ATI PN Fundamentals Online Practice 2020 A

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment. - D. Assist a client to get out of bed after a breathing treatment. A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? A. Discontinued medications B. Resolved health conditions C. Frequency of vital sigh collection D. Completed nursing interventions - Resolved health conditions- The nurse should report both unresolved and resolved health conditions to promote continuity of care. A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? A. Support the client's head with a pillow that maintains cervical flexion. B. Position the client's shoulders off the pillow for internal rotation. C. Place the client's arms at their sides to keep their elbows extended. D. Internally rotate the client's hips my using a trochanter roll. - D. Internally rotate the client's hips my using a trochanter roll. A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.) Full bounding pulse Cool extremities Moist crackles in the lungs Orthostatic hypotension Flat neck veins - Cool Extremities Orthostatic hypotension Flat neck veins A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? A. Place the client in a room with another client who has pharyngitis. B. Ensure that the client wears a surgical mask during transportation throughout the facility. C. Limit the client's visitors to visitations of 30 min. D. Provide the client a room with negative-pressure airflow of six air exchanges per hour. - B. Ensure that the client wears a surgical mask during transportation throughout the facility. A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)? A. Apply thromboembolic stockings. B. Monitor the circulation in all four extremities. C. Record the condition of the client's skin. D. Reinforce teaching about performing range-of-motion exercises. - A. Apply thromboembolic stockings. A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? A. Nasal cannula B. Simple face mask C. Venturi mask D. Nonrebreather mask - D. Nonrebreather mask A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? A. Administer an analgesic 30 min before starting the procedure. B. Hold the syringe 5 cm (2 in) above the upper end of the wound. C. Place the irrigation solution in a basin of cool water. D. Perform the wound irrigation with a 10-mL syringe with an angiocatheter. - A. Administer an analgesic 30 min before starting the procedure. A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching? A. "This can help prevent nausea." B. "This can help prevent pneumonia." C. "I should do this every 4 hours." D. "I should do this to keep my heart from beating too fast." - B. "This can help prevent pneumonia." A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever? A. Administer acetaminophen. B. Apply ice packs to the client's axillae. C. Maintain the room temperature at 18.3° C (64.9° F). D. Assist the client to ambulate four times a day. - A. Administer acetaminophen. A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? A. Precontemplation B. Preparation C. Maintenance D. Action - A. Precontemplation A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? A. Restrict the client's visitors to the immediate family. B. Assign the client to a negative-pressure airflow room. C. Discard personal protective equipment outside the client's room. D. Have the client wear a HEPA mask during transportation throughout the facility. - B. Assign the client to a negative-pressure airflow room. A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? A. Volunteer at the local food pantry. B. Attend an exercise program. C. Find an enjoyable hobby. D. Support environmental conservation. - B. Attend an exercise program. A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? A. "The reduced muscle tone has relaxed the jaw muscles." B. "That happens when a person gets close to death." C. "I can apply a chin strap to help hold the mouth closed." D. "You shouldn't worry about that at this time." - A. "The reduced muscle tone has relaxed the jaw muscles." A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? A. Explain the negative consequences of the refusal. B. Discuss with the client's partner why the treatment is necessary. C. Document the client's refusal of the treatment. D. Try to convince the client that the treatment is needed. - C. Document the client's refusal of the treatment. A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse? A. A client who has a respiratory rate of 12/min B. A client who has a blood pressure of 110/74 mm Hg C. A client who has a temperature of 37.3° C (99.2° F) D. A client who has a pulse rate of 110/min - D. A client who has a pulse rate of 110/min A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled. - B. Pad bony prominences on the wrist. A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? A. "I don't understand why everyone is so worried about me." B. "I don't know if I'll ever find someone who wants to marry me." C. "When I look at myself in the mirror, I don't know if I can go on." D. "I feel like the doctor pressured me into having the mastectomy." - C. "When I look at myself in the mirror, I don't know if I can go on." A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? A. A stage 3 pressure injury on the coccyx B. A contaminated wound that is closed after 72 hr C. A puncture wound that is sutured D. An abdominal surgical wound with intact staples - A. A stage 3 pressure injury on the coccyx A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Ask a family member who speaks the client's primary language to interpret. B. Plan a long teaching session initially to introduce the necessary material. C. Provide the least important information first. D. Provide handouts written in the client's primary language. - D. Provide handouts written in the client's primary language. A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? A. "Tell me what the afterlife means to you." B. "You should discuss the afterlife with your priest." C. "Keep praying. A miracle could happen." D. "Maybe your condition will lead you closer to God." - A. "Tell me what the afterlife means to you." A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B. Use an adhesive oximetry probe for a client who has a latex allergy. C. Remove polish from the client's fingernail before applying the oximetry probe. D. Lubricate the tip of the oximetry probe. - C. Remove polish from the client's fingernail before applying the oximetry probe. A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? A. Check for capillary refill proximally to the elastic bandages every 12 hr. B. Compare the client's pedal pulses bilaterally every 4 hr. C. Place the client's legs in a dependent position for 30 min before applying the elastic bandages. D. Remove the elastic bandages every other day to inspect the skin. - B. Compare the client's pedal pulses bilaterally every 4 hr. A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1. Close the fire doors on the unit. 2. Use a fire extinguisher to put out the fire. 3. Evacuate clients from the area. 4. Pull the lever on the fire alarm box. - 3. Evacuate clients from the area. 4. Pull the lever on the fire alarm box. 1. Close the fire doors on the unit. 2. Use a fire extinguisher to put out the fire. A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot? A. Posterior tibial B. Dorsalis pedis C. Popliteal D. Brachial - B. Dorsalis pedis A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? A. Young adults should receive a dental assessment every 6 months. B. Young adult males should have a testicular examination every 5 years. C. Young adult females should have a routine physical examination every 4 years. D. Young adults should receive a tuberculosis skin test every 3 years. - A. Young adults should receive a dental assessment every 6 months. A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? A. "Why are you angry about taking insulin?" B. "Don't worry. Diabetes runs in my family as well." C. "I see that you are angry. Let's sit down and talk." D. "You should take insulin, because it reduces the risk for complications." - C. "I see that you are angry. Let's sit down and talk." A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? A. Clamp the infusion tubing. B. Remove the dressing. C. Withdraw the catheter from the vein. D. Ensure the catheter is intact. - A. Clamp the infusion tubing. A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? A. Place the client's medication record on the bedside table while ambulating the client. B. Give report about the client's status while standing at the nurses' station. C. Speak with the client about their condition after visitors have left. D. Place a message board in the client's room to post dietary information. - C. Speak with the client about their condition after visitors have left. A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? A. Alarm clock that shakes the bed B. Flashing smoke alarm C. Low-pitched buzzer doorbell D. Telephone with an amplified receiver - B. Flashing smoke alarm A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? A. Urine specific gravity 1.015 B. Hematocrit 42% C. Urine pH 6.5 D. BUN 8 mg/dL - D. BUN 8 mg/dL