ATI fundamentals practice A questions with correct answers

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 1. The top of the cane is parallel to the client's waist. 2. When walking, the client moves the cane 46 cm (18 in) forward. 3. The client holds the cane on the stronger side of her body. 4. The client moves her stronger limb forward with the cane. Correct Answer - 3 The client should hold the cane on the stronger side of her body to increase support and maintain alignment. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions should the nurse take first? 1. Reposition the client. 2. Document the client's IV intake in the medical record. 3. Request a new IV fluid prescription. 4. Check the IV tubing for obstruction. Correct Answer - 4 The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. 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° prior to insertion of the NG tube.