ATI 2019 Fundamentals Proctored Exam

A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? a. Changing the dressing for a client who has a stage 3 pressure injury b. Determining a client's response to a diuretic c. Comparing radial pulses for a client who is postoperative d. providing postmortem care to a client

A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements? A. I take ginkgo biloba for a headache B. I take echinacea to control my cholesterol C. I use ginger when I get car sick D. I use garlic for my menopausal symptoms ​

A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? A. Wear a mask when working within 3 feet of the client B. Administer metronidazole C. Don protective eyewear before entering the room. D. Place the client in a negative airflow room.

A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take? A. Attach the restraints securely to the side rails of the client's bed. B. Apply the restraints to allow as little movement as possible C.Allow room for two fingers to fit between the clients skin and the restraints d. remove the restraints every 4 hours

A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? A. Droplet B. Airbornes c. protective environment d. contact

A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make? A. Have your child drink one large glass of water. B. Hang up and call a poison control center hotline. C. Bring your child into the clinic later today. D. Induce vomiting in your child with syrup of ipecac.

A nurse is documenting a client's medical record. Which of the following entries should the nurse record. A. Oral temperature slightly elevated at 0800 B. Administered pain medication C. Incision without redness or drainage D. Drank adequate amounts of fluid with meals.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Brush the clients teeth daily C. Apply mineral oil to the client's lips D. Rinse the client's mouth with an alcohol-based mouthwash

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify which of the following situations is an example of negligence? A. A nurse administers a medication without first identifying the client. B. An assistive personnel discusses client care in the facility cafeteria with visitors present. C. A nurse begins a blood transfusion without obtaining consent. D. An assistive personnel prevents a client from leaving the facility.

A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take? A. Wear sterile gloves when collecting the specimen. B. Offer the client oral hygiene after the collection C. Collect the specimen in the evening. D Collect 1 ml of sputum.

A nurse is assessing an older client. Which of the following findings should the nurse expect? a. Decreased sense of balanced b. Increased nighttime sleeping c. Heightened sense of pain d. Nighttime urinary incontinence

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (select all that apply) a. "Cut the opening of the pouch 1⁄8 of an inch larger than the stoma " b. "Place a piece a gauze over the stoma while changing the pouch" c. "Use povidone-iodine to clean around the stoma" d. "Empty the ostomy pouch when it becomes one-third full of contents" e. expect the stoma to turn a purple-blue color as its heals"

A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? a. "Request that an assistive personnel interpret the information for the client" b. "Use proper medical terms when giving information to the client" c. "Offer written information in the client's language" d. "Avoid using gestures when speaking to the client"

A nurse is teaching a client about home care equipment. Which of the following information should the nurse include in the teaching? (select all that apply) a. "Avoid using wool blankets when receiving oxygen" b. check the O2 delivery rate at least once a day c. align the middle of the ball in the flow meter with the line of the prescribed flow rate d. "Keep the oxygen delivery system 0.6 m (2 feet) from any heat source" e. "Lay the oxygen tank flat when storing"

A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime? a. Provide a late supper. b. Offer a wet washcloth for the client to wash her face c. Perform range-of-motion exercises d. Prepare hot cocoa or tea for the client

A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first? a. A client who has acute abdominal pain of 4 on a scale from 0 to 10 b. A client who has pneumonia and an oxygen saturation of 96% c. A client who has new onset of dyspnea 24hr after a total hip arthroplasty • d. A client who has a urinary tract infection and low-grade fever

A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) DOSAGE CALCULATION

A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which if the following requires the completion of an incident report? a. A client's prescribed laboratory testing was not obtained b. A client withdrew consent for a procedure c. An oncoming nurse arrived to work late d. A nurse transfused a unit of packed RBCs in 2 hr.

A nurse is caring for a client who has a new prescription for negative-pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention. a. The client's plan of care b. The nurse practice act c. The material safety data sheet d. The policy and procedure manual

A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take? a. Cover the area of percussion with a towel. b. Instruct the client to exhale quickly during vibration c. Schedule postural drainage after meals d. Perform percussion over the lower back

A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the following images indicates the correct number of mL the nurse should administer? (round answer to the nearest whole number.) DOSAGE CALCULATION

A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose and I'm worried I will lose it if it falls off."Which of the following is an appropriate response by the nurse? a. " I will place it in your drawer so it won't get lost." b. I can pin it to your hospital gown so you won't lose it." c. "I will hold onto it until a family member can take it home." d. I can put it in a locked storage unit for you

A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints? a. If the client is pacing in the hallway b. As a part of a fall prevention program c. At the request of the client's family d. When the client poses a threat to self

To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning? a. Case manager b. Client educator c. Client care provider d. Client advocate

A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include? a. "Delirium does not affect a client's perception of her environment." b. "Delirium does not affect a client's sleep cycle." c. "Delirium has an abrupt onset." d. "Delirium has a slow progression."

A nurse is speaking with a client who has recently received a diagnosis of a chronic illness. The client states, " The doctor must be wrong. I can't be that sick". The nurse should inform the client that their reaction is an example of which of the following expected responses to grief? a. Acceptance b. Denial c. Anger d. Depression

A Nurse on a medical-surgical unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions b. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications. c. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she "doesn't like him." d. the family of a client who has a terminal illness asks the provider not to tell the client the diagnosis

A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the clients indicates an understanding of the teaching? a. "I should perform my self-exam the week that my period starts" b. "I should make different patterns on each breast when I do my self-exam." c. "I should use the palm of my hand to apply pressure to each breast." d. "I should make circular motions with my fingertips under my arms."

A nurse is preparing to transfer a client who is partially weight bearing from the bed to the chair. Which of the following actions should the nurse take? a. Keep his knees straight when moving the client b. Position the chair next to the bed as a 90 degree angle c. Stand with his feet together when lifting the client d. Have the client bear weight on her stronger leg

A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. ( Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - Select the injection port of the IV tubing closest to the client. - Cleanse the injection port with an antiseptic swab. - Aspirate for blood return. - Inject the medication. - perform hand hygiene

A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements but the client indicates an understanding of the teaching a. I should wait 3 minutes after mixing the insulin to inject it b. I should draw up the NPH insulin before regular insulin c. I should inject air into the vial of regular insulin first d. I should roll the vial of NPH insulin between my hands before drawing it up

A nurse is assessing the body temperature of an adult client using a temporal artery thermometer. Which of the following actions should the nurse take? (Select all that apply) a. Slide the probe across the clients forehead b. Pull the clients pinna up & back c. Hold the client's hair aside while performing the procedure d. Document the client's temperature with "AX" next to the value e. Move the probe in a circular motion

A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the following actions should the nurse take to help dilate the vein? a. Stroke the skin near the vein in an upward position b. Dangle the client's arm over the edge of the bed c. Apply a cool compress to the vein for 10 min d. Instruct the client to flex their arm with the hand open

A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take? a. Apply intermittent suction during catheter insertion b. Suction the client's airway for 20 seconds with each pass c. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning d. decrease suction pressure to 150 mm Hg if the O2 sat levels drop during suctioning

A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the following finding is the nurse's priority? a. Last bowel movement was 3 days ago b. Reports pain of 8 on a scale of 0 to 10 c. Distended bladder d. Respiratory rate 7/min

A nurse is caring for a client who has been treated multiple times for STIs. Which of the following responses should the nurse take? a. "You must have too many sexual partners" b. "Why do you keep letting this happen?" c. "Let's explore why this might be re-occuring" d. "Don't you have access to condoms?"

