ATI Nursing Fundamentals Final Exam with Complete Questions and Answers

ATI Nursing Fundamentals Final Exam with Complete Questions and Answers a nurse is assessing a client who has required 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 b. decreased blood pressure c. calf swelling d. diminished bowel sounds - CORRECT ANSWER c. calf swelling a nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down & back toward her head d. tilt the client's head backward for 5 min. - CORRECT ANSWER a. press gently on the tragus of the client's ear a nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. which of the following actions should the nurse take? a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails - CORRECT ANSWER a. pad the client's wrist before applying the restraints a nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? a. verify the client's name on their identification bracelet w/ the MAR b. call the pharmacy to determine whether the client's medications are available c. compare the client's home medications w/ the provider's prescriptions d. place the client's home medication bottles in a secure location - CORRECT ANSWER c. compare the client's home medications w/ the provider's prescriptions 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. use a leading zero if it applies. do not use a trailing zero) a. 186 mL/hr b. 150 mL/hr c. 280 mL/hr d. 107 mL/hr - CORRECT ANSWER d. 107 mL/hr a nurse is planning care for a client who has had a stroke, resulting in aphasia & dysphagia. which of the following tasks should the nurse assign to an assistive personnel (AP)? (select all that apply) a. assist the pt w/ a partial bed bath b. measure the pt's BP after the nurse administers an antihypertensive medication c. test the pt's swallowing ability by providing thickened liquids d. use a communication board to ask what the pt wants for lunch e. irrigate the pt's indwelling urinary catheter - CORRECT ANSWER a. b. d. a nurse is using an open irrigation technique to irrigate a pt's indwelling urinary catheter. which of the following actions should the nurse take? a. place the pt in a side-lying position b. instill 15 mL of irrigation fluid into the catheter w/ each flush c. subtract the amt of irrigant used from the pt's urine output d. perform the irrigation using a 20-mL syringe - CORRECT ANSWER c. subtract the amt of irrigant used from the pt's urine output a home health nurse is performing a follow-up visit for a client who has a gastronomy tube through which they receive intermittent feedings & medications. the pt has recently developed diarrhea. which of the following findings should the nurse identify as a possible cause of the diarrhea? a. the pt is receiving formula at room temp b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the pt's caregiver washes out the feeding bag w/ warm water once every 24 hr d. the pt's caregiver flushes the tube w/ water before & after administering medications - CORRECT ANSWER c. the pt's caregiver washes out the feeding bag w/ warm water once every 24 hr a nurse is initiating a protective environment for a pt who has had an allogenic stem cell transplant. which of the following precautions should the nurse plan for this pt? a. make sure the pt's room has at least six air exchanges per hour b. make sure the pt wears a mask when outside her room if there is construction in the area c. place the pt in a private room w/ negative-pressure airflow d. wear an N95 respirator when giving the pt direct care - CORRECT ANSWER b. make sure the pt wears a mask when outside her room if there is construction in the area a nurse is caring for a pt who is postoperative & is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the pt's vital signs every 15 min & report back in 1 hr. which of the following actions should the nurse take next? a. document the provider's statement in the medical record b. complete an incident report c. consult the facility's risk manager d. notify the nursing manager - CORRECT ANSWER d. notify the nursing manager a nurse is planning to insert a peripheral IV catheter for an older adult pt. which of the following actions should the nurse plan to take? a. insert the catheter at a 45° angle b. place the pt's arm in a dependent position c. shave the excess hair from the insertion site d. initiate IV therapy in the veins of the hand - CORRECT ANSWER b. place the pt's arm in a dependent position a nurse is caring for a pt who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the pt? a. use a bed exit alarm system b. raise four side rails while the pt is in bed c. apply one soft wrist restraint d. dim the lights in the pt's room - CORRECT ANSWER a. use a bed exit alarm system a nurse is talking w/ the partner of a pt who has dementia. the pt's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. the