ATI-RN FUNDAMENTALS EXAM REVIEW

ATI-RN FUNDAMENTALS EXAM REVIEW Nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following should the nurse include in the teaching? - CORRECT ANSWER-Use tracheostomy covers when outdoors nurse is performing a follow-up visit for a client who has a G-tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a cause of the diarrhea? - CORRECT ANSWER-The client's care giver washed out the feeding bag once every 24 hours with warm water nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? - CORRECT ANSWER-Let's talk about how the change in your hob status will affect you. nurse is assessing a client who reports increased pain following pt. Which of the following questions should the nurse ask hen assessing the quality of the client's pain? - CORRECT ANSWER-Sharp & Dull nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? - CORRECT ANSWERReassure the client that this is an expected response to grief. nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? - CORRECT ANSWER-Pad the client's wrist before applying the restraints A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? - CORRECT ANSWER-The client uses no acetone nail polish remover. Nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning? - CORRECT ANSWER-Apply intermittent suction when withdrawing he catheter. Nurse is preparing for change of shift. Which document or tools should the nurse use to communicate? - CORRECT ANSWER-SBAR Nurse is planning care for a client who had a stroke. What should be assigned to the assistive personal? (SATA) - CORRECT ANSWER--Assist the client with a partial bed bath. -Measure the client's BP after the nurse administers antihypertensive meds. -Use a communication board to ask what the client wants for lunch. Nurse caring for a client who has dementia. What interventions should be taken to minimize risk for injury? - CORRECT ANSWER-Use bed exit alarm system Nurse performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy? - CORRECT ANSWER-A mole with an asymmetrical appearance Nurse is administering optic ear medication on an adult client. Which action should be done to ensure the medication reached the inner ear? - CORRECT ANSWER-Press gently on the tragus of the client's ear. Nurse is planning strategies to manage time effectively for client care. What should the nurse implement? - CORRECT ANSWER-Use the planning step of the nursing process to prioritize client care delivery. Nurse caring for a client who has a sodium level of 125. What findings should the nurse expect? - CORRECT ANSWER-Abdominal Cramping Nurse is preparing an education program for staff about advocacy. What information should the nurse include? - CORRECT ANSWER-Advocacy ensures clients' safety, health, and rights. Nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take? - CORRECT ANSWER-Administer the medication with the needle at a 45-degree angle. A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which precaution should the nurse plan for this client? - CORRECT ANSWER-a. Make sure the client wears a mask when outside her room if there is construction in the area. Nurse providing discharge instructions for client who will be using a walker. Which statement indicates an understanding of the teaching? - CORRECT ANSWER-I will hire someone to trim the tree that hands low over the stairs of my front porch. Nurse planning to insert IV for an older adult client. What actions should the nurse plan to take? - CORRECT ANSWER-Place the client's arm in a dependent position. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? - CORRECT ANSWER-During the admission process A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ED and I had a difficulty breathing?" Which of the following responses should the nurse make? - CORRECT ANSWER-We would give you oxygen through a tube in your nose. A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? - CORRECT ANSWER-Help the client take sips of water to promote insertion of the NG tube Nurse auscultating anterior chest who is newly admitted. Listen--- - CORRECT ANSWER-Normal breathing sounds Caring for a client who died. Which order do you do the steps? - CORRECT ANSWER1. Obtain order 2. Remove tubes 3. Wash client 4. Ask family 5. Place the tags A nurse is providing discharge teaching to a client about self-administering heparin. - CORRECT ANSWER-Administer medication in abdomen A nurse caring for a client who asks about the purpose of advance directives - CORRECT ANSWER-Indicate form of treatment a client is willing to accept 1. Nurse is assessing an older adult for risk for falls (SATA) - CORRECT ANSWER-- Pupil clarity -visual fields -visual acuity Nurse assessing a client who is on bed rest for past month. Indication of thrombophlebitis? - CORRECT ANSWER-Calf Swelling Deep tendon reflex -- patellar reflex - CORRECT ANSWER-Knee picture Postop client with fluid volume deficit. Changes indicate successful treatment - CORRECT ANSWER-Decrease in heart rate Nurse is reviewing EBP about administration of O2 therapy - CORRECT ANSWERRegulate O2 via nasal canula no more than 6L Nurse responding to call light and finds client on bathroom floor. FIRST - CORRECT ANSWER-Check client for injuries Nurse caring for client prescribed blood transfusion. Parents refuse due to religious beliefs. What should the nurse do? - CORRECT ANSWER-Examine personal values about the issues. Nurse caring for client approaching death. SOB, noisy respirations. What should they do? - CORRECT ANSWER-Turn client 2 hours Nurse is assessing readiness to learn about insulin self-administration. What indicates the client is ready to learn? - CORRECT ANSWER-I can concentrate best in morning. Nurse receives report about a client getting IV fluids infusing 125ml/hr but notes he has only gotten 80 mL over the last 2 hours. What should nurse do first? - CORRECT ANSWER-Check IV tubing for obstruction nurse is preparing an injection for opioid medication. Draws 1mL from 2mL vial, what should the nurse do? - CORRECT ANSWER-Ask another nurse to observe medication waste? Nurse caring for a group of clients. Prevent spread of infection - CORRECT ANSWERPlace a client with TB in negative pressure room. Nurse caring for client at end of life. Which statement by client's partner is effective coping? - CORRECT ANSWER-I am relying on support from out family during this time Nurse caring for postop client following knee arthroplasty and requires thigh high compression sleeves. What should the nurse do? - CORRECT ANSWER-Make sure two fingers can fit under the sleeve. Nurse using an open irrigation technique for client's catheter. What action should nurse take? - CORRECT ANSWER-Subtract amount of irritant used from client's urine output. Nurse is caring for a client who has pharyngeal diphtheria. Transmission precautions? - CORRECT ANSWER-Droplet Postop, signs of hemorrhagic shock. Nurse notifies surgeon and he said to continue to monitor vitals every 15 minutes and report in one hour. What should the nurse do next? - CORRECT ANSWER-Notify nurse manager Reviewing client's fluid and electrolytes status. What should nurse report to provider? - CORRECT ANSWER-Potassium 5.4 Nurse caring for client postop. When nurse prepares to change dressing, client says it hurts. Which intervention is the nurse's priority action? - CORRECT ANSWER