ATI RN Fundamentals Online Practice 2019 A test with complete solutions

ATI RN Fundamentals Online Practice 2019 A test with complete solutions 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 ...

ATI RN Fundamentals Online Practice 2019 A test with complete solutions 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 A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? 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 client's caregiver washes out the feeding bag with warm water once every 24 hr d. the client's caregiver flushes the tubing with water before and after administering medications A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. "You would have so much more time to spend with your family." b. "You should consider getting a part-time job or doing volunteer work." c. "Let's talk about how the change in your job status will affect you." d. "Why wouldn't you want to retire and relax?" 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?" . A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. discuss the risk factors of colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phases of loss and grief d. reassure the client that this is an expected response to grief 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 every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client uses nonacetone nail polish remover c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher. c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment 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 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 degree 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 A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? a. advocacy ensures clients' safety, health, and rights b. advocacy ensures that nurses are able to explain their own actions c. advocacy ensures that nurses follow through on their promises to clients d. advocacy ensures fairness in client care delivery and use of resources A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down and back toward her head d. tilt the clients head backward for 5 min A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. use a bed exit alarm system b. raise four side rails while the client is in bed c. apply one soft wrist restraint d. dim the lights in the client's room A nurse is initiating a protective environment for a client who has an allogenic 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 six 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 A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a. "I can place an extension cord across my living room to plug in my TV." b. "I will hire someone to trim that tree that hangs low over the stairs of my front porch" c. "I will place my alarm clock on my bedroom dresser across the room." d. "I will replace the old throw rug in my kitchen with a new one." A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a. combine client care tasks when caring for multiple clients b. wait until the end of the shift to document care c. use the planning step of the nursing process to prioritize client care delivery d. allow for interruptions in tasks to discuss client care issues with colleagues A nurse is planning to insert a peripheral IV catheter for an older adult. Which of the following actions should the nurse plan to take? a. insert the catheter at a 45 degree angle b. place the client's arm in a dependent position c. shave excess hair from the insertion site d. initiate IV therapy in the veins of the hand 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? (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 A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. a lesion with uniform pigmentation b. a new appearance of petechiae c. a mole with an asymmetrical appearance d. the presence of a papule 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 A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a. critical pathway b. situation, background, assessment, and recommendation (SBAR) c. transfer report d. medication administration record (MAR) 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 A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? a. "We would consult the person appointed by your health care proxy to make decisions." b. "We would give you oxygen through a tube in your nose." c. "You would be unable to change your previous wishes about your care." d. "We would insert a breathing tube while we evaluate your condition." A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b. remove the NG tube if the client begins to gag or choke c. apply suction to the NG tube prior to insertion d. have the client take sips of water to promote insertion of the NG tube into the esophagus 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. -place a name tag on the body -ask the client's family members if they would like to view the body -obtain the pronouncement of death from the provider -wash the client's body -remove tubes and indwelling lines A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. insert the needle at a 15 degree angle b. aspirate for blood return prior to administration c. administer the medication into the abdomen d. massage the site following the injection -the nurse should instruct the client not to massage the site because this can cause tissue damage and bruising