ATI FUNDAMENTALS EXAM QUESTIONS & ANSWERS (SCORED A+)

ATI FUNDAMENTALS EXAM QUESTIONS & ANSWERS (SCORED A+) 100% VERIFIED LATEST UPDATE A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? Tell the nurses that this conversation is not appropriate. A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? Ask the client what he already knows about meal planning. A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? Use warm water when bathing the client. A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? A client who has measles. A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? Actual loss. A nurse is reinforcing teaching with a new parent of an infant who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? I will remove all stuffed animals from my baby's crib. A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? The client has redness and warmth in his calf. A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? Stand with your feet together and your arms at your sides. A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? You should cleanse your eye from the inner to the outer edge prior to putting in the drops. A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. 1. Assess the client's gag reflex 2. Position the client on his side with his head turned to the side 3. Place a towel under the client's head with an emesis basin under his chin. 4. Separate the client's upper and lower teeth with an oral airway device 5. Cleanse the client's mouth using a toothbrush A nurse in a long term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? Choose a private room for the interview A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? It must be difficult facing this type of surgery. A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? Instruct the client to tilt her head forward while eating A nurse in an acute care setting is documenting postmortem care for a client. Which of the following information should the nurse include in the documentation? Release of personal belongings form A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? I know i can change my advance directives if i need to in the future A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? 3 + pitting edema A nurse is preparing to obtain a client's vital signs. When washing her hands, which of the following actions should the nurse take? Turn off the faucet with a clean paper towel after drying hands A nurse is caring for a group of clients in a long term care facility. Which of the following actions should the nurse take to prevent health care associated infections for these clients? 1. Wash hands after removing gloves 2. Use antimicrobial hand gel after refilling the client's water pitcher 3. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs A nurse in a provider's office is providing care for a middle adult client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? Take Vitamin D supplements A client who is scheduled to undergo surgery tells the nurse that she does not understand the procedure and is reconsidering her decision to have it. Which of the following actions should the nurse take? Notify the charge nurse of the client's concerns A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching? I should remove constrictive clothing prior to measuring my blood pressure A nurse working in a community clinic is talking with an older adult client who states that his life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? Ego integrity vs. despair A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the clients indicates an understanding of the teaching? I should turn on the ceiling fan to block out unwanted noise. A nurse is checking a client's muscle strength. Which of the following techniques should the nurse use? The client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider? A purple-colored stoma A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following entities? A physical therapist who is involved in the client's care A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? Pale, scaly skin A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions? Orthopneic A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A client who has just experienced the death of his child A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority? The client's output was 60 mL for the past 3 hr A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching? You should cover your mouth with a tissue when you cough A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask? Have you had small liquid stools? A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following actions should the nurse recommend to include in the plan? Support the client's feet with foot boots A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take? Measure the client's gastric residual before each feeding A nurse is caring for an older adult client who has advanced rheumatoid arthritis but seldom requests pain medication. Which of the following actions should the nurse take? Observe the client for nonverbal indications of pain A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? Please don't tell my doctor, but i am taking my partner's oxycodone A nurse is documenting client care in a client's electronic health record. Which of the following statements should the nurse include in the documentation? The client became short of breath when ambulating A nurse is caring for a client who has a prescription for a high protein diet to promote wound healing following surgery. The client's religion prohibits eating mean on particular days. Which of the following actions should the nurse take? Ask the dietitian to recommend alternative food choices for the client A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? Urine specific gravity 1.045 