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first? a. Move items in the room away from the client b. Turn the client onto their side c. Help the client lie on the floor d. Loosen the client's clothing

A nurse is testing a client for conduction deafness by performing Weber's test. Which of the following actions should the nurse take when performing this test? a. Move a vibrating tuning form in front of the client's ear canals one after the other b. Place the base of a vibrating tuning fork on the client's mastoid process c. Place the base of a vibrating tuning fork on the top of the client's head d. Count how many seconds a client can hear a tuning fork after it has been struck

A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify which of the following medications can interact adversely with this supplement? a. Warfarin b. Albuterol c. Levothyroxine d. Atorvastatin

A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take? a. Discuss alternative treatments with the client b. Explain to the client the risks involved with not having the procedure c. Express approval of the client's decision to not have the procedure d. Document the client's decision in the medical record

A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? a. " I will have my partner help me change position every 4 hours" b. " I will remove my antiembolic stockings while I am in bed" c." I will hold my breath when rising from a sitting position" d." I will perform ankle and knee exercises every hour."

A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Oatmeal b. Applesauce c. Scrambled eggs d. Plain Yogurt

A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history? a. " What medications are you currently taking?" b." Are you experiencing any Pain?" c. " Have any of your relatives been diagnosed with cancer?" d. " What Techniques do you use to cope with stress?"

A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect? a. Thickened outer layer of skin b. Increased skin elasticity c. Reduced sweat production d. Increased Production of oils

A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make? a. " I would get a second opinion if I were you." b " it might seem bad now, but things will get better." c " it must be difficult for you to receive this kind of news." d I think you would benefit from speaking with our chaplain."

A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take? a. Use the client's first name when initially meeting the client. b. Tell the client the purpose for collecting the information. c. Explain to the client the necessity of full disclosure of information. d. Avoid documenting direct quotes from the client as part of subjective data.

A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, " I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse? a. " Let's talk more about your dad's condition." b. "The social worker will help you answer those questions." c. " Try to help your dad enjoy this time as much as he can." d. " I think that you should discuss this with the hospice nurse."

A Nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity? a. The client's room number b. The client's admitting diagnosis c. The name of the client's next of kind. d. The client's telephone number

A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team. a. Social worker b. Occupational therapist c. Registered Dietician d. Primary care provider

A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse indicates an understanding of the teaching? a. " I will place the client in a Private room." b. " I will remove my gown before my gloves after providing client care." c. " I will wear an N95 respirator mask when caring for the client." d. " I will tell the client's visitors to wear a mask when they are within 3 feet of the client."

A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan? a. Cover the blood pressure cuff with a stockinette. b. Wear powdered gloves when providing care to the client. c. Apply adhesive tape when securing an IV insertion site. d. Use plastic syringes for medication administration.

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, " I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take? a. Describe the surgery to the client. b. Notify the Provider. c. Complete an incident report d. Provide brochures about the procedure.

A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. " SQ" for subcutaneous b. "SS" for sliding scale c. "BRP" for bathroom privileges d. "OJ" for orange juice

A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take? a. Give detailed instructions for the client to follow. b. Complete the bath even if the client is in distress. c. Use distractions when bathing the client. d. Allow the client to select the temperature of the bath water.

A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity? a. Provide guided imagery exercises to the client. b. Refrain from discussing the client's prognosis c. Suggest that the client keep a journal. d. Encourage the client to share their life story.

A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take? a. Wear sterile gloves when emptying the container. b. Reset the container with the drainage port closed c. Connect the drain to high pressure suction. d. .Cleanse the drain plug with alcohol after emptying

A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make? a. " Will you please spell the name of that medication for me?" b. "Let me clarify that you want the medication given qid, correct?" c. " I will sign my name now and leave a space for you to sign your name." d. "Let me provide you with the client's medical record number for identification."

During change of shift report, a nurse discovers she overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first? a. Inform the provider of the delay in obtaining the type and cross-match. b. Obtain the client's type and cross-match. c. Prepare an incident report for risk management. d. Document the incident in the client's medical record.

A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag? a. An emesis basin filled with blood from severe coughing b. A bedpan containing diarrhea from a client who was receiving antibiotics c. A disposable tissue containing expectorated sputum d. A calibrated toilet insert filled with urine.

A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula? a. Check for gastric residual volume b. Encourage the client to breathe deeply and cough. c. Flush the tube with sterile 0.9% sodium chloride irrigation. d. Encourage the client to take sips of water.

