ATI RN FUNDAMENTALS QUESTIONS&ANSWERS

ATI RN FUNDAMENTALS 2 VERSIONS QUESTIONS&ANSWERS 1. Nurse observes assistive personnel (AP) reprimanding a client for not using urinal properly. The AP tells him she will put a diaper on him if he doesn't use urinal more carefully next time. Which of following torts is AP committing? A: Assault B: Battery C: False imprisonment D: Invasion of privacy A. Assult 2. Adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. Nurse believes that this is not in client's best interest, so she administers a PRN sedative med that the client has not requested along with his usual med. Which of following types of tort has nurse committed? A: Assault B: False imprisonment C: Negligence D: Breach of confidentiality B. False imprisonment 3.Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of following statements by client indicates to nurse that he understands them? A: "I'd rather have my brother make decisions for me, but I know it has to be my wife." B: "I know they won't go ahead with the surgery unless I prepare these forms." C: "I plan to write that I don't want them to keep me on a breathing machine" D: "I will get my regular doctor to approve my plan before I hand it in at the hospital" C. "I plan to write that I don't want them to keep me on a breathing machine" 4. A Client is about to undergo an elective surgical procedure. Which of following actions are appropriate for nurse providing pre-op care regarding informed consent? (Select all that apply.) A: Make sure the surgeon obtained the client's consent B: Witness client's signature on consent form C: Explain the risks/benefits of procedure D: Describe consequences of choosing not to have surgery E: Tell client about alternatives to having surgery A. Make sure the surgeon obtained the client's consent, B. Witness client's signature on consent form 5. Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of following actions should nurse take? A: Remind nurse that safe client care is priority on unit B: Ask other s on team whether they have seen same behavior C: Report observations to nurse manager on unit D: Conclude her coworker's fatigue is not her problem to solve B. Report observations to nurse manager on unit 6. Nurse is preparing info for change-of-shift report. Which of following info should nurse include in report? A: Client's input & output for shift B: Client's blood pressure from previous day C: Bone scan that is scheduled for today D: Med routine from Med Admin Record C. Bone scan that is scheduled for today 7. Nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should nurse document this in client's chart? A: Client fell in shower B: Client states he fell in shower & was able to get himself back into chair C: Nurse shouldn't document this info in chart b/c she didn't witness the fall D: Client fell in shower but is now resting comfortably B. Client states he fell in shower & was able to get himself back into chair 8.Nursing instructor reviewing documentation with students. Which of following legal guidelines should they follow when documenting in client record? (Select all that apply.) A: Cover arrows with correction fluid, & write in correct info B: Put date & time on all entries C: Document objective data, leaving out opinions D: Use as many abbreviations as possible E: Wait until the end of shift to document B. Put date & time on all entries, C. Document objective data, leaving out opinions 9.Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain Which of following actions are appropriate? (Select all that apply.) A: Repeat details of prescription back to provider B: Have another nurse listen to phone prescription C: Obtain prescribes signature on prescription within 24 hours D: Decline verbal prescription b/c it is not emergency situation E: Tell charge nurse that the provider has prescribed morphine by phone A. Repeat details of prescription back to provider, B. Have another nurse listen to phone prescription, C. Obtain prescribes signature on prescription within 24 hours 10. A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP? A: Feeding client who was admitted 24h ago with aspiration pneumonia B: Reinforcing teaching w/ client who is learning to walk using quad cane C: Reapplying a condom catheter for client who has urinary incontinence D: Applying sterile dressing to pressure ulcer C. Reapplying a condom catheter for client who has urinary incontinence 11. Nurse delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.) A: The roommate is up independently B: Client ambulates with his slippers on over his antiembolic stockings C: Client uses front-wheeled walker when ambulating D: Client had pain med 30 min ago E: Client is allergic to codeine F: Client ate 50% of his breakfast this morning B. Client ambulates with his slippers on over his antiembolic stockings C. Client uses front-wheeled walker when ambulating D. Client had pain med 30 min ago 12. RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question? A: Assisting a client who is 24h post-op to use incentive spirometer B: Collecting clean-catch urine specimen from client who was admitted on previous shift C: Providing nasopharyngeal suctioning for client with pneumonia D: Replacing cartridge & tubing on PCA pump D. Replacing cartridge & tubing on PCA pump 13. Nurse is preparing in-service program about delegation. Which of following elements should she identify when presenting 5 rights of delegation? (Select all that apply.) A: Right client B: Right supervision/evaluation C: Right direction/communication D: Right time E: Right circumstances B. Right supervision/evaluation, C. Right direction/communication, E. Right circumstances 14. Nurse manager of med-surg unit is assigning care responsibilities for oncoming shift. Client is awaiting transfer back to unit from PACU following thoracic surgery. To which staff member should nurse assign to this client? A: Charge nurse B: RN C: LPN D: Assistive personnel (AP) C. RN 15. By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process? A: Reassess client to determine reasons for unsatisfactory pain relief B: See whether pain lessens during next 24h C: Change plan to ensure client achieves adequate pain relief D: Teach client about plan of care for managing his pain A. Reassess client to determine reasons for unsatisfactory pain relief 16. Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.) A: Respiratory rate of 22/min with even, unlabored respiration's B: "I can only walk 3 blocks before my legs start to hurt" C: Pain level 3/10 D: Skin pink, warm, dry E: Urine output 300 mL/8 hr F: Dressing clean, dry, intact A. Respiratory rate of 22/min with even, unlabored respiration's, D. Skin pink, warm, dry, E. Urine output 300 mL/8 hr, F. Dressing clean, dry, intact Nursing instructor is reviewing which actions nurses can initiate w/o provider's prescription. Students should identify which of following as nurse-initiated? (Select all that apply.) A: Give morphine sulfate 1-2 mg IV every 1h as needed for pain B: Insert NG tube to relieve client's gastric distension C: Show client how to use progressive muscle relaxation D: Perform daily bath after evening meal E: Re-position client every 2h to reduce pressure ulcer risk C: Show client how to use progressive muscle relaxation D: Perform daily bath after evening meal E: Re-position client every 2h to reduce pressure ulcer risk During eval, nurse must gather info about the client to... A: identify whether client outcomes have been met B: organize resources to proceed with implementing interventions C: establish client-centered, measurable & realistic outcomes D: determine priority of care & appropriate interventions A. identify whether client outcomes have been met Nurse tells client that she will call surgeon & ask about his request. Surgeon hears nurse's report & prescribes full liquid diet. Nurse used which of following levels of critical thinking? A: basic B: commitment C: complex D: integrity A. basic Nurse is caring for client who is 24h post-op following abdominal surgery. Nurse suspects client's pain management is inadequate. Which of following data reinforce suspicion? (Select all that apply.) A: client seems easily agitated B: client is nonadherent with coughing, deep breathing, dangling C: client may have pain med every 4-6h but accepts it every 6-7h D: client reports tenderness in his right lower leg E: client's vital signs are heart rate 110/min, respiratory rate 20/min, temp 37C, BP 136/80 mmHg B: client is nonadherent with coughing, deep breathing, dangling C: client may have pain med every 4-6h but accepts it every 6-7h E: client's vital signs are heart rate 110/min, Nurse caring for client who has new prescription. Prior to admin, nurse uses electronic database to gather info about med & effects it might have on this client. Which following component of critical thinking is nurse using when he reviews med info? A: knowledge B: experience C: intuition D: competence A. knowledge Nurse receives prescription for antibiotic for client with cellulitis. Nurse checks client's med record, discovers she's allergic to it, & calls provider to request different one. Which of following attitudes did the nurse demonstrate? A: fairness B: responsibility C: risk taking D: creativity B. responsibility Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate? A: confidence B: perseverance C: integrity D: discipline D. discipline Nurse performing an admission assessment for older adult client. After gathering assessment data & performing review of systems, which of following actions is priority for nursing? A: orient client to his room B: conduct client care conference C: review client's medical orders D: develop plan of care A. orient client to his room Nurse admitting client with acute cholecystitis to med-surg unit. Which of following actions are essential to admission procedure? (Select all that apply.) A: explain roles of other care delivery staff B: begin discharge planning C: provide info about advance directives D: document the client's wishes about organ donation E: introduce client to his roommate A: explain roles of other care delivery staff B: begin discharge planning C: provide info about advance directives E: introduce client to his roommate Nurse transferring client from acute-care hospital to rehab facility. Which of following info about client should nurse include in transfer report? (Select all that apply.) A: alert & oriented B: refuses to eat spinach C: has shellfish allergy D: requests morphine every 4h E: misses the 2 cats he has at home A: alert & oriented C: has shellfish allergy D: requests morphine every 4h Nurse is preparing discharge summary for client whose had knee surgery & is going home. Which following info about client should nurse include in it? (select all that apply) A: advance directives status B: where to go for follow-up care C: instructions for diet/meds D: most recent vital sign data E: contact info for home healthcare agency B: where to go for follow-up care C: instructions for diet/meds E: contact info for home healthcare agency As part of admission process, nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family? A: BMI B: usual times for meals/snacks C: favorite foods D: any difficulty swallowing D: any difficulty swallowing When entering client's room to change dressing, nurse notes client is coughing & sneezing. When preparing sterile field, it's important the nurse... A: keep sterile field at least 6 ft away from client's bedside B: instruct client to not cough/sneeze during dressing change C: place mask on client to limit spread of microorganisms into surgical wound D: keep box of Kleenex nearby for client to use during dressing change C: place mask on client to limit spread of microorganisms into surgical wound Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique? (Select all that apply.) A: bottle containing sterile solution B: edge of sterile drape at base of filed C: inner wrapping of an item on sterile field D: irrigation syringe on sterile field E: 1 gloved hand with the other gloved hand C: inner wrapping of an item on sterile field D: irrigation syringe on sterile field E: 1 gloved hand with the other gloved hand Nurse has removed sterile pack from its outside cover & placed it on clean work surface in prep for invasive procedure. Which of following flaps should nurse unfold first? A: flap closest to bodies B: right side flap C: left side flap D: flap farthest from the body D: flap farthest from the body Nurse is reviewing hand hygiene techniques with group of AP; which instructions should nurse include when discussing handwashing? (Select all that apply.) A: apply 3-5 mL of liquid soap to dry hands B: wash hands with soap & water for at least 15 seconds C: rinse hands with hot water D: use clean paper towel to turn off hand faucets E: allow hands to air dry after washing B: wash hands with soap & water for at least 15 seconds D: use clean paper towel to turn off hand faucets Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field? (Select all that apply.) A: provider drops sterile instrument onto near side of sterile field B: nurse moistens cotton ball with sterile NS & places it on sterile field C: procedure is delayed 1h b/c provider receives emergency call D: nurse turns to speak to someone who enters through door behind nurse E: client's hand brushes against outer edge of sterile field B: nurse moistens cotton ball with sterile NS & places it on sterile field C: procedure is delayed 1h b/c provider receives emergency call D: nurse turns to speak to someone who enters through door behind nurse Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting? (Select all that apply.) A: planning & evaluating control & prevention strategies B: determining public health priorities C: ensuring proper medical treatment D: identifying endemic disease E: monitoring for common-source outbreaks A: planning & evaluating control & prevention strategies B: determining public health priorities C: ensuring proper medical treatment E: monitoring for common-source outbreaks Nurse contributing to care plan for client being admitted to facility with suspected dx of pertussis. Which should nurse include in care plan? (Select all that apply.) A: place client in room with negative air pressure of at least 6 exchanges per hour B: wear mask when providing care within 3 ft of client C: place mask on client if transportation to another dept is unavoidable D: use sterile gloves when handling soiled linens E: wear gown when performing care that may result in contamination from secretions B: wear mask when providing care within 3 ft of client C: place mask on client if transportation to another dept is unavoidable E: wear gown when performing care that may result in contamination from secretions Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crustings. Which should nurse suspect? A: allergic reaction B: ringworm C: systemic lupus erythematosus D: herpes zoster D: herpes zoster Nurse caring for client who reports severe sore throat, pain with swallowing, swollen lymph nodes. Client is experiencing which of following stages of infection? A: prodromal B: incubation C: convalescence D: illness C: convalescence Nurse educator is reviewing with newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. Nurse indicates understanding when she states that which are manifestations of systemic? (Select all that apply.) A: fever B: malaise C: edema D: pain/tenderness E: increase in pulse & respiratory rate A: fever B: malaise E: increase in pulse & respiratory rate Nurse caring for client just admitted after falling. This client is oriented 3x & can follow directions Which action(s) by nurse are appropriate to decrease risk of fall? (select all that apply) A: place belt restraint on him when he's sitting on bedside commode B: keep bed in low position with full side rails up C: ensure client's call light is within reach D: provide client with nonskid footwear E: complete fall-risk assessment C: ensure client's call light is within reach D: provide client with nonskid footwear E: complete fall-risk assessment Nurse manager is reviewing care of client with seizures with nurses on unit. which statements by nurse requires more instruction? A: "I will place the client on his side" B: "I will go to the nurses' station for assistance" C: "I will administer meds as prescribed" D: "I will be prepared to insert an airway" B: "I will go to the nurses' station for assistance" Nurse observes smoke coming form under door of staff lounge. Which is priority action by the nurse? A: extinguish fire B: pull fire alarm C: evacuate the clients D: close all open doors on the unit C: evacuate the clients Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station? A: 43 yo client post-op following laparoscopic cholecystectomy B: 61 yo client being admitted for telemetry to rule out MI C: 50 yo client post-op following open reduction internal fixation of ankle D: 79 yo client post-op following below-the-knee amputation D: 79 yo client post-op following below-the-knee amputation Nurse is caring for newly admitted client with history of falls. Which is priority action by nurse? A: complete fall-risk assessment B: educate client & family on fall risks C: complete physical assessment D: survey client's belongings A: complete fall-risk assessment Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.) A: family members who smoke must be at least 10 ft from client when his oxygen is on B: nail polish shouldn't be sued near client receiving oxygen C: a "no smoking" sign should be placed on front door D: cotton bedding/clothing should be replaced with items made from wood E: fire extinguisher should be readily available in