A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? I will place a gel pad directly above your pubic area before i place the probe A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? Removing and inverting a lid before placing it onto a nonsterile surface A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions should the nurse take to maintain the client's confidentiality while providing care? Provide information to another nurse at change of shift A nurse is caring for a client who is receiving chemotherapy and has stomatitis. Which of the following actions should the nurse take to reduce the client's discomfort? Use 0.9% sodium chloride solution to rinse the client's mouth. A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences? Do you consume pork products? A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? Tighten your stomach muscles A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh? 13.6 A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? Remove the staple from the skin after both sides are visible A nurse is planning to administer medication to a client who has a Clostridium difficile infection. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? Remove the cover gown in the client's room after providing care A nurse is administering an intramuscular (IM) injection to an adult client. Which of the following actions should the nurse take? Identify the landmarks for the ventrogluteal site before cleaning the skin A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? Guided imagery A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? Put the client's bed in the lowest position A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that she is afraid to go to sleep, fearing she will not wake up. Which of the following is a therapeutic response the nurse should make? Describe your concerns about sleeping to me A nurse is caring for a client who has breast cancer and expresses fear about the future. Which of the following responses should the nurse make? You seem really afraid. Let's talk more about your feelings A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? Clean the perineal area at least once a day A nurse is collecting data from a client who requires bed rest and reports abdominal discomfort. The nurse notes abdominal distention. Which of the following conditions should the nurse identify as an adverse effect of bed rest? Constipation A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to sure client safety? Attach a humidifier to the case of the flow meter A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? 1. Keep the family updated about the client's status 2.Encourage the family to comb the client's hair 3. Tell the client's family what to expect as the client's death nears A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? Latex A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? Count the client's radial and apical pulses simultaneously with another nurse A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off her right left. Which of the following is the proper crutch gait for the client? Three-point A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? 1. Pre contemplation 2. Preparation 3. Maintenance 4. Action Pre contemplation A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following finding as indications that the client has fluid volume deficit? (Select all that apply) 1. Full bounding pulse 2. Decreased skin turgor 3. Moist crackles in the lungs 4. Orthostatic hypotension 5. Flat neck veins Decreased skin turgor, orthostatic hypotension, flat neck veins A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? 1. Explain the negative consequences of the refusal 2. Discuss with the client's partner why the treatment is necessary 3. Document the client's refusal of the treatment 4. Try to convince the client that the treatment is needed Document the client's refusal of the treatment A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? 1. Clamp the infusion tubing 2. Remove the dressing 3. Withdraw the catheter from the vein 4. Ensure the catheter is intact Clamp the infusion tubing A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication. 1. Provide an artificial voice box 2. Avoid using facial gestures 3. Speak to the client in a louder voice 4. Ask the client close-ended questions Ask the client close-ended questions A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? 1. Urine specific gravity 1.015 2. Hematocrit 42% 3. Urine pH 6.5 4. BUN 8mg/dl BUN 8mg/dl A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching? 1. Carbon monoxide gas smells like rotten eggs 2. Headache is a manifestation of carbon monoxide poisoning 3. A pulse oximeter is used to diagnose carbon monoxide poisoning 4. Dusky mucous membranes are an early indication of carbon monoxide poisoning Headache is a manifestation of carbon monoxide poisoning. A client who had a recent below the knee amputation says " I don't know how I can continue to live my life without my leg." Which of the following responses should the nurse make? 1. " You can have a prosthesis after your recovery has progressed." 2. " I am so sorry. I know I would hate to lose my leg." 3. " Tell me what concerns you have about your future." 4. " Your focus right now should be on recovering from the surgery." " Tell me what concerns you have about your future." A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? 1. "We will make sure she eats 3 meals a day." 2. "We will decrease her pain medication if she gets too drowsy." 3. "We will keep her room cool to help her breathe better." 4. "We will make sure to provide oral care twice a day." "We will keep her room cool to help her breathe better." A nurse is reinforcing teaching with an older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep? 1. The need for sleep diminishes with age. 2. Older adults have longer rapid eye movement periods 3. Sleep patterns change with age 4. Sleep apnea decreases with age Sleep patterns change with age A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? 1. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds 2. Use an adhesive oximetry probe for a client who has latex allergy 3. Remove polish from the client's fingernail before applying the oximetry probe 4. Lubricate the tip of the oximetry probe Remove polish from the client’s fingernail before applying the oximetry probe A nurse is reinforcing teaching with a client who is receiving PCA. Which of the following statements by the client indicates an understanding of the teaching? 1. "I will not allow anyone to press the PCA button for me." 2. "I will overdose if press the PCA button more than 6 times an hour." 3. "I will wait to press the PCA button until my pain is intolerable." 4. "I will inform my nurse of my pain level before I press the PCA button." "I will not allow anyone to press the PCA button for me" A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age related changes? 1. Body regulation of heat and cold increases with age. 2. Circulation becomes less efficient with age. 3. Increased metabolic rate occurs with age, increasing body temperature. 4. Sweat gland activity is increased with age Circulation becomes less efficient with age A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? 1. volunteer at the local food pantry 2. Attend an exercise program 3. Find an enjoyable hobby 4. Support environment conservation Attend an exercise program A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client’s bowel sounds. Which of the following actions should the nurse take? 1. Replace the NG tube. 2. Place the client in Sim's position 3. Decrease the rate of the feeding 4. Check the clients blood glucose Decrease the rate of the feeding A nurse is preparing to administer oxygen to a client who has a heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? 1. Nasal cannula 2. Simple face mask 3. Venturi mask 4. Nonrebreather mask Nonrebreather mask A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? 1. Confidentiality 2. Nonmaleficence 3. Accountability 4. Autonomy Autonomy A nurse is reinforcing teaching with a client about using guided imagery. Which of the following actions should the nurse take? 1. Instruct the client to alternately tighten and relax muscles 2. Evaluate the client's energy field 3. Attach electronic sensors to the client prior to beginning therapy 4. Direct the client to visualize tension leaving the body Direct the client to visualize tension leaving the body A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? 1. The client has smooth, brown, irregular lesions on the back of each hand. 2. The client has glossy, white circles around the periphery of the corneas. 3. The client reports urinary incontinence. 4. The client reports a decreased sense of taste The client reports urinary incontinence (this is not an expected age-related change) A nurse in contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? 1. Place client in a room with another client who has pharyngitis 2. Ensure that the client wears a surgical mask during transportation throughout the facility 3. Limit the clients family member visitation to 30 minutes 4. Provide the client a room with negative pressure airflow of six air exchanges per hr Ensure that the client wears a surgical mask during transportation throughout the facility A nurse is reinforcing teaching with client who has hearing loss about how to modify his home environment? Which of the following is a priority modification that the nurse should include? 1. Alarm clock that shakes the bed 2. Flashing smoke alarm 3. Low pitched buzzer doorbell 4. Telephone with an amplified receiver Flashing smoke alarm A nurse is reinforcing dietary teaching with a client who has a chronic kidney disease and requires a low potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? 1. 1 cup of canteloupe 2. 1 large baked potato 3. 4 oz of banana chips 4. 1 cup of applesauce 1 cup applesauce Upgrade to remove ads Only $35.99/year A nurse is caring for a client who has clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? 1. Isopropyl alcohol 2. Mild soap 3. Chlorhexidine 4. Triclosan Mild soap A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? 1. " Why are you angry about taking insulin" 2. "Don't worry, Diabetes runs in my family as well." 3. "I see that you are angry. Let's sit down and talk" 4. "You should take insulin because it reduces the risk for complications." "I see that you are angry. Let's sit down and talk." A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? 1. Ensure a client can use crutches before discharge 2. Check a clients ability to swallow following a stroke 3. Obtain a clients rating prior to physical therapy 4. Assist a client to get out of bed after breathing treatment Assist a client to get out of bed after breathing treatment A nurse is reinforcing teaching with an older adult client about oral hygiene. Which of the following instructions should the nurse include in the teaching? 1. Use a firm bristled toothbrush 2. Use lemon glycerine sponges between meals for dry mouth 3. Replace her toothbrush every 6 months 4. Replace her toothbrush following an illness Replace her toothbrush following an illness A nurse is contributing to the plan of care for a client who has prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? 1. Check for capillary refill proximally to the elastic bandages every 12 hr. 2. Compare the client's pedal pulses bilaterally every 4 hr 3. Place the client's legs in a dependent position for 30 minutes before applying the elastic bandages 4. Remove the elastic bandages every other day to inspect the skin Compare the clients pedal bilaterally every 4 hours A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? 