nurse should identify that the partner is experiencing which of the following types of role-performance stress? a. role ambiguity b. sick role c. role overload d. role conflict - CORRECT ANSWER c. role overload a nurse is caring for a pt who has a terminal illness & is at the end of life. the nurse should recognize that which of the following statements by the pt's partner indicates effective coping? a. "i am not worried bc i still have hope that he will be okay" b. "i am relying on support from our family during this time" c. "we can plan our family reunion once he recovers & comes home" d. "we don't see any reason to start discussing funeral arrangements right now" - CORRECT ANSWER b. "i am relying on support from our family during this time" a nurse is administering 1 L of 0.9% sodium chloride to a pt who is postoperative & has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful? a. increase in hematocrit b. increase in respiratory rate c. decrease in heart rate d. decrease in capillary refill time - CORRECT ANSWER c. decrease in heart rate a nurse is planning strategies to manage time effectively for pt care. which of the following strategies should the nurse implement? a. combine pt care tasks when caring for multiple pts b. wait until the end of shift to document pt care c. use the planning step of the nursing process to prioritize pt care delivery d. allow for interruptions in tasks to discuss pt care issues w/ colleagues - CORRECT ANSWER c. use the planning step of nursing process to prioritize pt care delivery a nurse is providing discharge instructions to a pt who will be using a walker. which of the following pt statements indicates an understanding of the teaching? a. "i can place an extension cord across my living room to plug in my TV" b. "i will hire someone to trim the tree that hangs low over the stairs of my front porch" c. "i will place my alarm clock on my bedroom dresser across the room" d. i will replace the old throw rug in my kitchen w/ a new one" - CORRECT ANSWER b. "i will hire someone to trim the tree that hangs low over the stairs of my front porch" a nurse is assessing four adult pts. which of the following physical assessment techniques should the nurse use? a. use the face, legs, activity, cry, & consolability (FLACC) pain rating scale for a pt who is experiencing pain b. ensure the bladder of the blood pressure cuff surrounds 80% of the pt's arm c. obtain an apical heart rate by auscultating at the third intercostal space left of the sternum d. palpate the pt's abdomen before auscultating bowel sounds - CORRECT ANSWER b. ensure the bladder of the blood pressure cuff surrounds 80% of the pt's arm a nurse is admitting a pt who is having an exacerbation of heart failure. in planning this pt's care, when should the nurse initiate discharge planning? a. during the admission process b. as soon as the pt's condition is stable c. during the initial team conference d. after consulting w/ the pt's family - CORRECT ANSWER a. during the admission process a nurse is caring for a pt who has a pharyngeal diphtheria. which of the following types of transmission precautions should the nurse initiate? a. contact b. droplet c. airborne d. protective - CORRECT ANSWER b. droplet a nurse is performing a skin assessment for a pt who expresses concern about skin cancer. which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. a lesion w/ uniform pigmentation b. new appearance of petechiae c. a mole w/ an asymmetrical appearance d. the presence of a papule - CORRECT ANSWER c. a mole w/ an asymmetrical appearance a nurse is caring for a pt who asks about the purpose of advance directives. which of the following statements should the nurse make? a. "they allow the court to overrule an adult pt's refusal of medical treatment" b. "they indicate the form of treatment a pt is willing to accept in the event of a serious illness" c. "they permit a pt to withhold medical information from health care personnel" d. "they allow health care personnel in the emergency department to stabilize a pt's condition" - CORRECT ANSWER b. "they indicate the form of treatment a pt is willing to accept in the event of a serious illness" a nurse is caring for a pt who has herpes zoster & asks the nurse about the use of complementary & alternative therapeutics for pain control. the nurse should inform the pt that this condition is a contraindication for which of the following therapies? a. biofeedback b. aloe c. feverfew d. acupuncture - CORRECT ANSWER d. acupuncture a nurse is assessing a pt who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the pt's pain? a. "is your pain constant or intermittent?" b. "what would you rate your pain on a scale of 0 to 10?" c. "does the pain radiate?" d. "is your pain sharp or dull?" - CORRECT ANSWER d. "is your pain sharp or dull?"