NUR 204 ATI Fundamentals Final Review. docx

ATI Fundamentals Final Review 1. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indica ...

ATI Fundamentals Final Review 1. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A) Increase in hematocrit B) Increase in respiratory rate C) Decrease in heart rate D) Decrease in capillary refill time 2. A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legally witness? (Select all that apply.) A) A teacher who brings in a 7-year-old student B) A 16-year-old client who is married C) A 27-year-old client who has schizophrenia D) An adoptive parent who brings in his 8-year-old son E) A 17-year-old mother who brings in her toddler 3. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A) Insert the suction catheter while the client is swallowing. B) Apply intermittent suction when withdrawing the catheter. C) Place the catheter in a location that is clean and dry for later use. D) Hold the suction catheter with her clean, nondominant hand. 4. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet? A) Beef liver B) Shellfish C) Egg yolks D) Avocados 5. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? A) Rock the client up to a standing position. B) Pivot on the foot that is the farthest from the chair. C) Assess the client for orthostatic hypotension. D) Apply a gait belt to the client. 6. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) Carry a client's soiled linens out of the room in a mesh linen bag. B) Place a client who has tuberculosis in a room with negative-pressure airflow. C) Provide disposable plates and utensils for a client who is HIV-positive. D) Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag. 7. A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? A) Talk directly to the client, instead of the interpreter, when speaking. B) Use a family member as the client's interpreter. C) Make sure that the interpreter has a college degree. D) Avoid asking the client personal questions through the interpreter. 8. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? A) Urine has an unusual odor. B) Urine specific gravity is 1.035. C) Bladder scan shows 525 mL of urine. D) Urine is positive for ketones. 9. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? A) Have the client wear a mask when receiving visitors. B) Wash her hands before and after contact with the client. C) Assign the client to a room with negative-pressure airflow exchange. D) Instruct all visitors to limit their time with the client. 10. 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) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization. 11. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? A) Thread the IV catheter so that the hub rests at the insertion site. B) Shave excess hair from around the insertion site. C) Cleanse the site with hydrogen peroxide before IV catheter insertion. D) Palpate the site carefully just before inserting the IV catheter. 12. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? A) Oat cereal B) Refried beans C) Peanut butter D) Cheddar cheese 13. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.) A) Check the cord routinely for frays or tearing. B) Keep the unit at least 4 feet away from a gas stove. C) Consider purchasing a generator for power backup. D) Observe for signs of hypoxia. E) Select synthetic clothing and bedding. 14. A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first? A) Reposition the client. B) Document the client's IV intake in the medical record. C) Request a new IV fluid prescription. D) Check the IV tubing for obstruction. 15. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? A) Reduce dietary sodium B) Administer a loop diuretic C) Evaluate electrolytes D) Restrict intake of oral fluids 16. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? A) Insert the IV catheter into the back of the client's hand. B) Massage the area of the venipuncture site vigorously. C) Insert the IV catheter without using a tourniquet. D) Apply traction to the skin proximal to the insertion site to stabilize the vein 17. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? A) Second intercostal space at the left sternal border B) Fourth intercostal space at the right sternal border C) Fourth intercostal space at the left sternal border D) Second intercostal space at the right sternal border 18. A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? A) Turn the client every 4 hr. B) Elevate the head of the client's bed. C) Hold oral care. D) Increase the room's temperature. 19. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? A) "We can talk about advance directives, and I can also give you some brochures about them." B) "You should set up a time to talk with your provider about that." C) "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." D) "Why do you want to discuss this without your partner here to plan this with you?" 20. A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A) "Is your pain constant or intermittent?" B) "What would you rate your pain on a scale of 0 to 10?" C) "Does the pain radiate?" D) "Is your pain sharp or dull?" 21. A nurse is giving a change-of-shift report about a client he 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 22. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? A) Albumin level of 3 g/dL B) HDL level of 90 mg/dL C) Norton scale score of 18 D) Braden scale score of 20 23. A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? A) Loss of skin turgor on the back of the hands B) Varicosities on the lower extremities C) Thick, discolored nails with ridges D) Bruises on the arms in various stages of healing 24. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? A) Document the provider's statement in the medical record. B) Notify the nursing manager. C) Consult the facility's risk manager. D) Complete an incident report. 25. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? A) Small air bubbles are in the IV tubing. B) IV flow stops when the client bends her arm. C) Swelling and coolness are observed at the IV site. D) Blood is visible in the IV catheter and tubing. 26. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? A) Activate the emergency fire alarm. B) Extinguish the fire. C) Evacuate the client. D) Confine the fire. 27. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client? A) "Rashes are very common, especially if you have dry skin. Did it go away on its own?" B) "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic." C) "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash." D) "We need to document the exact medication you were taking because you might be allergic to it." 28. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? 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 29. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A) Pad the client's wrist before applying the restraints. B) Evaluate the client's circulation once per shift after application. C) Remove the restraints every 4 hr. to evaluate the client's status. D) Secure the restraint ties to the client's bed side rails. 30. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take? A) Assist the client into a prone position. B) Place a sleeve over the top of each leg with the opening at the knee. C) Make sure two fingers can fit under the sleeves. D) Set the ankle pressure at 65 mm Hg. 31. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr.? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 107 ml/hr. 32. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A) Make sure the client's room has at least 6 air exchanges per hour. B) Make sure the client wears a mask when outside her room if there is construction in the area. C) Place the client in a private room with negative-pressure airflow. D) Wear an N95 respirator when giving the client direct care. 33. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? A) Administer the medication with the needle at a 45° angle. B) Administer the medication into the client's nondominant arm. C) Pull the client's skin laterally or downward prior to administration. D) Massage the injection site after administration. 34. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? A) Examine personal values about the issue. B) Tell the parents that this is a necessary procedure. C) Inform the parents that the staff does not require their consent. D) Contact a spiritual support person to explain the importance of the procedure 35. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A) 2 cups of soup B) 1 quart of water C) 8 oz of ice chips D) 6 oz of tea 36. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A) Role play B) Group discussions C) Question-answer meetings D) Practice sessions 37. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A) Remove the outer cannula cautiously for routine cleaning. B) Use tracheostomy covers when outdoors. C) Use sterile technique when performing tracheostomy care at home. D) Cleanse irritated skin with full-strength hydrogen peroxide. 38. A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? A) "We will determine who the durable power of attorney for health care form has designated." B) "We will apply oxygen through a tube in your nose." C) "We will ask if you have changed your mind." D) "We will insert a breathing tube while we evaluate your condition." 39. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A) Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B) Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. C) Make sure the reservoir bag of a partial rebreathing mask remains deflated. D) Use petroleum jelly to lubricate the client's nares, face, and lips. 40. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) A) Assist the client with a partial bed bath. B) Measure the client's BP after the nurse administers an antihypertensive medication. C) Test the client's swallowing ability by providing thickened liquids. D) Use a communication board to ask what the client wants for lunch. E) Irrigate the client's indwelling urinary catheter. 41. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field? A) The nurse opens the sterile field on a wet surface. B) The nurse opens the first fold away from his body. C) The nurse holds sterile objects above the waist. D) The outer edge of the sterile field is touching a bottle. 42. A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? A) Uniform pigmentation B) A regular border C) An uneven shape D) A diameter smaller than 6 mm 43. A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? A) "I will return shortly after I document this in your record." B) "Most men live a long time with prostate cancer." C) "I am available to talk if you should change your mind." D) "I will make a referral to a cancer support group for you." 44. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? A) Wrap blankets around all four sides of the bed. B) Apply restraints during seizure activity. C) Place the client in a supine position during seizure activity. D) Have a tongue depressor at the client's bedside. 45. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A) Numbness of the extremities B) Bradycardia C) Positive Chvostek's sign D) Abdominal cramping 46. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A) A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. B) A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. C) A client with a do-not-resuscitate (DNR) status has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. D) A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she would give her. 47. A nurse is auscultating the anterior chest of a client newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through his stethoscope and identify the type of breath sounds he hears. A) Crackles B) Rhonchi C) Friction rub D) Normal breath sounds 48. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? A) The client is receiving formula at room temperature. B) The feedings infuse at a slow, continuous drip over 8 hr. each night. C) The family member washes out the feeding bag with warm water once every 24 hr. D) The family member flushes the tubing with water before and after giving medications. 49. A nurse has just inserted an NG tube for a client. Which of the following assessment 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. 50. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? A) Clean sutures along the incision site. B) Grasp at the knot of the sutures with forceps. C) Cut the sutures close to the skin on one side. D) Pull out the sutures with forceps in one piece. 51. A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body 52. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A) Back of foot (heel) B) Knee cap C) Elbow D) Back of elbow 53. A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? A) Encourage the client to relax and take deep breaths during the dressing change. B) Educate the client about the importance of the dressing change to prevent infection. C) Assist the client to a comfortable position for the dressing change. D) Administer pain medication 45 min before changing the client's dressing. 54. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A) "When descending stairs, I will first shift my weight to my right leg." B) "I should place my crutches 12 inches in front and to the side of each foot." C) "As I sit down, I will hold one crutch in each hand." D) "I will make sure the shoulder rests are snug against my armpits." 55. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? A) "I think I should take my pain medication more often, since it is not controlling my pain." B) "Breathing faster will help me keep my mind off of the pain." C) "It might help me to listen to music while I'm lying in bed." D) "I don't want to walk today because I have some pain." 56. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A) Contact B) Droplet C) Airborne D) Protective 57. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? A) During the admission process B) As soon as the client's condition is stable C) During the initial team conference D) After consulting with the client's family 58. A middle adult client tells the nurse, "I feel so 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." 59. 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 bedrail onto the floor. Which of the following statements should the nurse document about this incident? A) "Incident report completed." B) "Client climbed over the bedrails." C) "Client found lying on floor." D) "Client was trying to get out of bed." 60. 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 she 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."