1. Give the paper to a member of the clients family 2. Place the paper in a receptacle at the nurse's station 3. Shred the paper in a secure container 4. Discard the paper at home Shred the paper in a secure container A nurse is reinforcing preoperative teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? 1. Ask a family member who speaks the clients primary language to interpret 2. Plan a long teaching session initially to introduce the necessary material 3. Provide the least important information first 4. Provide handouts written in the clients primary language Provide handouts written in the clients primary language A nurse is caring for a client who is alert and in a long term care facility. Which of the following actions should the nurse take to protect the clients privacy? 1. Place laboratory results on the bedside table while ambulating the client 2. Give report about the clients status while standing in the hallway 3. Ask the client before discussing his condition when family is present 4. Place a message board on the clients room to post vital sign values. Ask the client before discussing his conditions when family is present A nurse is caring for a female client who has urinary incontinence. Which of the following actions should the nurse take? 1. Instruct the client to perform the Vasalva maneuver during urinary urges 2. Clean the clients labia minora before cleaning the labia majora 3. Apply a moisture skin barrier to the clients perineal area 4. Implement a toileting schedule for the client with 4hr intervals Apply a moisture skin barrier to the clients perineal area A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? 1. Evacuate clients from the area 2. pull the level on the fire alarm box 3. close the doors on the unit 4. use fire extinguisher to put out the fire A nurse is assisting with the admission of a client who has brought her medications to the facility. Which of the following actions should the nurse take? 1. Allow the client to continue taking medications as she did at home 2. Take the medications from the client and discard them 3. Compare the medications the provider has prescribed with the clients medications from home 4. Place the medications in the medication cart and administer them as the client took them at home Compare the medications the provider has prescribed with the clients medications from home. A nurse is planning to perform wound irrigation for client who has a large abdominal wound. Which of the following actions should the nurse plan to take? 1. Administer an analgesic 30 minutes before starting the procedure 2. Hold the syringe 5cm(2 in) above the upper end of the wound 3. Place the irrigation solution in a basin of cool water 4. Perform the wound irrigation with a 10mL syringe with an Angio catheter Administer an analgesic 30 minutes before starting the procedure A nurse is contributing to the plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? 1. Check that the restraint is tied to a fixed frame of the bed 2. Pad bony prominences on the wrist 3. Remove the restraint every 4 hours to allow movement 4. Tie the restraint with a knot that will tighten when pulled. Pad bony prominences on the wrist A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should be nurse use to verify correct placement of the NG tube in place 1. Check the pH of the gastric aspirate 2. Observe the color of the gastric aspirate after adding blue dye to the formula 3. Auscultate over the epigastrium 4. Measure the length of the inserted NG tube Check the pH of the gastric aspirate A nurse is caring for a client who has metastatic cancer and practices catholicism. The client ask the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the clients spiritual needs? 1. "Tell me what the after life means to you?" 2. " You should discuss the afterlife with your priest." 3. "Keep praying. A miracle could happen." 4. "Maybe your condition will lead you closer to God." "Tell me what the after life means to you." A nurse is reviewing the vital signs of 4 clients. Which of the following findings requires further data collection by the nurse? 1. A client who has a respiratory rate of 12/min 2. A client who has a blood pressure of 110/74 mm Hg 3. A client who has a temp of 37.3 degrees C (99.2 F) 4. A client who has a pulse of 110bpm A client who has a pulse of 110bpm A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? 1. "Keep your knees locked in position when standing for prolonged periods of time" 2. "Bend at the waist when lifting a heavy object." 3. "Keep your feet close together when lifting a heavy object." 4. "When lifting a heavy object, keep it close to your body." " When lifting a heavy object, keep it close to your body." A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicated hypomagnesemia? 1. Bone pain 2. Drowsiness 3. Bowel Hypo motility 4. Positive Chvostek's sign Positive Chvostek's sign (if clients facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels) A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? 1. Using hand sanitizer to cleanse her hands of spilled food from a client's meal tray. 2. Setting aside her gown for future use in the room of a client who has a wound infection. 3. Removing her gloves after exiting a client’s room 4. Donning a mask to measure the vital signs of a client who has pertussis Donning a mask to measure the vital signs of a client who has pertussis. A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9 C (102) F. Which of the following interventions should the nurse include in the plan of care to treat the fever. Administer acetaminophen Apply ice packs to the client’s axillae Maintain the room temp at 18.3 degrees C (64.9F) Assist the client to ambulate 4 times a day Administer acetaminophen a nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection? 