A nurse is caring for a client immediately following the insertion of an NG tube. Which of the following should indicate to the nurse that the tube is placed incorrectly? a. The client has a dry mouth b. The client is coughing c. The client has active bowel sounds d. The client is hiccuping

A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a. Assess the client for a gag reflex b. Measure the pH of the gastric c. Place the end of the NG tube in the water to observe for bubbling d. Asculatate 2.5 cm above the umbilicus while injecting 15 ml of water

A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain meds are not an option for managing pain. Which of the following is an appropriate response by the nurse? a. Would you like to get you a back massage? b. Why do you think pain med is not going to help you? c. You may take any herbal remedies you bring from home d. I'm sure it will work if you just give it a chance

a nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect? a. Bradycardia b. Postural hypotension c. Distended neck vein d. Dependent edema

A nurse is caring for a client who is immunocompromised which of the following actions should the nurse take? a. Use sterile gloves to provide perineal care b. Cleanse hands with an alcohol based hand rub before client contact c. Have the client apply a mask when children are visiting d. Place the client in a semi-private room

Which of the following veins should the nurse select when initiating iv therapy? a. The radial vein on the left arm b. The cephalic vein in the left distal forearm c. The cephalic within on the back of the right hand d. The basilic vein in the right antecubital fossa

interventions should the nurse take to prevent skin breakdown? a. Apply powder to the client perineal area b. Restrict client's fluid intake c. Request a prescriptions for an indwelling urinary catheter d. Apply a moisture barrier ointment after perineal hygiene

client tells the nurse" I am looking forward to seeing my grandchildren grow up." the nurse should identify the client is experiencing which of the following stages of grief? a. Acceptance b. Bargaining c. Anger d. Denial

A nurse is teaching a client about the care and use of hearing aids. Which of the following instructions should the nurse include in the teaching? a. clean the hearing aid by soaking it in warm water b. Turn the hearing aid off and the volume down before insertion c. Replace the battery if the hearing aid emits a whistling sound d. Leave the battery in place when the hearing aid is not in use

A nurse is teaching a client about the care and use of hearing aids. Which of the following should the nurse take? a. Observe the client's eyes for the six cardinal position of gaze b. Verify the client's ability to read letters on a snellen eye chart c. Check the client's pupil reaction when focusing on distant and nearby objects d. Test the client's eyes for reactions to light response

A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching? a. holding the object close to the body b. holding the object away from the body

A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take? a. Change the clients position every 4 hours b. Apply petroleum base ointment in the red area c. Assess the red area for blanching d. Use friction when cleansing the client's skin

A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care. a. request a prescription for an indwelling urinary cath

A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should be included in the teaching? (select all that apply) a. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation b. Remove from the artificial eye by retracting the upper eyelid c. Apply pressure just below artificial eye to break the suction d. Clear the artificial eye with hydrogen peroxide before storing e. Retract the upper and lower lids to reinsert the artificial eye

A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? a. Determine areas of resonance across the abdomen using a systematic approach b. Expose the client's abdomen to look for changes in appearance c. Perform abdominal palpation by pressing gently with the finger pads d. Use the diaphragm of the stethoscope to listen for bowel sounds

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority? a. Determine the client's reading ability b. Review the use of an artificial larynx c. With the client schedule a support session d. For the client explain the techniques of esophageal speech

A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply) a. I will use the bars when getting in and out of the bath tub b. I need to check my medications for expiration dates c. I need to have a fire escape plan with my family d. I will apply tape over frayed areas of electrical cords e. I need to set my hot water heater to 140 degrees Fahrenheit

a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first? a. Offer pain medication b. Palpate the abdomen c.Auscultate bowel sounds d.Administer an antiemetic

A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statement by the client partner indicates maladaptive coping? a. I don't know if I will be able to meet his physical needs.

