ATI RN Fundamentals 65 QUESTIONS WITH 100% CORRECT ANSWERS

ATI RN Fundamentals 65 QUESTIONS WITH 100% CORRECT ANSWERS A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the ...

ATI RN Fundamentals 65 QUESTIONS WITH 100% CORRECT ANSWERS A nurse is giving change-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 test results - 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. 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 30º. C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol. - B. Tell the client to keep the head of the bed elevated at least 30º. 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. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) 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. - A, B, E A. 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. B. 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. C. 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. D. 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. E. 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. A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? A. Touch the face with a cotton ball. B. Apply 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. - C. Have the client stand with their arms at their sides and their feet together.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. A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? A. 92 mm Hg B. 102 mm Hg C. 112 mm Hg D. 122 mm Hg - D. 122 mm Hg 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. A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg - B. 0.3 mg 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. 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." - A. "I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? A. Place a pillow under the client's knees. B. Position a trochanter 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. - D. Apply an ankle-foot orthotic device to the client's feet. 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. 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. - D. Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? A. Assign a staff member to feed the client. B. Provide small-handled utensils for the client. C. Thicken liquids on the client's tray. D. Arrange food in a consistent pattern on the client's plate. - D. Arrange food in a consistent pattern on the client's plate. 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. 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. - A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. 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. 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 plan 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. - B. Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at 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." - C. "You should have a fecal occult blood test every year." 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.