ATI FUNDAMENTALS FINAL EXAM (F1) ANSWERS AVAILABLE

A nurse is caring for a client who has a new RX for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A) Knowledge B) Experience C) Intuition D) Competence - correct answersA) Knowledge A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A) Check to see whether the catheter is patent. B) Reassure the client that it is not possible for her to urinate. C) Recatheterize the bladder with a larger-gauge catheter. D) Collect a urine specimen for analysis - correct answersA) Check to see whether the catheter is patent. A nurse is caring for a client who has a RX for a 24-hr urine collection. Which of the following actions should the nurse take? A) Discard the first voiding B) Keep the urine in a singe container at room temp C) Ask the client to urinate and pour the urine into a specimen container D) Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. - correct answersA) Discard the first voiding A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain med 6 hr ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed n - correct answersA. Assessment A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (SATA) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handli - correct answersB. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable E. Wear a gown when performing care that may result in contamination from secretions. A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment B. Put the client in a room with a client who has hearing loss C. Provide a quiet room and limit stimulation D. Speak at a higher volume to the client and encourage ambulation. - correct answersC. Provide a quiet room and limit stimulation A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (SATA) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear - correct answersA. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (SATA) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone - correct answersA. Furosemide B. Ibuprofen A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aid - correct answersD. "I take the batteries out of my hearing aids when I take them off at night." A nurse is caring for an adolescent who client who is 2 days post-op following an appendectomy and has type I DM. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the fo - correct answersB. Impaired circulation C. Impaired/suppressed immune system A nurse is collecting data from a client who is 5 days post-op following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (SATA) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - correct answersA. Increase in incisional pain B. Fever and chills C. Reddened wound edges A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (SATA) A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - correct answersA. Stage III pressure ulcer E. Open burn area A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (SATA) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with his hips and knees b - correct answersA. Cover the area with saline-soaked sterile dressings. D. Position the client supine with his hips and knees bent. A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (SATA) A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed. - correct answersA. Keep the head of the bed elevated 30 degrees. D. Have the client sit on a gel cushion when in a chair. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (SATA) A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed in its lowest position with all side rails up C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall- - correct answersC. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses station for assistance." C. "I will administer his medications." D. "I will prepare to insert an airway." - correct answersB. "I will go to the nurses station for assistance." A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurses priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are near by D. Close all open doors on the unit - correct answersC. Move clients who are near by A nurse is caring for a client who has a history of falls. Which of the following is the nurses priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the clients environment D. Make sure the client uses assistive aids in his possession - correct answersA. Complete a fall-risk assessment A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses station? A. A middle adult who is post-op following a laproscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is post-op following an open reduction internal fixation of the ankle D. An older adult who is post-op following a below-the-knee am - correct answersD. An older adult who is post-op following a below-the-knee amputation A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (SATA) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items - correct answersB. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states that the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - correct answersA. Hypotension A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 F." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will place my baby on his stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib." - correct answersD. "Once my infant starts to push up, I will remove the mobile from over the crib." A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body. - correct answersD. Carbon monoxide binds with hemoglobin in the body. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (SATA) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. D. Healthy individuals usually recover from the illness in a few weeks - correct answersB. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning. A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg - correct answersB. Semi-Fowler's A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer. - correct answersD. Assess the client's ability to help with the transfer. A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow. B. Lie flat on her stomach with her head to one side. C. Sit on the side of her bed and rest her arms over follows on top of her bedside table. D. Lie on her side with her weight on her - correct answersC. Sit on the side of her bed and rest her arms over follows on top of her bedside table. A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (SATA) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscle - correct answersA. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals. - correct answersB. Instruct the client to tuck her chin when swallowing. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (SATA) A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should c - correct answersA. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the fo - correct answersA. "Water helps clear the tube so it doesn't get clogged." A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented. - correct answersB. Verify the placement of the NG tube. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (SATA) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents. - correct answersA. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. The specimen cannot be contaminated with urine. - correct answersD. The specimen cannot be contaminated with urine. A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (SATA) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts. - correct answersA. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts. Which of the following actions should the nurse take each time he provides tracheostomy care? (SATA) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder. - correct answersA. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. A nurse in a providers office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the clients difficulty sleeping? (SATA) A. "Does your lack of sleep interfere with your ability to function during the day?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" - correct answersA. "Does your lack of sleep interfere with your ability to function during the day?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds when you are asleep?" E. "Tell me about any personal stress you are experiencing." A nurse is caring for an older adult client who has been following the facilities routines and bathing in the morning. However, at home, she always takes a warm bath just before bed time. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the clients back for 15 minutes before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for a sleeping medication - correct answersC. Allow the client to take a bath in the evening A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction - correct answersC. Alarm reaction A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain - correct answersA. Role conflict Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse-client communication no time limit D. Allow communication to occur spontaneously throughout the nurse-client relationship - correct answersB. Encourage the client to communicate his thoughts and feelings A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (SATA) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea - correct answersC. Bradypnea D. Orthostatic hypotension E. Nausea A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A. The client's input and output for the shift B. The client's blood pressure from the previous day C. A bone scan that is scheduled for today D. The medication routine from the medication administration record - correct answersC. A bone scan that is scheduled for today A nurse is reviewing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (SATA) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of her medical record E. A nurse may photocopy a clients medical record fo - correct answersB. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of her medical record E. A nurse may photocopy a clients medical record for transfer to another facility