ATI fundamentals practice test A
ANS-wrap monitoring cords with stockinette and tape them in place (rationale: many cords have
latex, cover them with a non-latex barrier)In preparation for the client's procedure, which of the
following precautions should the nurse take? ANS-wrap monitoring cords with stockinette and
tape them in place A client with an abdominal wound that has a lot of purulent drainage is being
admitted by a nurse. The nurse should take which of the following transmission precautions:
ANS-contact precautions ANS-distended neck veins (rationale: fluid volume excess symptoms
include distended neck veins, edema, tachycardia, crackles, dyspnea, a bounding pulse, and an
increase in blood pressure) - 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
bounding pulse and an increase in blood pressure A nurse is caring for a client who is
postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon,
who tells the nurse to continue to measure the client's vital signs every 15 min and to report
back in 1 hr Which of the following actions should the nurse take next - ANS-notify the nursing
manager (rationale: go up the chain of command)
A nurse is caring for a client who is postoperative. They tell the nurse, "Every time you change
my bandage, it hurts so much," as they get ready to change the client's dressing. Which of the
following is the nurse's priority action? - ANS-administer pain medication 45 minutes before
changing the client's dressing - ANS-withhold the blood transfusion (rationale: principle of
autonomy ensure a client who is competent has the right to refuse treatment) A nurse is caring
for a client who refuses a blood transfusion for religious reasons. The client's partner wants the
client to have the blood transfusion. A client with heart failure is the subject of a nurse's
evaluation of the teaching. Which of the following 3 statements by the client indicates an
understanding of the teaching? - ANS-"I have been weighing myself every other morning" is
incorrect. The client should weigh in every day to monitor for fluid retention.
The statement "I am trying to reduce the amount of potassium in my diet" is incorrect. The client
took more furosemide, which can cause more potassium to be eliminated. Increasing potassium
intake is a lifestyle modification that is important in controlling hypertension.
It is true that "I am limiting my sodium intake to 2 grams daily." The recommended daily sodium
intake for heart failure patients is 2 to 3 g. "I am eating fewer potato chips and more fruit for
snacks" is correct. Chips are a processed snack food that contains high levels of sodium.
Additionally, fruits contain electrolytes and fiber, both of which are important to controlling blood
pressure and lipid levels.
"I lie down and rest after meals" is incorrect. The client should be taught to lie down and rest
before meals as eating requires energy and oxygen consumption. The client should also be
instructed to eat small, frequent meals rather than large meals to help relieve shortness of
breath and fatigue.
It is true that "I know to call my doctor if I gain 3 pounds or more in two days." The client should
monitor weight on a daily basis and call the provider for a weight gain of 1.36 kg (3 lb) or more
in 2 days to prevent an exacerbation of their heart failure.
ANS-wrap monitoring cords with stockinette and tape them in place (rationale: many cords have
latex, cover them with a non-latex barrier)In preparation for the client's procedure, which of the
following precautions should the nurse take? ANS-wrap monitoring cords with stockinette and
tape them in place A client with an abdominal wound that has a lot of purulent drainage is being
admitted by a nurse. The nurse should take which of the following transmission precautions:
ANS-contact precautions ANS-distended neck veins (rationale: fluid volume excess symptoms
include distended neck veins, edema, tachycardia, crackles, dyspnea, a bounding pulse, and an
increase in blood pressure) - 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
bounding pulse and an increase in blood pressure A nurse is caring for a client who is
postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon,
who tells the nurse to continue to measure the client's vital signs every 15 min and to report
back in 1 hr Which of the following actions should the nurse take next - ANS-notify the nursing
manager (rationale: go up the chain of command)
A nurse is caring for a client who is postoperative. They tell the nurse, "Every time you change
my bandage, it hurts so much," as they get ready to change the client's dressing. Which of the
following is the nurse's priority action? - ANS-administer pain medication 45 minutes before
changing the client's dressing - ANS-withhold the blood transfusion (rationale: principle of
autonomy ensure a client who is competent has the right to refuse treatment) A nurse is caring
for a client who refuses a blood transfusion for religious reasons. The client's partner wants the
client to have the blood transfusion. A client with heart failure is the subject of a nurse's
evaluation of the teaching. Which of the following 3 statements by the client indicates an
understanding of the teaching? - ANS-"I have been weighing myself every other morning" is
incorrect. The client should weigh in every day to monitor for fluid retention.
The statement "I am trying to reduce the amount of potassium in my diet" is incorrect. The client
took more furosemide, which can cause more potassium to be eliminated. Increasing potassium
intake is a lifestyle modification that is important in controlling hypertension.
It is true that "I am limiting my sodium intake to 2 grams daily." The recommended daily sodium
intake for heart failure patients is 2 to 3 g. "I am eating fewer potato chips and more fruit for
snacks" is correct. Chips are a processed snack food that contains high levels of sodium.
Additionally, fruits contain electrolytes and fiber, both of which are important to controlling blood
pressure and lipid levels.
"I lie down and rest after meals" is incorrect. The client should be taught to lie down and rest
before meals as eating requires energy and oxygen consumption. The client should also be
instructed to eat small, frequent meals rather than large meals to help relieve shortness of
breath and fatigue.
It is true that "I know to call my doctor if I gain 3 pounds or more in two days." The client should
monitor weight on a daily basis and call the provider for a weight gain of 1.36 kg (3 lb) or more
in 2 days to prevent an exacerbation of their heart failure.