A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings? a. Dry gauge b. Transparent c. Calcium alginate d. Hydrogel

A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse? a. "lets discuss your concerns about your father," or anything along those lines that is therapeutic.

a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching? a. I can apply lotion to soften the calluses as long as I don't put lotion between my toes b. I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly c. I should soak my feet in warm water daily to soften corns and calluses d. I should use an over the counter liquid medication to remove corns

A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Tie the restraints to the side rail b. Secure restraints with a square knot c. Remove one restraint at a time d. Remove the restraints every 3 hours

A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply a. Use an N95 respirator while providing client care b. wear a gown and gloves when providing client care c. assign the client to a private room with positive air flow d. wash hands with soap and water after contact with the client e. Ensure the client does not receive fresh fruits

A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? a. Schedule the client as the first surgical procedure of the day b. Cleanse the stoppers with primidone iodine for withdrawing medication c. Remove the stop stocks from iv tubing d.Ensure the gloves in the surgical suite are powdered gloves

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following action should the nurse take? a. direct verbal discharge instruction to the interpreter

A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn? a. The client's belief that his needs will be met through education b. The nurse explaining the need for education to the client c. The client seeking family approval by agreeing to a teaching plan d. The nurse's empathy about the client having to self-inject

A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take? a. Heat the formula to 105 degrees Fahrenheit b. Flush the tubing with 10 ml of water every 2 hours c. Change the tubing every 72 hours d. Aspirate residual volume every 4 hours (Every 4-8 hours is correct)

A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following answers indicates the proper method of cleaning a wound site? a. use a different sterile swab for each stroke

A nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching? a. The client picks up the walker with each step b. The client stoops slightly forward when moving the walker c. The client stands with her elbows slightly flexed while holding the walker d. The client moves the walker ahead 10 inches with each step (Incorrect b/c 6 inches max)

A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts? a. Libel b. Defamation of character c. Assault d. Battery

A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take? a. Stabilize the vein by applying traction above the insertion site b. Engorge the vein by placing the arm in the dependent position c. Use friction at the insertion site to increase venous distention d.Leave the tourniquet on for 30 to 60 seconds after initial insertion

A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care? a. Prepare the client for a central venous line b. Change the PN infusion bag every 48 hours c. Administer the PN and fat emulsion separately d.Obtain a random blood glucose daily

A nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don't understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take? a. Provide brochures about the procedure b. Notify the provider c. Complete an incident report d. Describe the surgery to the client

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts? a. False imprisonment b. Invasion of privacy c. Assault d. Negligence

A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take? a.Place an activated tuning fork in the middle of the client's head

A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield. a. Changing the brief of an older client who has Clostridium difficile

An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest? a. Use the television to mask external noises b. Listen to soft music before lying down c. Exercise just prior to bedtime d.Keep the sleeping environment warm

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? a. Eat a light carbohydrate snack before bedtime b. Exercise 1 hour before bedtime c. Drink a cup of hot cocoa before bedtime d.Take a 30 min nap daily

A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her provider. Which of the following is an appropriate response by the nurse? a. You should ask the provider if she recommends traditional Chinese medicine.

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching? a. Each element has a range 1 to 5 points b. The higher the score the higher the pressure ulcer risk c. The clients age is part of the measurement d. The scale measures six elements

A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? a. Ensure the client is free of metal objects b. Administer 240 ml (8oz) oral contrast before the procedure c. Monitor the client for pain in the suprapubic region d. Assist the client with a bowel cleansing

A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include a. I don't know if I will be able to meet his physical needs.

A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. Which of the following should the nurse take to obtain the sample? a. The pad of the finger tip b. The lateral aspect of the finger c. The pinna of the ear d. The side of the wrist

A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first? a. Provide the client with a contact number for a diabetes education specialist b. Make a copy of the medication record of the reconciliation for the client c. Determine whether the client can afford the insulin administration supplies d. Obtain printed information about self-administration

A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? a. Wear a mask when working within 3 feet of the client

A nurse is delegating client's care to the assistive personnel. Which of the following tasks should the nurse delegate to the AP? obtain input & output for the patient that was stable ADLs specimen collection I&O vital signs if stable

A nurse is teaching about home safety with. Which of the following instructions should the nurse include? a. Use electrical tape to secure extension cords next to base boards on the floor b. Replace carpet floors with tiles c. Unplug electronics by grasping the cord d. To use a fire extinguisher, aim high at the top of the flames

A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first? a. Elimination needs b. Comfort level c. Peripheral pulses d. Skin integrity

A nurse in a long-term care facility is assessing a client. Which of the following findings should the nurse recognize as an indication a fecal impaction? a. Seepage of liquid stool

A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? a. Cotton tip applicator to clean the inside of the cannula b. Soak the outer cannula in warm soapy tap water c. Cleanse the skin around the stoma with normal saline d. Secure the tracheostomy ties to allow one finger to fit snuggly underneath

A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse? a. I don't know of if I will be able to meet his physical needs.

A nurse is preparing to transfer a client who is partially weight bearing from the bed to a chair. Which of the following action should the nurse a. Have the client bear weight on her stronger leg

A nurse in an acute care facility is preparing to transfer a client to a long-term facility. Which of the following information should be nurse include in the hand off report? a. Effectiveness of the last dose of pain medication

A nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the following statements by the client indicates understanding of the teaching? a. I will keep my eyes closed for 5 mins after inserting drops b. I will insert the drops in the center of the eye c. I will press the inner corner of my eye after insert drops d. I will raise my eye lid up while looking down and insert drops

A nurse in a long-term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer? a. A client who is incontinent of urine 1 to 2 times a day b. A client who is receiving enteral tube feedings c. Client who requires assistance to transfer from the bed to a chair d. Client who is unresponsive to pain stimuli

A nurse is assessing a client's personal hygiene. Which of the following findings indicates that the client might have difficulty with routinely bruising their teeth? A. Theclientsmucosaismoist B. The client gums feel spongy C. The client has a missing tooth D. The Client's tongue is a dull red color

A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first? A. Makea B. Provide C. Determine whether the client can afford the insulin administration supplies D. Obtain printed about insulin self administration

A community health nurse is teaching a group of clients about kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include? A. Contact your pelvic muscle when performing the exercises B.Expect improvement after 2 weeks of performing the exercises C. Hold your breath when performing the exercises D. Tighten your buttocks when performing the exercises

A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority? A. Skin tags noted in the neck region B. A change in appearance of a mole on the shoulder C. A flat, nonpalpable, discovered area of skin on the trunk D. Atrophic wart on the left index finger

A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take? A cover the client with heavy blankets after shivering subsides B place ice packs on the clients neck and behind the knees C apply a bath blanket between the client and a cooling blanket D give the client a sponge bath using alcohol water solution

A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of the following individuals should sign the consent form? A. The infants 17 year old mother B. The infants provider C. The infants grandmother D. The mother's 21 year old sibling

A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use? A. Encourage the client to try to defecate for 20 min while on the fracture pan. B. Keep the bed flat while the client is on the fracture pan. C. Hyperextend the clients back while the fracture pan is in place. D. Place the shallow end of the fracture pan under the clients buttocks.

A nurse is reviewing the medical record of a client who asks about the use of a magnet therapy for pain relief. The nurse should identify which of the following findings is a contraindication for receiving this type of therapy? A. The client is allergic to penicillin B. The client has a prescription for metoprolol C. The client has a history of alcohol use disorder D. The client has an implanted defibrillator

A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the clients room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first? A. Gloves B. Eyewear C. Gown D. Mask

A nurse is teaching a newly licensed nurse about the care of a client who has methicillin resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. I will wear an N95 respirator mask when caring for the client b. I will tell the clients visitors to wear a mask when they are within 3 feet of the client. c. I will place the client in a private room d. I will remove my gown before my gloves after providing client care.

