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Exam (elaborations)

ATI FUNDAMENTAL PRACTICE QUESTIONS

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1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements indicates an understanding of the teaching? a. I had a bowel movement, but I was able to save the urine – should be free of feces b. I have a specimen in the bathroom from about 30 minutes ago- Client should place any urine in the container immediately and keep it on ice or in the fridge. c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24 hr urine collection, the client should discard the first voiding and save all subsequent voiding. d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified amount 2. 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? a. Bladder distention – urinary retention which causes bladder distension is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles b. Decreased blood pressure – client on bed rest can develop postural hypotension. Drop in BP when the client moves from a lying to a sitting position. Nurse should assess for pulse rate and dizziness. c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations of thrombophlebitis, a common complication of immobility d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis. Constipation is common complication of immobility. 3. 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? a. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse – any healthcare professional directly caring for a client has access to the medical information.

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