ATI NCLEX Fundamentals Assessment 1 questions and solutions

ATI NCLEX Fundamentals Assessment 1 questions and
solutions

A nurse is performing blood glucose monitoring for a client. After identifying the client and performing hand hygiene, in
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what order should the nurse take the following steps?
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A. Apply clean gloves
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B. Hold the client's hand in a dependent position
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C. Clean the clients finger with an antiseptic
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D. Apply the blood to the test strip
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E. Have the client wash their hands
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F. Puncture the lateral side of the clients finger to obtain blood - answersCorrect order:
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E. Have the client wash their hands
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A. Apply clean gloves
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B. Hold the client's hand in a dependent position
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C. Clean the clients finger with an antiseptic
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F. Puncture the lateral side of the clients finger to obtain blood
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D. Apply the blood to the test strip
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Wash hands first to reduce the presence of micro-organisms. Then apply gloves to prevent blood contamination. Then
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hold the clients hand in a dependent position to increase blood flow to the fingertips. Do not squeeze the finger! Then cle
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the site, allow it to try. Chose a lateral side to avoid many nerve endings. Puncture the site, wipe away the first drop of blo
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(has fewer RBC and may have serous fluid), then apply the second drop of blood to the strip.
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A nurse is providing discharge instructions to a client who has a new gastrostomy tube. Which of the following statemen
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by the client indicates an understanding of the instructions?
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A. "I can sit up in a chair during the feeding"
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B. "I'll replace the bag and tubing every week"
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C. "I'll keep the formula cold until I begin the feeding"
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D. "I don't have to worry about the placement of the tube, because my nurses have already checked that" - answersA
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The clients head should be elevated at 30-45 degrees during the feeding. They can be in bed with their head raised, sittin
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in a chair, or ambulating as long as their head is at 30-45 degrees. Never be supine, causes aspiration!
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B, the tubing and bag should be replaced every 24 hours to prevent bacterial growth. Other things to do: clean top of
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formula can before opening, avoid touching the opening of the feeding container and other parts of tubing that come in
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contact with the formula
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C, enteral formula should be kept at room temperature! Cold causes gastric gramps, nausea,and vomiting.
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D, the caregiver should check the pH level of secretions before feedings
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A client is reviewing data for a group of clients at the beginning of the shift. For which of the following clients should the
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nurse initiate a dietary referral?
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A. A client whose BMI is 23
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,B. A client who gained 1.8kg (4lbs) overnight after receiving IV fluids
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C. A client whose pre-albumin level is 11 mg/dL
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D. A client who has a sodium level of 140 mEq/L after taking a thiazide diuretic - answersC
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Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of acute nutritional changes!
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A, expected range of BMI is 18.5-24.9
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B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for fluid overload. However, th
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does not indicate a need for dietary referral.
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D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low sodium levels.
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A nurse is caring for a client who has died. Identify the sequence of steps the nurse should follow for postpartum care.
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A. Attach identification tags to the body
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B. Remove medical equipment from the body
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C. Cleanse the body while adhering to body-fluid precautions
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D. Verify the client's organ and tissue donation status
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E. Confirm that the provider certified and documented the death - answersCorrect order:
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E. Confirm that the provider certified and documented the death
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D. Verify the client's organ and tissue donation status
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B. Remove medical equipment from the body
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C. Cleanse the body while adhering to body-fluid precautions
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A. Attach identification tags to the body
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A nurse is caring for a client in a rehabilitation facility. The client says, "I am upset about not being able to attend my churc
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while living here." Which of the following responses should the nurse make
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A. "Have you attended services at this facility?"
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B. "You will be going home soon and can get back to church"
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C. "Perhaps your friend will pick you up for a church service"
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D. "I would like to hear more about your church" - answersD
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A nurse is preparing to teach a client who speaks a different language than the nurse about how to perform a dressing
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change. Which of the following actions should the nurse plan to take
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A. Speak loudly during the teaching session
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B. Request the services of an interpreter
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C. Ask a family member to translate for the client
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D. Simply communicate by asking "yes" or "no" questions - answersB
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A nurse is assessing a client who has a calcium level of 11.2 mg/dL. Which of the following findings should the nurse
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expect
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A. Positive Chvostek's sign
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B. Positive Trousseau's sign
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D. Hyporeflexia - answersD
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Expected calcium range: 9.0-10.5. This pt has hypercalcemia. Manifestations include hyporeflexia, lethargy, fatigue,
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anorexia, confusion, nausea, vomiting, and constipation.
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