ATI fundamentals practice B PDF

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ATI Practice questions funamentals assessments. A good and accurate review of fundamentals of nursing ATI...

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1. A nurse is giving chance-of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? a) Admitting diagnosis. b) Breath sounds. c) Body temperature. d) Diagnostic results. Correct answer: B. Breath sounds - When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. 2. A nurse is caring for a client who has an NG tube and is receiving 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°. c) Make sure the enteral formula is at room temperature. d) Wipe the top of the formula can with alcohol. Correct answer: B. - The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus 3. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? a) Place the client in a room with negative-pressure airflow 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 antimicrobial sanitizer for hand hygiene Correct answer: A, B, E. - Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room. Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions. Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled. 4. A nurse is performing a Romberg test during a physical assessment of a client. Which of the following techniques should the nurse use? a) Touch the face with a cotton ball. b) Apply a vibrating tuning fork to the client's forehead. c) Have the client stand with their arms at their sides and their feet together. d) Perform direct percussion over the area of the kidneys. Correct answer: C - A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

5. A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mmHg. Which of the following images displays the measurement in mmHg to which the nurse should inflate the cuff when obtaining the blood pressure? a

b

c

d

Correct answer: D.To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff. 6. The 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 nuse transcribe the dosage of this medication in the medical record? a) .3 mg b) 0.3 mg

c) 0.30 mg d) 3/10 mg Correct answer: B – The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. 7. A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements 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." Correct answer: A.- Echinacea is taken to promote immunity and reduce the risk of infection. Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion. 8. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take t decrease the client’s risk of developing plantar flexion contractures? a) Place a pillow under the client's knees. b) Position a trochanter roll 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's feet. Correct answer: D.- The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. 9. A nurse is reviewing 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. Correct answer: D. – It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. 10. 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 feedings? 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. Correct answer: D. - Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals. 11. 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 requires intervention by the charge nurse? a) The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

b) The newly licensed nurse places sterile objects 2.5 cm (1 inch) 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. Correct answer: A.- The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field. 12. A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plant to take? a) Use a resuscitation bag with 80% oxygen prior to the procedure. b) Select a suction catheter that is half the size of the lumen. c) Place the end of the suction catheter in water-soluble lubricant. d) Adjust the wall suction apparatus to a pressure of 170 mm Hg. Correct answer: B.- The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. 13. A nurse in a clinic is caring for a middle adult client who states, “the doctor says that, since I am an average risk for colon cancer, I should have a routine screening/ what does that involve?” Which of the following responses should the nurse make? a) "I'll get a blood sample from you and send it for a screening test." b) "Beginning at age 60, you should have a colonoscopy." c) "You should have a fecal occult blood test every year." d) "The recommendation is to have a sigmoidoscopy every 10 years." Correct answer: C.- Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually. 14. A nurse has just 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) Bowel sounds are present on auscultation. d) The client reports relief of nausea. Correct answer: B.- An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement. 15. 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 a semi-Fowler's position prior to medication administration. d) Verify the dosage by measuring the liquid before administering it Correct answer: A.- The nurse should gently shake the liquid medication to ensure that the medication is mixed. 16. A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? a) Droplet b) Airborne c) Contact d) Protective environment

Correct answer: A.- Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. Clients who have a compromised immune system, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment. 17. A nurse is reviewing 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 Correct answer: C.- In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. 18. A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to HIPAA guidelines? a) A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b) A nurse asks a nurse from another unit to assist with documentation for a client. c) A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. d) A nurse discusses a client's status with the physical therapist who is caring for the client. Correct answer: B.- Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines. 19. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a) Walking briskly b) Riding a bicycle c) Performing isometric exercises d) Engaging in high-impact aerobics Correct answer: A.- Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. 20. A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse’s responsibility? a) Describe the procedure to the client. b) Witness the client's signature on the consent form. c) Inform the client of alternatives to the procedure. d) Tell the client which team members will assist with the procedure. Correct answer: B.- The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure. 21. 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) b) c) d)

Seal unused medications from the facility in a plastic bag. Evaluate the client's ability to self-administer medications. Report an identified discrepancy to The Joint Commission. Compare prescriptions with medications the client received while at the facility.

Correct answer: D.- When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge. 22. A nurse is teaching a group of staff 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 client? 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 Correct answer: D.- Some essential oils can cause bronchospasm; therefore, the nurse should consult the client’s provider before using this therapy for a client who has asthma. 23. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a) "This type of hearing aid does not allow for fine tuning of volume." b) "I shouldn't have trouble keeping the hearing aid in place during exercise." c) "I expect to hear a whistling sound when I first insert the hearing aid." d) "I will be sure to remove my hearing aid before taking a shower." Correct answer: D.- Clients should remove any hearing devices before showering because exposure to water can damage them. 24. A nurse if caring for a client who is receiving 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 hr. c) Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. d) Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high. Correct answer: A.- The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain. 25. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. 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's family to intervene. Correct answer: The principle of autonomy ensures that a client who is competent has the right to refuse treatment. 26. A nurse is planning care for a client who has tuberculosis. The nurse should use which o the following pieces of personal protective equipment when providing care for the client? a) Gown b) N95 respirator c) Shoe covers

d) Surgical cap Correct answer: B.- The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria. 27. A nurse is performing a peripheral vascular assessment of a client. When placing the bell of the stethoscope on the clinet’s neck, the nurse hears the following sound. This sound indicates which of the following? (click on the audio)

rncms_2019_opfb_f un_4C-39.mp3

a) b) c) d)

Narrowed arterial lumen Distended jugular veins Impaired ventricular contraction Asynchronous closure of the aortic and pulmonic valves

Correct answer: A.- Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. Blood flowing through distended jugular veins does not produce a sound. Impaired ventricular function produces extra heart sounds, either S3 or S4. These sounds are best heard over the aortic area of the heart. Asynchronous closure of the aortic and pulmonic valves is known as "splitting" of S2, so the nurse should hear two "dub" sounds during auscultation. This sound is best heard over the aortic area of the heart. 28. A middle adult client tells the nurse, “I feel useless now that my children do not need me anymore.” Which of the following responses should the nurse make? a) "Most people are happy when their children grow up and leave home." b) "You should be proud that your children are becoming independent." c) "Maybe you should consider why you are feeling useless." d) "People in middle adulthood often find satisfaction in nurturing and guiding young people." Correct answer: D.- According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people. 29. A nurse enters a client’s room and finds her on the floor. The client’s roommate 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 floor." d) "Client was trying to get out of bed." Correct answer: C.- The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause. 30. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) Wear sterile gloves when removing the old dressing. b) Warm the irrigation solution to 40.5° C (105° F). c) Cleanse the wound from the center outwar...