home B: nail polish shouldn't be sued near client receiving oxygen C: a "no smoking" sign should be placed on front door E: fire extinguisher should be readily available in home Nurse educator conducting parenting class for new parents. Which statement made by participant indicates need for further teaching? A: "I will begin swimming lessons as soon as my baby can close her mouth under water" B: "Once my baby can sit up, he should be safe in bathtub" C: "I will test the temp of water before placing baby in bath" D: "Once my infant starts to push up, I will remove mobile from over the bed" B: "Once my baby can sit up, he should be safe in bathtub" A home health nurse is discussing dangers of carbon monoxide poisoning with client. Which of following info should nurse include in her counseling? A: carbon monoxide has distinct odor B: water heaters should be inspected every 5 years C: lungs are damaged from carbon monoxide inhalation D: carbon monoxide binds with Hgb in body D: carbon monoxide binds with Hgb in body Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when new nurse states client who has heat stroke will have which of following? A: hypotension B: bradycardia C: clammy skin D: bradypnea A: hypotension Home health nurse is discussing dangers of food poisoning with client. Which info should nurse include in counseling? (Select all that apply.) A: most food poisoning is caused by virus B: immunocompromised individuals are at risk for complications from food poisoning C: clients who are esp. at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, other dairy products D: healthy people usually recover from illness in few weeks E: handling raw & fresh food separately to avoid cross contamination may prevent food poisoning B: immunocompromised individuals are at risk for complications from food poisoning C: clients who are esp. at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, other dairy products E: handling raw & fresh food separately to avoid cross contamination may prevent food poisoning Nurse is caring for client receiving enteral tube feedings d/t dysphagia. Which of following bed positions is appropriate for safe care of this client? A: supine B: semi-fowler's C: semi-prone D: trendelenburg B: semi-fowler's Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time? A: obtain walker for client to use to transfer back to bed B: call for additional personnel to assist with transfer C: use transfer belt & assist client to bed D: assess client's ability to help with transfer D: assess client's ability to help with transfer Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, "When I have difficulty breathing at night, I will... A: lie on my back with head & shoulders elevated on a pillow" B: lie flat on my stomach with head to one side" C: sit on side of my bed & rest my arms over pillows on top of my raised bedside table" D: lie on my side with my weight on my hips & shoulder with my arms flexed in front of me" C: sit on side of my bed & rest my arms over pillows on top of my raised bedside table" Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the followign should nurse manager include in teaching? (Select all that apply.) A: request assistance when repositioning a client B: avoid twisting spine or bending at waist C: keep knees slightly lower than hips when sitting for long periods of time D: use smooth movements when lifting & moving clients E: take break from repetitive movements every 2-3h to flex & stretch joints & muscles A: request assistance when repositioning a client B: avoid twisting spine or bending at waist D: use smooth movements when lifting & moving clients Nurse educator is teaching module on proper body mechanics during employee orientation. Which statements by new nurse indicates need for more teaching? A: "My line of gravity should fall outside my base of support" B: "The lower my center of gravity, the more stability I have" C: "To broaden my base of support, I should spread my feet apart" D: "When I lift an object, I should hold it as close to my body as possible" A: "My line of gravity should fall outside my base of support" Nurse is caring for many clients during mass casualty event. Which client is highest priority? A: client with crush injuries to chest/abdomen & expected to die B: client with 4-inch laceration to head C: client with partial & full-thickness burns to face, neck, chest D: client with fractured fibula & tibia C: client with partial & full-thickness burns to face, neck, chest Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.) A: client who's dehydrated & receiving IV fluid/electrolytes B: client with NG tube to treat small bowel obstruction C: client who's scheduled for TURP (prostate resection) D: client who is 24h post-op after mastectomy E: client scheduled for appendectomy C: client who's scheduled for TURP (prostate resection) D: client who is 24h post-op after mastectomy Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.) A: open doors to client rooms B: place blankets over clients who are confined to beds C: move beds away from windows D: draw shades & close drapes E: relocate ambulatory clients in hallways back to rooms B: place blankets over clients who are confined to beds C: move beds away from windows D: draw shades & close drapes Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan? A: irrigate affected area with running water B: wash affected area with antibacterial soap C: brush chemical off skin & clothing D: apply neutralizing agent C: brush chemical off skin & clothing Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure? A: "I will get the caller off the phone ASAP to alert the staff" B: "I will use overhead paging to alert entire facility" C: "I will not ask any questions & just let the caller talk" D: "I will listen for background noises" D: "I will listen for background noises" Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention? A: measure the vital signs B: encourage HIV screening C: determine client's risk factors D: instruct client to use condoms C: determine client's risk factors Nurse in clinic caring for 21 yo client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client? A: testicular exam B: blood glucose C: fecal occult blood D: prostate-specific antigen A: testicular exam Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed? A: "So I don't need colon cancer procedure for another 2-3 yrs" B: "For now, I should continue to have mammogram each year" C: "B/c doctor just did pap smear, I'll come back next year for another" D: "I had my blood glucose test last year so I won't need it again till next year" B: "For now, I should continue to have mammogram each year" Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.) A: help client see benefits of her actions B: identify client's support systems C: suggest & recommend community resources D: devise & set goals for client E: teach stress management strategies A: help client see benefits of her actions B: identify client's support systems C: suggest & recommend community resources E: teach stress management strategies When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place? A: client able to discuss appropriate technique B: client able to demonstrate appropriate technique C: client states he understands D: client is able to write steps on piece of paper B: client able to demonstrate appropriate technique Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains? A: cognitive B: affective C: psychomotor D: kinesthetic B: affective Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn? A: "I don't want my spouse to see my incision" B: "Will you be able to give me pain meds after surgery?" C: "Can you tell me about how long the surgery will take?" D: "My roommate listens to everything I say" C: "Can you tell me about how long the surgery will take?" Nurse preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client? A: encourage client to participate actively in learning B: select instructional materials appropriate for older adult C: identify goals nurse & client can agree are reasonable D: determine what client knows about stress incontinence D: determine what client knows about stress incontinence Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning? A: encourage client to ask questions B: ask client to explain how to select or prepare meals C: encourage client to fill out eval form D: ask client if she has resources for further instruction on topic B: ask client to explain how to select or prepare meals Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.) A: rolls from back to front B: bears weight on legs C: walks holding onto furniture D: sits unsupported E: sits down from standing position A: rolls from back to front B: bears weight on legs D: sits unsupported Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant? A: "My baby loved to play with crib gym, but I took it from him" B: "I just bought a soft mattress so my baby will sleep better" C: "My baby really likes sleeping on fluffy pillow we just got for him" D: "I just bought a child-safety gate that folds like accordion" A: "My baby loved to play with crib gym, but I took it from him" Nurse reviewing carseat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include? A: use car seat that has 3-point harness B: position car seat so that infant is rear-facing C: secure car seat in front passenger seat of car D: put soft padding in car seat behind infants back & neck B: position car seat so that infant is rear-facing Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.) A: "It might be good to add bananas, as they help with loose stools" B: "Let's make list of foods he's eating so we can spot problems" C: "Did the changes begin after you started 1 particular food?" D: "Has he been vomiting since he started these new foods?" E: "Most babies react with indigestion when you start new foods" B: "Let's make list of foods he's eating so we can spot problems" C: "Did the changes begin after you started 1 particular food?" D: "Has he been vomiting since he started these new foods?" Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.) A: keep toxic agents in locked cabinets B: keep toilet seats up C: turn pot handles toward back of stove D: place safety gates across stairways E: make sure balloons are fully inflated A: keep toxic agents in locked cabinets C: turn pot handles toward back of stove D: place safety gates across stairways Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.) A: building simple models B: working with clay C: filling & emptying containers D: playing with blocks E: looking at books C: filling & emptying containers D: playing with blocks E: looking at books Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline? A: establish consistent boundaries B: place him in room with door closed C: have him learn by trial & error D: use favorite snacks as rewards A: establish consistent boundaries A mother tells nurse that her 2 yo has temper tantrums. Child says "no" every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is... A: trying to gain her independence B: developing sense of trust C: manifesting anger management problem D: attempting to finish a project she started A: trying to gain her independence Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group? A: "I should keep feeding my son whole milk until he's 3 yo" B: "It's okay for me to give him a cup of apple juice with each meal" C: "I'll give my son about 2 tablespoons of each food at mealtimes" D: "My son loves popcorn, & I know it's better for him than sweets" C: "I'll give my son about 2 tablespoons of each food at mealtimes" Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.) A: assembling puzzles B: pulling wheeled toys C: using musical toys D: using finger paints E: coloring with crayons A: assembling puzzles C: using musical toys