers office is teaching a client about foods high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? a. High in Fiber: Black beans, whole grain bread b. Not high in fiber: canned peaches, white rice, tomato juice 32. A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? a. Decreased cardiac output 33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? a. Elevate pedal pulses 34. A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classification. a. Plasma volume expanders 35. A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? a. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage. Unstable vs. Stable Priority Setting Framework o Problems involving the airway, breathing or circulatory  then risk for decreased VS and laboratory values 36. A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. “if I do this often, I would get pneumonia 37. A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 – 600 mL occurs each day through which of the following organs? a. Skin 38. A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? a. Hct 55% Explanation o An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated bun, elevated BUN, increased urine specific gravity, and decreased urine output. 39. A nurse is supervising a newly licensed nurse who is suctioning a client’s tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Administering high-flow oxygen prior to the procedure Explanation o The nurse should instruct the newly licensed nurse to administer 3 – 4 breaths of 100% oxygen via a resuscitations bag before suctioning to the client to reduce the risk of hypoxia Electrolyte Ranges o Na: 135 – 145 mEq/dL o Ca: 9 – 10.5 mg/L o K: 3.5 – 5 mEq/ L o Mg: 1.3 – 2.1 mEq/L 40. A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? a. Stabilizing the position of the tube b. Preventing aspiration of secretions c. Preventing air leaks 41. A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? a. Coat the tip of the tip of the tube with a water-soluble lubricant b. Ask the client to swallow water while the tube enters her throat c. Tell the client to tilt her head backward as insertion beings 42. A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain. The client asks the nurse how TENS unit helps relieve pain. Which of the following response should the nurse make? a. “it modulates the transmission of the pain impulses” 43. A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? a. Circle the injection area with a pen Explanation o Circling the area with a pen ensures the nurse will examine the correct site when reading the test 48 – 72 hours later 44. A nurse is preparing to change a dressing on a client is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? a. Turn off the vacuum on the NPWT device and administer the prescribed analgesic  remove the soiled dressing and perform hand hygiene  apply sterile or clean gloves and irrigate the wound  apply a skin protectant on a barrier film to the skin around the wound  place prepared foam into the wound bed and cover with a transparent dressing  connect the tubing to transparent film and turn on the NPWT unit Types of Spine Abnormalities o Scoliosis: C- shaped spinal column and uneven shoulder or hip heights o Lordosis: exaggeration of the anterior convex curvature in the lumbar region o Torticollis: head inkling toward the affect side with a contraction of the sternocleidomastoid muscle o Kyphosis: increased convex curvature in the thoracic region of the spine