ATI RN fundamentals Practice Assessment (CORRECTLY ANSWERED)

ATI RN fundamentals Practice Assessment (CORRECTLY ANSWERED)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? 1. Ask another nurse to observe the medication wastage 2. Notify the pharmacy when wasting the medication 3. Lock the remaining medication in the controlled substances cabinet 4. Dispose of the vial with the remaining medication in sharps container 1. Ask another nurse to observe the medication wastage rationale: A second nurse must witness the disposal of any portion of a dose of a controlled substance A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number). 107 mL/hr rationale: 750/7 = 107 mL/hr A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? 1. "We would consult the person appointed by your health care proxy to make decisions" 2. "We would give you oxygen through a tube in your nose" 3. "You would be unable to change your previous wishes about your care" 4. "We would insert a breathing tube while we evaluate your condition" 2. "We would give you oxygen through a tube in your nose" rationale: Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. 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 actions is the nurse's priority? 1. Request that a respiratory therapist discuss the technique for incentive spirometry with the client 2. Determine the reasons why the client is refusing to use the incentive spirometer 3. document the client's refusal to participate in health restorative activities 4. Administer a pain medication to the client 2. Determine the reasons why the client is refusing to use the incentive spirometer. rationale: The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment A nurse on a medical-surgical unit is caring for a client for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? 1. Pad the client's wrist before applying the restraints 2. Evaluate the client's circulation every 8 hours after application 3. Remove the restraints every 4 hours to evaluate the client's status 4. Secure the restraint ties to the bed's side rails 1. Pad the client's wrist before applying the restraints rationale: The use of restraints without padding can abrade the client's skin, resulting in client injury A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? 1. "You would have so much more time to spend with your family" 2. "You should consider getting a part-time job or doing volunteer work" 3. "Let's talk about how the change in your job status will affect you" 4. "Why wouldn't you want to retire and relax?" 3. "Let's talk about how the change in your job status will affect you" rationale: This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? 1. Contact 2. Droplet 3. Airborne 4. Protective 2. Droplet rationale: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? 1. Carry a client's soiled linens out of the room in a mesh linen bag 2. place a client who has TB in a room with negative-pressure airflow 3. Provide disposable plates and utensils for a client who is HIV-positive 4. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag 2. Place a client who has tuberculosis in a room with negative-pressure airflow rationale: A client who has TB requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) pupil clarity, visual fields, and visual acuity A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body 4. Ask the client's family members if they would like to view the body 5. Place a name tag on the body. rationale: The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? 1. "I think I should take my pain medication more often, since it is not controlling my pain" 2. "Breathing faster will help my keep my mind off of the pain" 3. " It might help me to listen to music while I'm lying in bed" 4. "I don't want to walk today because I have some pain" 3. "It might help me listen to music while I'm lying in bed" rationale: Listening to music is an effective non-pharmacological intervention for the management of mild pain A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 1. Remove the outer cannula cautiously for routine cleaning 2. Use tracheostomy covers when outdoors 3. Use sterile technique when performing tracheostomy care at home 4. Cleanse irritated skin with full-strength hydrogen peroxide 2. Use tracheostomy covers when outdoors. rationale: Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family 1. During the admission process rationale: Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? 1. "Is your pain constant or intermittent?" 2. What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?" 4."Is your pain sharp or dull?" Rationale: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? 1. Examine personal values about the issue 2. Tell the parents that this is a necessary procedure 3. Inform the parents that the staff does not require their consent 4. Contact a spiritual support person to explain the importance of the procedure 1. Examine personal values about the issue rationale: Nurses should examine their own personal values about the issue in question in order to provide care that is without bias A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L Potassium 5.4 mEq/L rationale: This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? 1. Insert the suction catheter while the client is swallowing 2. Apply intermittent suction when withdrawing the catheter 3. Place the catheter in a location that is clean and dry for later use 4. Hold the suction catheter with her clean, nondominant hand 2. Apply intermittent suction when withdrawing the catheter. rationale: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? 1. Numbness of the extremities 2. Bradycardia 3. Positive Chvostek's sign 4. Abdominal cramping 4. Abdominal cramping rationale: This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? 1. "I can concentrate best in the morning" 2. "It is difficult to read the instructions because my glasses are at home" 3. "I'm wondering why i need to lean this" 4. "You will have to talk to my wife about this" 1. "I can concentrate best in the morning" rationale: The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn 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? 1. Critical pathway 2. SBAR 3. Transfer report 4. MAR 2. SBAR rationale: SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? 1. "I will return shortly after I document this in your record" 2. "Most men live a long time with prostate cancer" 3. "I am available to talk if you should change your mind" 4. "I will make a referral to a cancer support group for you" 3. "I am available to talk if you should change your mind" rationale: When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? 1. Document the provider's statement in the medical record 2. Complete an incident report 3. Consult the facility's risk manager 4. Notify the nursing manager 4. Notify the nursing manager rationale: The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care A nurse is preparing an education program for a staff about advocacy. Which of the following information should the nurse include? 1. Advocacy ensures clients' safety, health, and rights 2. Advocacy ensures that nurses are able to explain their own actions 3. Advocacy ensures that nurses follow through on their promises to clients 4. Advocacy ensures fairness in client care delivery and use of resources 1. Advocacy ensures clients' safety, health, and rights rationale: Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care 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? 1. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube 2. Remove the NG tube if the client begins to gag or choke 3. Apply suction to the NG tube prior to insertion 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus rationale: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1. "I can place an extension cord across my living room to plug in my television" 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" 3. "I will place my alarm clock on my bedroom dresser across the room" 4. "I will replace the old throw rug in my kitchen with a new one" 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" rationale: Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? 1. Have the client wear a mask when receiving visitors 2. Limit the client's time with visitors to no more than 30 minutes per day 3. Assign the client to a room with negative-pressure airflow exchange 4. Wear a gown when caring for the client 4. Wear a gown when caring for the client rationale: The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? 1. Use a bed exit alarm system 2. Raise four side rails while the client is in bed 3. Apply one soft wrist restraint 4. Dim the lights in the client's room 1. Use a bed exit alarm system rationale: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? 1. Encourage the client to relax and take deep breaths during the dressing change 2. Educate the client about the importance of the dressing change to prevent infection 3. Assist the client to a comfortable position for the dressing change 4. Administer pain medication 45 min before changing the client's dressing 4. Administer pain medication 45 min before changing the client's dressing rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.