Fundamentals Final ATI Study Questions

A nurse is cleaning a client’s wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? a. preventing the transfer of microorganisms to the nurse b. keeping microorganisms from entering the wound c. applying minimal pressure to the wound d. keeping excess moisture from entering the wound. Answer: B A nurse is caring for a. client who required a dressing change. Which of the following actions should the nurse take? a. clean the incision from bottom to top b. apply sterile gloves prior to opening dressing packages c. remove the tape by pulling away from the wound d. clean the drain site from the center outward Answer: D A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? a. autonomy b. fidelity c. nonmaleficence d. justice Answer: B A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? a. lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube b. position the client to the right side c. insert the tip of the tubing 8 cm (3.1 in) d. hold the enema container 61 cm (24 in) above the rectum Answer: C A nurse enters a client’s room and finds the client sitting on the floor and learning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? a. complete an incident report b. check the client for injuries c. make sure the client has skid-free footwear d. remind the client to ask for help when getting out of bed Answer: B A nurse is caring for a. client who is producing large amounts of urine. The nurse should document this finding as which of the following? a. retention b. oliguria c. diuresis d. dysuria Answer: C A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? a. a client who has multiple sclerosis and uses a wheelchair b. a client who has end0stage cirrhosis c. a client who have hemiplegia due to a stroke d. a client who have cancer and receives weekly radiation therapy Answer: B A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? a. a client who has a prescription for a transfusion of packed red blood cells b. a client who is being transported for a radiograph of the kidneys, ureters, and bladder c. a client who has a prescription for a tuberculin skin test d. a client who has a distended bladder and needs urinary catheterization Answer: A A nurse in a provider’s office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? a. osteoporosis b. scoliosis c. kyphosis d. lordosis Answer: A A nurse is preparing to administer an optic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? a. hold the dropper 1 cm (0.5 in) above the ear canal during administration b. apply pressure to the nasolacrimal duct following administration c. place a cotton ball into the inner ear canal for 30 minutes following administration d. straighten the ear canal by pulling the auricle down and back prior to administration Answer: A A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? a. select a vein in the client’s dominant arm b. choose the most proximal vein in the extremity c. choose a vein that is soft on palpation d. select a site distal to previous venipuncture attempts Answer: C A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, “you are not putting that hose down my throat.” Which of the following statements should the nurse make? a. “Let’s get the process over with because you won’t get better without this tube.” b. “You should talk to your provider about your fears.” c. “Why don’t you want the tube inserted?” d. “I can see that this is upsetting you.” Answer: D A nurse is employing a thorough, systematic method while obtaining objective data about a client. Thorough which of the following methods should the nurse collect this information? a. health history b. physical examination c. review of systems d. interview Answer: B