A charge nurse in a long term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include? A. Delirium has an abrupt onset

A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take? A.choose the most proximal site on the extremity selected B. apply a cool compress for several minutes before insertion of the IV catheter C. place the tourniquet below the proposed insertion site D. place the extremity in a dependent position

A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching? A.Your partner must be present when you sign the advance directives B. You will receive written information about advance directives prior to signing C. You are required to sign advance directives prior to surgery D. Your provider must sign the advance directives before surgery

A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Remove one restraint at a time

A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take? A. Dilute each crushed medication with sterile water B. Mix the medication together in a single syringe C. Flush the NG tube with 5mL of sterile water prior to administration D. Combine the medication with the formula in the feeding bag

A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care? a. Toilet the client every 4hr while the client is awake b. Apply a moisture barrier in a thick layer to vulnerable skin areas c. Cleanse the skin with antibacterial soap and hot water after each incontinence episode d. Reduce the clients daily fluid intake

A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A. Complete an incident report B. Obtain the client's vital signs C. Document the fluid infusion in the client's chart D. Report the incident in to the unit manager

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA) a. I need to check my medications for expiration dates b. I will use the grab bars when getting in and out of the bathtub c. I need to have a fire escape plan with my family

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, I trust my doctor, but I don't understand what is meant by resecting my intestine. Which of the following actions should the nurse take? a. notify the provider

A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage? A. Dilated pupils B. Physical exhaustion C. Bradycardia D. Depression

A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? A. Unplug the pump B. obtain a replacement pump C. Notify the biomedical department to fix the pump D. Label the pump with a defective equipment sticker

A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective? A. The client's skin on the lower back is intact without redness B. The client's laughing at a television show C. The client states that he is able to concentrate while eating D. The clients's vital signs are within the expected reference range

A nurse is preparing a sterile field to assist with suturing a clients laceration. Which of the following actions should the nurse plan to take? A. Pour the sterile solution with the bottle 20cm(8in) above the sterile bowl B. Hold the bottle of sterile solution so that the label is facing the palm of the hand C. Place the lid of the sterile solution bottle face down on the sterile drape D. Apply sterile gloves before opening the bottle of sterile solution

A nurse is caring for a client who is scheduled to have his alanine amino transferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? A. This test will determine if your heart is performing properly B. This test will indicate if you are at risk for developing blood clots C. This test is used to check how your kidneys are working D. This test will provide information about the function of your liver

a nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? A. Ensure that the provider signs the prescription B. Write down the complete prescription C. Read back the prescription to the dr d. Document the prescription as a telephone prescription in the medical record

A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? A. Petechiae on the client's right anterior thigh B. Flat rash on the client's ankle C. non-palpable macule on the client's left shoulder D. Non Blanching darkened area over the client's trochanter

A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching? A. After insert the hearing aid, i will turn it up as high as it will go B. I should leave the battery in the hearing aid when i take it out to sleep C. I will need to get a new hearing aide every year D. I should gradually increase the time that i wear the hearing aid

A nurse is preparing to collect a specimen from a client. Which of the following actions should the nurse take? a. Collect the sputum specimen in the morning

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia? A. Thirst B. Confusion C. Coolskin D. Shakiness

A nurse is assessing an older adult client. Which of the following findings should the nurse expect? a. Decreased sense of balance

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take? A. Report any discrepancy in the court total of the controlled substance after administration B. Place the assisted portion of the controlled substance in the sharps container C. Verify the count total of the controlled substance after removing the amount needed D. Ask a second nurse to report her signature when wasting any unused portion of the controlled substance

A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, i'm worried about the bag. Which of the following is an appropriate response by the nurse? A. You are worried about having to wear a colostomy bag? B. Have you ever known someone who has a colostomy C. Let's wait until after the surgery to discuss your concerns about your colostomy D. The surgeon will only place the colostomy if it is necessary

A nurse is preparing to administer medication to a client. Which of the following should the nurse use as a client identifier? A. Age B. Room number C. Photograph D. Bed number

A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the injection? A. Discard the needle in a puncture proof container B. Place the needle on the bedside table C. Remove the needle from the syringe D. Recap the needle before disposal

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage? A. Assist the client in setting goals to make the change B. Develop a plan for the client to integrate the change into her lifestyle C. Present information about the benefits of quitting smoking D. Recommend small changes for the client to make to change her behavior overtime

A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching? A. I will keep my legs crossed while sitting B. I will perform exercises once every 4 hours while i am awake C. I should massage my legs when they hurt D. I should limit the time that i spend sitting in a chair

A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. BRP for bathroom privileges

A nurse who is documenting information in a clients electronic medical record is asked to assist with an emergency. Which of the following actions should the nurse take? A. Ask another nurse to monitor the computer B. Turn the computer off C. Move the computer to a secure place D. Print out the current notes to finish later

A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?' A. Diarrhea one time in a 24 hour period B. A weight gain of 0.91kg(2Ib) in 2 days C. A gastric residual of 300mL at the end of the shift D. A blood glucose level of 110 mg/dL

A nurse is planning care for a female client who has an indwelling urinary catheter.Which of the following actions should the nurse include in the plan? A. Tape the catheter to the lower abdomen B. Attach the drainage bag to the side rails of the bed C. Keep the drainage bag below the level of the bladder D. Empty the drainage bag when it is three quarters full

A nurse is reviewing the medical record for a newly admitted client. Which of thefollowing laboratory values should the nurse report to the provider? A. Sodium 140 B. Potassium 1.8 C. Magnesium 1.9 D. Calcium 6.5

A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220Ib. How many mg should the nurse administer? (Round to the nearest whole number.Use a leading zero if it applies. Do not use trailing zero). DOSAGE CALCULATION

A nurse is caring for a client who tells the nurse, since I retired, I have a lot of time on my hands and nothing to do. I guess nobody needs me. Which of the following responses should the nurse make? A. If i were you, i would volunteer my time B. Do you have family members you can visit C. You need to realize that you have valuable skills to offer others D. Tell me about some hobbies you enjoy

A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The nurse should identify that which of the following findings indicates a need for restraints? A. The client's family is unable to stay with the client B. The client becomes confused at night C. The client gets out of bed to use the bathroom frequently D. The client is assigned a room near the nurses station

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation? A. No changes noted to the wound from previous nursing notes B. Client pre-medicated with MSO4 sunq prior to dressing change C. The wound seems clean and does not appear to be infected D. New dressing applied as prescribed, no drainage on old dressing

a nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take? A. Place the clients arms at their sides B. Flex the client's knees C. Place the client at the side of the bed nearest the direction they will be turned D. Roll the client as one unit in a smooth continuous motion.

A nurse is caring for a client who has TB. which of the following precautions should the nurse plan to implement when working with the client? a. airborne

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? a. Oral suction equipment and oral airway.

A nurse is providing teaching to the family of a client who is at the end stage of life. Which of the following client manifestations should the nurse instruct the family to expect? A. Increased periods of wakefulness B. Altered breathing patterns C. Increased salivation D. Warm and dry extremities

A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take? a. recommend an interpreter who is the same gender as the client.

A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take? a. Aspirate residual volume every 4 hr

A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy? a. The cephalic vein in the left distal forearm

A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Plain yogurt

A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care? a. Schedule the client as the first procedure

Type 2 diabetes mellitus patient with corns and calluses. a. I can apply lotion to soften calluses as long as i don't put lotion between my toes

A nurse is caring for a male client who has a prescription for intermittent catheterization with a coude catheter. Which of the following images show the type of catheter the nurse should use? a. The picture with the curled end of the catheter

A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first? A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to a breast cancer support group C. identify the impact of the mastectomy on the client's body image D. encourage the client to assist with her dressing change

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Place them in order of performance. Use all steps) - 1. Provide adequate lighting to inspect the abdomen - 2. Listen to the abdomen arteries using the bell of a stethoscope - 3. Percuss all four quadrants of the abdomen to measure sound quality - 4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the abdomen - 5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen

a nurse working on a medical surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel? a. assisting with ambulation for a client who has a pulmonary infection.

A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first? a. Inject air into the short acting insulin vial.

A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? a. Develop a list of goals