E: coloring with crayons Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.) A: invite child to assist with mealtime activities B: cluster invasive procedures whenever possible C: assign caregivers with whom the child is familiar D: have parents bring in favorite toy from home E: engage child in pretend play with toy medical kit A: invite child to assist with mealtime activities D: have parents bring in favorite toy from home E: engage child in pretend play with toy medical kit Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.) A: Haemophilus influenzae type b B: Varicella C: polio D: hepatitis A E: seasonal influenza B: Varicella C: polio E: seasonal influenza Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention? A: "He doesn't keep up with other kids in activities like running & jumping" B: "He keeps trying to find ways around household rules; he always wants to make deals with us" C: "We think he is trying too hard to excel in math just to get top grades in his class" D: "He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems" A: "He doesn't keep up with other kids in activities like running & jumping" Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.) A: building models B: playing video games C: reading books D: using toy carpentry tools E: shaping modeling clay A: building models B: playing video games C: reading books Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children? A: "She wants to eat as much as us, but we're afraid she'll be overweight." B: "She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner." C: "We limit fast food restaurant meals to 3x/week now" D: "We reward her school achievements with point system instead of pizza or ice cream" D: "We reward her school achievements with point system instead of pizza or ice cream" Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children? (Select all that apply.) A: childhood obesity B: substance use disorders C: scoliosis screening D: front-seat seatbelt use E: stranger awareness A: childhood obesity B: substance use disorders C: scoliosis screening E: stranger awareness Nurse is talking with father of 12 yo boy who's concerned he hasn't observed any signs his son is approaching puberty. Nurse should explain that first sign of sexual maturation in boys is... A: appearance of downy hair on upper lip B: hair growth in axillae C: enlargement of testes & scrotum C: enlargement of testes & scrotum Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client? (Select all that apply.) A: suggest his parents room in with him B: provide a TV & DVDs for him to watch C: limit visitors to immediate family D: devise a regular schedule for inpatient routines E: allow him to perform his own morning care B: provide a TV & DVDs for him to watch E: allow him to perform his own morning care Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention? A: "I kind of like this girl in my class, but she doesn't like me back like that." B: "I like hanging out with the guys in the science club, but the jocks pick on them." C: "I just don't seem to be good at anything. I can't play sports at all." D: "My dad wants me to be a lawyer like him, but I don't want to learn all that stuff." C: "I just don't seem to be good at anything. I can't play sports at all." Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.) A: rotavirus B: varicella C: herpes zoster D: HPV E: seasonal influenza B: varicella D: HPV E: seasonal influenza Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include? (Select all that apply.) A: scoliosis is more common in girls than in boys B: loss of height is often first sign of scoliosis C: scoliosis screening is essential during adolescent growth spurt D: slouching is common cause of scoliosis, esp. in adolescents E: scoliosis is forward curvature of spine A: scoliosis is more common in girls than in boys C: scoliosis screening is essential during adolescent growth spurt Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding? A: "I already had my immunizations as a child, so I'm protected in that area." B: "It's important to schedule routine healthcare visits even if I'm feeling well" C: "If I'm having any discomfort, I'll just go to an urgent care center" D: "If I'm feeling stressed, I will remind myself that this is something I should expect" B: "It's important to schedule routine healthcare visits even if I'm feeling well" Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development? A: becoming actively involved in providing guidance to next generation B: adjusting to major changes in roles/relationships due to losses C: devoting great deal of time to establishing occupation D: finding oneself "sandwiched" between being responsible for 2 generations C: devoting great deal of time to establishing occupation Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention? A: "I have my own apt now, but it's not easy living away from my parents" B: "It's been so stressful for me to even think about having my own family" C: "I don't even know who I am yet, & now I'm supposed to know what to do" D: "My girlfriend is pregnant, & I don't think I have what it takes to be a good father" C: "I don't even know who I am yet, & now I'm supposed to know what to do" Nurse is reviewing safety precautions with group of young adults at community health fair. Which recommendations should nurse include specifically for this age group? (Select all that apply.) A: install bath rails & grab bars in bathrooms B: wear helmet while skiing C: install carbon monoxide detector D: secure firearms in safe location E: remove throw rugs from the home B: wear helmet while skiing C: install carbon monoxide detector D: secure firearms in safe location Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.) A: HPV B: measles, mumps, rubella C: varicella D: Haemophilus influenzae type b E: polio A: HPV B: measles, mumps, rubella C: varicella Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A: client evaluates his behavior after social interaction B: client states he is learning to trust others C: client wishes to find meaningful relationships D: client expresses concerns about next generation D: client expresses concerns about next generation Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.) A: develop acceptance of diminished strength & increased dependence on others B: feel frustrated that time is too short for trying to start another life C: welcome opportunities to be creative & productive D: commit to finding friendship & companionship E: become involved in community issues & activities C: welcome opportunities to be creative & productive E: become involved in community issues & activities Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.) A: metabolism B: ability to hear low-pitched sounds C: gastric secretion D: far vision E: glomerular filtration A: metabolism C: gastric secretion E: glomerular filtration Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.) A: Haemophilus influenzae type b B: varicella C: herpes zoster D: HPV E: seasonal influenza B: varicella C: herpes zoster E: seasonal influenza Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention? A: "I'm struggling to accept my parents are aging & need so much help" B: "It's been so stressful for me to think about having intimate relationships" C: "I know I should volunteer my time for good cause, but maybe I'm just selfish" D: "I love my grandchildren, but my son expects me to relive my parenting days" B: "It's been so stressful for me to think about having intimate relationships" Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention? A: "I spent my whole life dreaming about retirement, & now I wish I had my job back" B: "It's been so stressful for me to have to depend on my son to help around the house" C: "I just heard my friend Al died. That's the 3rd one in 3 months." D: "I'm struggling with helping out in my community. I just don't know what I can do." D: "I'm struggling with helping out in my community. I just don't know what I can do." Nurse is admitting older adult who lost 4.5 kg since last admission 6 mo ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.) A: "Do you eat alone or with someone?" B: "Do you watch TV while eating your meals?" C: "Have you started any new meds in past 6 mo?" D: "What foods have you eaten in past 24 hrs?" E: "Are you on a fixed income?" A: "Do you eat alone or with someone?" C: "Have you started any new meds in past 6 mo?" D: "What foods have you eaten in past 24 hrs?" E: "Are you on a fixed income?" ATI RNFundamentals 1- A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medicationsthe client received during hospitalization. 2- A nurse isreviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? a. medication name b. route of administration c. medication dose d. frequency of administration 3- A nurse isteaching a group ofstaff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma 4- A nurse is admitting a client who hasrubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment 5- A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it 6- A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.) A) Narrowed arterial lumen B) Distended jugular veins C) Impaired ventricular contraction D) Asynchronous closure of the aortic and pulmonic valves 7- A nurse is caring for a client who isrefusing a blood transfusion for religiousreasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A) Ask the client to consider a direct donation. B) Withhold the blood transfusion. C) Request a consultation with the ethics committee. D) Ask the client'sfamily to intervene. 8- A nurse in an acute care facility is preparing a discharge summary for a client who istransferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports 9- A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A) Erythema on pressure points B) Lower-extremity pulse strength of 2+ C) Fluid intake of 3,000 mL per day D) A bowel movement every other day 10- A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions 11- A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A) "I'm having mild pain." B) "The pain is like a dull ache in my stomach." C) "I notice that the pain gets worse after I eat." D) "The pain makes me feel nauseous." 12- A nurse isreviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A) Insert an implanted port. B) Close a laceration with sutures. C) Place an endotracheal tube. D) Initiate an enteral feeding through a gastrostomy tube. 13- A client who is non ambulatory notifies the nurse that histrash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore 14- A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following clientstatements indicates an understanding of herbal supplement use? A) "I can take echinacea to improve my immune system" B) "I can take feverfew to reduce my level of anxiety" C) "I can take ginger to improve my memory" D) "I can take ginkgo biloba to relieve nausea" 15- A nurse enters a client'sroom and finds her on the floor. The client'sroommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? A) "incident report completed" B) "client climbed over the side rails" C "client found lying on the floor" D) "client was trying to get out of bed" 16- A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? A) touch the face with a cotton ball B) apply vibrating tuning fork to the client'sforehead C) have the client stand with their arms at theirsides and their feet together D) perform direct percussion over the area of the kidneys 17- A nurse isteaching a client whose left leg isin a cast about using crutches. Which of the following statementsshould the nurse identify as an indication that the client understands the teaching? A) "When descending stairs, I will first shif t my weight to my right leg." B) "Ishould place my crutches 12 inches in front and to the side of each foot." C) "As Isit down, I will hold one crutch in each hand." D) "I will make sure the shoulder rests are snug against my armpits." 18- A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? A) dissolve each medication in 5 mL of sterile water B) draw up medicationstogether in the syringe C) push the syringe plunger gently when feeling resistance D) flush the tube with 15 mL of sterile water 19- A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week 20- A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. assign a staff member to feed the client b. provide small handled utensils for the client c. thicken liquids on the client's tray d. arrange food in a consistent pattern on the client's plate 21- A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years" 22- A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg 23- A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A) Auscultate lung sounds. B) Measure urine output. C) Monitor blood pressure readings. D) Monitorserum electrolyte levels. 24- A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. place a pillow under the client's knees b. position a trochanter toll under each of the client's hips c. advise the client to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the client'sfeet 25- A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap 26- A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A) Ensure sterilization of nondisposable items with ethylene oxide. B) Wrap monitoring cords with stockinette and tape them in place. C) Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. D) Wear hypoallergenic latex glovesthat contain powder. B) Wrap monitoring cords with stockinette and tape them in place. 27- A nurse is assessing a client who received an IV fluid bolusfor dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins 28- A nurse is caring for a client who haslimited mobility in hislower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A) Place the client in high-Fowler's position. B) Increase the client'sintake of carbohydrates. C) Massage reddened areas with unscented lotion. D) Have the client use a trapeze bar when changing position. 29- A nurse is caring for a client who isreceiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? A) instruct the family to refrain from pushing the button for the client while she is asleep B) inform the client that because she is on PCA, vital signs will be taken every 8 hours C) teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 D) increase the basal rate and shorten the lock-out interval time if the client's pain level istoo high 30- A nurse hasjust inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowelsounds are present on auscultation d. the client reports relief of nausea 31- A home health nurse is completing an admission assessment of an older adult client who hastheir caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a. the caregiver is the client'sfinancial power of attorney b. the client is in a wheelchair with the wheels locked c. the client reports receiving a full bath twice each week d. the caregiver insists on remaining in the room 32- A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. Aftersecuring a safe environment, which of the following actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assessthe client for orthostatic hypotension d. apply gait belt to the client 33- A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside 34- The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which ofthe following instructions should the nurse provide to the client and his family? select all that apply. a. check the cord routinely for frays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generator for power backup d. observe forsigns of hypoxia t synthetic clothing and bedding 35- A nurse is caring for a client who has an NG tube and isreceiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol 36- A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'llsave the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this with you?" 37- A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea 38- A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wearsterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degreesfarenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound. 39- A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client'sroom c. clean contaminated surfaces in the client'sroom with a phenolsolution d. have family members wear a gown and gloves when visiting 40- A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly" 41- A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly" 42- A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administersubcutaneously. Determine the correct order of the steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle c,a,d,b 43- A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic 44- A nurse is caring for a client who hastuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobialsanitizer for hand hygiene 45- A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg 46- A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requiresintervention by the charge nurse? a. the newly licensed nurse places the cap of a bottle ofsterile solution on the sterile field b. the newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field c. the newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring d. the sterile field is positioned at the level of the newly licensed nurse's waist 47- A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. a client who is unaware of her recent cancer diagnosis asks the nurse ifshe has cancer, and the nurse responds affirmatively. b. a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes c. a client who has a DNR order has a cardiac arrest, and the nurse does not perfrom CPR despite requests from the client's family d. a client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure