ATI fundamentals practice test B with 100% correct answers

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? compare prescriptions with medications the client received while are the facility A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider? medication dose: In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. A nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. A client who has history of physical abuse b. A client who has a permanent pacemaker c. A client who has ulcerative colitis d. A client who has asthma d. A client who has asthma: Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma. A nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate? droplet: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? gently shake the container of medication prior to administration: The nurse should gently shake the liquid medication to ensure that the medication is mixed. A nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following? narrowed arterial lumen: Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? withhold the blood transfusion: The principle of autonomy ensures that a client who is competent has the right to refuse treatment. A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include? a. Client flow sheet b. Acuity ratings c. Current medications d. Incident reports c. Current medications: The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care. A nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene? erythema on pressure points: Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. A nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning? practice sessions: Practice sessions require psychomotor skills when learning. A nurse is caring for a client who reports pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain." b. "The pain is like a dull ache in my stomach." c. "I notice that the pain gets worse after I eat." d. "The pain makes me feel nauseous." b. "The pain is like a dull ache in my stomach.": The client is describing the quality of the pain, which is how the pain feels in the client's own words. the nurse should obtain a description of how the pain feels or specify the intensity. A nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? a. Insert an implanted port. b. Close a laceration with sutures. c. Place an endotracheal tube. d. Initiate an enteral feeding through a gastrotomy tube. d. Initiate an enteral feeding through a gastrotomy tube: implanted ports and other central venous devices requires insertion by a physician, surgeon, or advanced practice nurse. Surgeons and other physicians close wounds with sutures. Physicians and clinicians with special training insert endotracheal tubes. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? evacuate the client A nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use? I can take echinacea to improve my immune system: Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion. A nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident? client found lying on floor: The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause. A nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use? have the client stand with their arms at their sides and their feet together: A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance. A nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." b. "I should place my crutches 12 inches in front and to the side of each foot." c. "As I sit down, I will hold one crutch in each hand." d. "I will make sure the shoulder rests are snug against my armpits." a. "When descending stairs, I will first shift my weight to my right leg.": To descend stairs, the client should first shift his body weight to the unaffected leg. The client should place crutches 15 cm in front and to the side of each foot. Just before sitting down, the client should hold both crutches by their hand bars in one hand. To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? flush the tube with 15 mL of sterile water A community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension? a client who smokes one pack of cigarettes each day A nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. Assign a staff member to feed the client b. Provide small-handed utensils for the client c. Thicken liquids on the client's tray d. Arrange food in a consistent pattern on the client's plate d. Arrange food in a consistent pattern on the client's plate A nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include? you should receive a pneumococcal immunization every 10 years: 1. Older adults should have an eye examination every year. Older adults should receive a tetanus booster every 10 years. Older adult clients will receive a shingles vaccine when they are 60 years old. Older adult clients will receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect? a. Neck vein distention b. Urine specific gravity 1.010 c. Rapid heart rate d. Blood pressure 144/82 mmHg c. Rapid heart rate: Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Typically, a client's specific gravity is greater than 1.030 in the presence of fluid volume deficit. JVD is a manifestation of fluid volume excess. A nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? auscultate lung sounds: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. A nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? apply an ankle-foot orthotic device to the client's feet A nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client? N95 respirator A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? wrap monitoring cords with stockinette and tape them in place: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. A nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? a. Hypotension b. Weak, thready pulse c. Slow capillary refill d. Distended neck veins d. Distended neck veins: Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure. Hypotension, weak thready pulse, decrease in capillary refill = fluid volume deficit. a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown? have the client use a trapeze bar when changing position: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development. A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take? instruct the family to refrain from pushing the button for the client while she is asleep: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development. A nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement? an x-ray shows the end of the tube above the pylorus A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse? a. The caregiver is the client's financial power of attorney b. The client is in a wheelchair with the wheels locked c. The client reports receiving a full bath twice each week d. The caregiver insists on remaining in the room d. The caregiver insists on remaining in the room: A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. A is necessary. B is a matter of safety. C is sufficient. A nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next? a. Rock the client up to a standing position b. Pivot on the foot that is the furthest from the chair c. Assess the client for orthostatic hypotension d. Apply a gait belt to the client c. Assess the client for orthostatic hypotension: The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair. All other actions are appropriate however not a priority. A nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care? wrap blankets around all four sides of the bed: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures. A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family? 1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take first? tell the client to keep the head of the bed elevated at least 30 degrees: the first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advance directives. which of the following responses should the nurse make? we can talk about advance directives, and i can also give you some brochures about them A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea 8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. 1 oz = 30 mL; 8 oz = 1 cup 2 cups = 480 mL 1 quart water = 960-1,000 mL 6 oz = 180 mL A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining blood pressure? the one close to 120 mm Hg: To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff. A nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take? cleanse the wound from the center outward: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation. A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting d. Have family members wear a gown and gloves when visiting The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. A nurse is caring for a client who requires a 24 hr urine collection. which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine." b. "I have a specimen in the bathroom from about 30 minutes ago." c. "I flushed what I urinated at 7:00 am and have saved all urine since." d. "I drink a lot, so I will fill up the bottle and complete the test quickly." c. "I flushed what I urinated at 7:00 am and have saved all urine since.": For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voiding. Urine should be free of feces. Urine should be placed in the container immediately and kept on ice or in the refrigerator. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure 1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle