ATI Standard Quiz- Fundamentals Final Questions & Answers

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation - ANSWERSA A nurse is providing discharge to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes - ANSWERSD A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increase urinary output C. Tachycardia D. Bradypnea - ANSWERSC Rationale: Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse first? A. Inspection B. Auscultation C. Percussion D. Palpation - ANSWERSA A nurse is responding to a parents question about his infants expected physical development during the first year of life. Which of the following information should the nurse include? A. A 2 month old infant can turn from his abdomen to his back B. A 10 month old infant can pull up to a standing position C. A 4 month old infant can sit up without support D. A 6month old infant can crawl on his hands and knees - ANSWERSB A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the clients respirations C. Prepare to administer oxygen D. Give the client a back rub to help her relax - ANSWERSB A nurse is planning to insert a NG tube for a client after explaining the procedure. The client states, "you are not putting that hose down my throat". Which of the following statements should the nurse make? A. I would try to get it over with because you won't get better without this tube B. You should talk to your provider about it C. Why dont you want the tube inserted? D. I can see that this is upsetting you - ANSWERSD An assistive personnel is assisting a nurse with the care of a female client who has a indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area B. The AP tapes the catheter to the clients inner thigh C. The AP hangs the collection bag at the level of the bladder D. The AP ensures that there are no kinks in the drainage tubing - ANSWERSC A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form that has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiography of the kidneys, ureters, and bladder C. A client who has a prescription for a TB test D. A client who has a distended bladder and needs urinary catherization - ANSWERSA A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500mg/day of vitamin E C. Limit fluid intake to 20mL/kg of body weight per day D. Provide a protein intake of 1.5g/kg of body weight per day - ANSWERSD A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed B. Tie the restraint with a quick release knot C. Allow one finger beneath between the restraint and the clients chest D. Place the restraint under the clients clothing - ANSWERSB A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. Two point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test - ANSWERSD A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A. Carminative B. Hypertonic C. Oil retention D. Sodium polystyrene sulfate - ANSWERSC A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. intake and output - ANSWERSA A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan of care based on which of the following factors contributing to this postoperative complication? A. Blood loss B. NPO status after surgery C. NG suctioning D. Impaired peristalsis of the intestines - ANSWERSD A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouth piece with an alcohol swab after each use D. Use the spirometer every 8 hours - ANSWERSC A nurse is teaching a client who has lower extremity weakness how to use a four point crutch gait. Which of the following instructions should the nurse include in the teaching? A. Support the majority of your weight on the axillae B. Keep elbows extended C. Bear weight on both of your legs D. Move both crutches forward at the same time - ANSWERSC A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice - ANSWERSB A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pain from the extinguisher D. Sweep the hose from side to side to dispense material - ANSWERSC A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish brown urine in the clients urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis - ANSWERSA A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the clients provider and verify the prescription D. Ask the client if she takes this medication at home - ANSWERSA Rationale: A nurse must have knowledge about medications to administer them safely. The nurse should become familial with the medication by looking it up it in the medication reference on the unit A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the clients wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the clients surgeon D. Reassure the client - ANSWERSA Rationale: The nurse should apply the safety and risk reduction priority setting framework when caring for this client. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert rectal tube 15.2cm (6in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36in) above the clients rectum - ANSWERSC A nurse in a long term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A. A lot of clients who are cared for at home have the same problem B. Dont worry about it. He will get a bath, and that will take care of the odor C. It must be difficult to care for someone who is confined to bed D. When was the last time that he had a bath - ANSWERSC