1. Empty the urine drainage bag every 12hr 2. Drain urine from the tubing before ambulation 3. Use clean technique for urine specimen collection 4. Hang the urine drainage bag at the level of the bladder Drain urine from the tubing before ambulation A nurse is calculating the intake and output for a client over the last 8hr. The client is receiving a continuous IV infusion at 150 mL/h and had 4oz of juice and .5 L of water. How many mL of fluid should the nurse document as the clients intake? 1820 mL A nurse is reinforcing teaching with a client Who has a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following information should the nurse include in the teaching? 1. Place the electrodes near the pain site 2. The TENS unit has one constant 3. The TENS creates a sharp burning sensation when turned on. 4. The electrodes can be placed over hair. Place the electrodes near the pain site A nurse is caring for a client who has a subscription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into 2 smaller pieces. The nurse is demonstrating which of the following ethical principles? 1. Autonomy 2. Beneficence 3. Justice 4. Nonmaleficence Beneficence (nurse is acting at the clients best interest to make the pill swallowing possible) A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? 1. "I don't understand why everyone is so worried about me." 2. "I don't know if ill ever find someone who wants to marry me." 3. "When I look at myself in the mirror, I don't know if I can go on." 4. "I feel like the doctor pressured me into having the mastectomy." "When I look at myself in the mirror, I don't know if I can go on." A client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? 1. Keep the conversation moving by asking about his family 2. Let the client know that he is available and willing to listen 3. Ask if the clients understands what to expect in the advanced stages of the illness 4. Ask the client's visitors to not say anything about the advanced disease Le t the client know that he is available and willing to listen A nurse is caring for a client who has an NG tube and is receiving continuous enteral feeding. Which of the following actions should the nurse take? 1. Hold the feedings for 2 consecutive gastric residuals greater than 250 mL 2. Change the bag and tubing every 12 hr 3. Flush the tube with 0.9% sodium chloride irrigant every 8hr 4. Heat the formula to a body temperature before administering. Hold the feedings for 2 consecutive gastric residuals greater than 250 mL ( after 2, check to reduce risk of gastric aspiration) A nurse in a long term care facility is contributing to the plan of care for a client who is at risk for pressure ulcers. Which of the following recommendations should the nurse include in the plan? Complete a Braden scale at the first indication of pressure ulcer formation Perform a thorough skin inspection each day. Gently massage skin over bony prominences Place a dehumidifier in the clients room Perform thorough skin inspection each day A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? 1. Show the assistive personnel where to apply the medication 2. Ask the client when the previous nurse last applied the medication 3. Identify the client by comparing the medication administration record with the clients room # 4. Compare the label of the medication container with the medication administration record three times. Compare the label of the medication container with the medication administration record three times A nurse is moving a client up in a bed with the assistance of a second nurse. Which of the following actions should the nurse take? 1. Stand facing the center of the bed at the clients side 2. Place feet apart with the foot nearest the head of the clients bed in front of the other foot 3. Keep knees and hip straight while bending at the waist towards the client. 4. Encourage the client to keep his legs straight and remain still Place feet apart with the foot nearest the head of the clients bed in front of the other foot A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? 1. Restrict the clients visitors to the immediate family 2. Assign the client to a negative pressure airflow room 3. Discard ppe outside the clients room 4. Have the client wear a HEPA mask during transportation throughout the facility Assign the client to a negative pressure airflow room A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? 1. Support the clients head with a pillow that maintains cervical flexion 2. Position the clients shoulder off the pillow for internal rotation 3. Place the clients arms at hid sides to keep his elbows extended 4. Internally rotate the clients hips using a trochanter roll Internally rotate the clients hips using a trochanter roll A nurse is providing wound care for a group of clients. Which of the following wounds should a nurse identify as healing by secondary intention? 1. A stage 3 pressure ulcer on the coccyx 2. A contaminated wound that is closed after 72 hrs 3. A punctured wound that is sutured 4. An abdominal surgical wound with intact staples A stage 3 pressure ulcer on the coccyx A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? 1. Ensure the client is wearing nonskid slippers 2. Place patient in a room near nurse's station 3. Reinforce teaching about how to use the call bell A nurse is collecting data from a patient who is menopausal. Which o the following statements indicated that the nurse should screen the client for depression? 1. "Everything is fine. I started a glass bowling class this week." 2. "I am really not old enough to be going through menopause." 3. "My family doesn't need me anymore. I've failed them in so many ways." 4. "I am only 50 and my children treat me like I am old." "My family doesn't need me anymore. I've failed them in so many ways". A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? Young adults should receive a dental assessment every 6 months Young adult males should have a testicular examination every 5 yrs Young adult females should have a routine physical Young adults should receive a tuberculosis skin test every 3 yrs Young adults should receive a dental assessment every 6 months A nurse is palpating the pulse located on top of a clients foot. Which of the pulses should the nurse document that she is palpating? 1. Posterior tibial 2. Dorsalis Pedis 3. Popliteal 4. Femoral Dorsalis Pedis A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? 1. "I will be sure to keep the crutch tips dry." 2. "I will hold a crutch in each hand when sitting down." 3. "I will place my weight on my underarms" 4. "I will lead with my right leg when going upstairs." "I will be sure to keep the crutch tips dry." 66. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? A. Measure the pH of the gastric aspirate B. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water C. Place the end of the NG tube in the water to observe for bubbling D. Assess the client for a gag reflex A. Measure the pH of the gastric aspirate 65. A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Avoid using gesture when speaking to the client B. Request that assistive personnel interpret the information for the client C. Offer written information in the client's language D. Use proper medial terms when giving information to the client A. Avoid using gesture when speaking to the client A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take? A. Provide brochures about the procedure B. Notify the provider C. Describe the surgery to the client D. complete an incident report B. Notify the provider A nurse is collaborating with risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence? A. An assistive personnel discuses client care in the facility with victors' present B. Assistive personnel prevent a client from leaving the facility C. A nurse begins a blood transfusion without obtaining consent from a client D. A nurse administers a medication without first identifying the client D. A nurse administers a medication without first identifying the client A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health cate team? A. Occupational therapist B. Social worker C. Primary care provider D. Registered dietician B. Social worker 60. A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect? A. Thickened outer layer of skin B. Reduced sweat production C. Increased productions of oils D. Increased skin elasticity B. Reduced sweat production is providing teaching to a client who is preoperative for a total hip arthroplasty. Which of the following findings should the nurse identify as a barrier to learning? A. BP 148/90 mm Hg B. Report pain as 8 on a scale of 0 10 C. Wears glasses for reading D. Has a high school education B. Report pain as 8 on a scale of 0 10 A nurse is caring for a client who has pneumonia. The nurse should recognize that which of the following should be discarded in a biohazard bag? A. An emesis basin filled with blood from severe coughing B. A calibrated toilet inset filled with urine C. A disposable tissue containing expected sputum D. A bedpan containing diarrhea --= a client who was receiving antibiotics A. An emesis basin filled with blood from severe coughing A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take? A. Use sterile gloves to provide perineal care B. Have the client apply a mask when children are visiting C. Cleanse hands with an alcohol-based hand rub before client contact B. Have the client apply a mask when children are visiting 54. A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take? A. Complete the bath even if the client is distress B. Allow the client to select the temperature of the bath water C. Give detained instructions for the client to follow D. Use distraction when bathing the client B. Allow the client to select the temperature of the bath water A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test? A. Place the base of a vibrating tuning fork on the top of the client's head B. Count how many seconds a client can hear a tuning fork after it has been struck C. Place the base of a vibrating tuning fork on the client's mastoid process A. Place the base of a vibrating tuning fork on the top of the client's head . A nurse is teaching a client who has diabetes mellitus about mixing regular insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should draw up the NPH insulin before the regular insulin." B. "I should inject air into the vial of regular insulin first." C. "I should roll the vial of NPH insulin between my hands before drawing it up." D. "I should wait 3 minutes after mixing the insulin to inject it." C. "I should roll the vial of NPH insulin between my hands before drawing it up." A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? A. Administer metronidazole B. Place the client in a negative airflow room C. Wear a mask when working within 3 feet of the client D. Don protective eyewear before entering the room B. Place the client in a negative airflow room A nurse is assessing an older adult client. Which of the following findings should the nurse expect? A. Decreased sense of balance B. Increased nighttime sleeping C. Nighttime urinary incontinence D. Heightened sense of pain A. Decreased sense of balance A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following situations requires the completion of an incident report? A. A nurse transfused a unit of packed RBCs in 2 hr. B. An oncoming nurse arrived to work late C. A client's prescribed laboratory testing was not obtained D. A client withdrew consent for a procedure A. A nurse transfused a unit of packed RBCs in 2 hr. obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take? A. Apply the restraints to allow as little movement as possible B. Attach the restraints securely to the side rails of the client's bed C. Allow room for two fingers to fit between the client's skin and the staints C. Allow room for two fingers to fit between the client's skin and the staints A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? A. "I should perform my self-exam the week that my period starts." B. "I should make different patterns on each breast when I do my self-exam." C. "I should make circular motions with my fingertips under mu arms." D. "I should use the palm of my hand to apply pressure to each breast." A. "I should perform my self-exam the week that my period starts." A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein? A. Instruct the client to flex their arm with the hand open B. Stroke the skin near the vein in an upward direction C. Apply a cool compress to the vein for 10 min D. Dangle the client's arm over the edge of the bed D. Dangle the client's arm over the edge of the bed A nurse on a medical-surgical unit is receiving a changed of shift report for four clients. Which of the following clients should the nurse see first? A. A client who has urinary tract infection and low-grade fever B. A client who has acute abdominal pain of 4 on a scale from o to 10 C. A client who has pneumonia and an oxygen saturation of 96% D. A client who has new onset of dyspnea 24 hrs after a total hip arthroplasty D. A client who has new onset of dyspnea 24 hrs after a total hip arthroplasty 4. A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify that which of the following medication can interact adversely with this supplement? A. Albuterol B. Warfarin C. Atorvastatin D. Levothyroxine B. Warfarin . A nurse is planning care for a client who is disoriented, has history of wandering, and is at risk for falling. Which of the following actions should the nurse plan to take? A. Request a prescription for a PRN restraint. B. Apply a motion - sensor alarm to the client's bed C. Place the bedside tablet away from the client's bed D. Assign the client to a room near an exit A. Request a prescription for a PRN restraint A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first? A. Help the client lie on the floor B. Turn the client onto their side C. Loosen the client's clothing D. Move items in the room away from the client A. Help the client lie on the floor A nurse is providing teaching to a client about reducing the adverse effect of immobility. Which of the following statements by the client indicates an understanding of the teaching? A. "I will remove my anti-embolic stockings while I am in bed." B. "I will have my partner help change position every 4 hours." C. "I will hold my breath when rising from a sitting position." D. "I will perform ankle and knee exercises every hour." B. "I will have my partner help change position every 4 hours." A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? A. Airborne B. Droplet C. Protective environment D. Contact A. Airborne is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." The nurse should identify that the client is experiencing which of the following stages of grief A. Anger. B. Acceptance C. Denial D. Bargaining C. Denial 2. A nurse is caring for a client who is crying and states, I'm fine." Which of the following actions should the nurse take? A. Ask the client why they are crying. B. Suggest that the client listen to calming music. C. Request that the client clarify their statement. D. Offer to sit quietly next to the client D. Offer to sit quietly next to the client A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect? A. Postural hypotension B. Bradycardia C. Dependent edema D. Distended neck veins A. Postural hypotension A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the following actions should the nurse take prior to administering the formula? A. Encourage the client to breathe deeply and cough. B. Check for gastric residual volume. C. Flush the tube with sterile 0.9% sodium chloride irrigation D. Encourage the client to take sips of water B. Check for gastric residual volume A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication? A. A sharp decrease in blood pressure B. A feeling of swelling in the feet C. sudden decrease in heart rate D. Pain at the injection site A. A sharp decrease in blood pressure A nurse is preparing to transfer a client who is partially weight- bearing from the bed to a chair. Which of the following actions should the nurse take? A. Keep his knees straight when moving the client B. Position the chair next to the bed at a 90" angle. C. Have the client bear weight on her strong leg D. Stand with his feet together when lifting the client C. Have the client bear weight on her strong leg A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take? A. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning. B. Suction the client's airway for 20 seconds with each pass C. Decrease suction pressure to 150 mm Hg the oxygen saturation level drop during suctioning D. Apply intermittent suction during catheter insertion A. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning A nurse is caring for a client who reports a pain level of 5 on scale from 0 to 10. The client informs the nurse that pain medications are not an option for managing pain. which of the following is an appropriate response by the nurse? A. "Why do you think pain medication is not going to help you?" B. "I'm sure it will work for you if you just give it a chance." C. "You may take any herbal remedies you bring from home" D. "Would you like me to give you a back message?" A. "Why do you think pain medication is not going to help you? A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse' priority? A Distended bladder B. Last bowel movement was 3 days ago C. Respiratory rate 7/min D. Reports pain of 8 on scale from 0 to C. Respiratory rate 7/min A nurse is caring for a client following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Urine output of 80 mL in 4 hr B. Hypoactive bowel sounds C. Temperature of 37.2" C (99 F) D. Reports pain as 3 on a scale of 0 to 10 A. Urine output of 80 mL in 4 hr A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for ondansetron 4 mg IV bolus every 6 hr PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. (Move the steps into the box on the right. Place them in the order of performance. Use al the steps. A. Perform hand hygiene B. Select the injection port of the IV tubing closest to the client. C. Cleanse the injection port with an antiseptic swab. D. Inject the medication E. Aspirate for a blood return. B. Select the injection port of the IV tubing closest to the client A. Perform hand hygiene C. Cleanse the injection port with an antiseptic swab E. Aspirate for a blood return D. Inject the medication A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a side lying position B. Apply mineral oil to the client's lips C. Brush the client's teeth daily D. Rinse the client's mouth with an alcohol -based mouthwash A. Place the client in a side lying position A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan? A. Apply adhesive tape when securing an IV insertion site B. Use plastic syringe for medication administration. C. Wear powdered gloves when providing care for the client. D. Cover the blood pressure cuff with a stockinette C. Wear powdered gloves when providing care for the client. 14. A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take? A. Wear sterile gloves when collecting the specimen. B. Collect 1 mL of sputum. C. Collect the specimen in the evening. D. Offer the client oral hygiene after collection D. Offer the client oral hygiene after collection A nurse is preparing a client who has terminal cancer for discharge. Which of the Following questions should the nurse ask when assessing the client's psychosocial history? A. "Have any of your relatives been diagnosed with cancer?" B. "Are you experiencing any pain?" C. "What medications are you currently taking?" D. "What techniques do you use to cope with stress?" D. "What techniques do you use to cope with stress?" A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take? A. Discuss alternative treatments with the client. B. Express approval of the client's decision to not have the procedure. C. Document the client's decision in the medical record. D. Explain to the client the risks involved with not having the procedure. D. Explain to the client the risks involved with not having the procedure. A nurse is caring for a client who has urinary incontinence. Which of the following interventions should the nurse take to prevent skin breakdown? A. Request a prescription for an indwelling urinary catheter. B. Apply powder to the client's perineal area. C. Apply a moisture barrier ointment after hygiene. D. Restrict the client's fluid intake A. Request a prescription for an indwelling urinary catheter. A nurse is caring for a client who has a new prescription for negative - pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention? A. The material safety data sheet B. The nurse practice act C. The client's plan of care D. The policy and procedure manual D. The policy and procedure manual A nurse receives a telephone prescription from a provider for a client who is experiencing pain. which of the following responses should the nurse make? A. "Let me provide you with the client's medical record number for identification." B. "Will you please spell the name of the medication for me?" C. "Let me clarify that you want the medication given qid, correct? " D. "I will sign my name now and leave a space for you to sign you name." B. "Will you please spell the name of the medication for me?" A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take? A. Schedule postural drainage after meals. B. Instruct the client to exhale quickly during vibration C. Cover the area of percussion with towel D. Perform percussion over the lower back. C. Cover the area of percussion with towel A nurse measures a client's blood pressure and finds a significant decrease in systolic pressure and a significant increase in diastolic pressure from baseline measurement. The nurse should identify that which of the following potential errors in technique has occurred? A. Deflating the cuff too rapidly B. Using a cuff that is too low C. Not supporting the client's arm D. Wrapping the cuff too loosely D. Wrapping the cuff too loosely A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, "I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse? A. "The social worker will help answer those questions." B. "Try to help your dad enjoy this time as much as he can." C. "I think that you should discuss this with the hospice nurse." D. "Let's talk more about your dad's condition." D. "Let's talk more about your dad's condition." A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements? A. "I use garlic for my menopausal symptoms" B. "I take echinacea to control my cholesterol." C. "I use ginger when I get car sick." D. "I take ginkgo biloba for a headache." B. "I take echinacea to control my cholesterol." A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take? A. Avoid documenting direct quotes from the client as a part of subjective data. B. Tell the client the purpose for collecting the information. C. Explain to the client the necessary of full disclosure of information. D. Use the client's first name when initially meeting the client B. Tell the client the purpose for collecting the information.