Virtual ATI Fundamentals Pre-Assessment Quiz | Answered with Rationales

Virtual ATI Fundamentals Pre-Assessment Quiz | Answered with Rationales A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling wit ...

Virtual ATI Fundamentals Pre-Assessment Quiz | Answered with Rationales A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - Remove the clients from the room - Activate the fire alarm - Close the door - Extinguish the fire A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? A. Blistering B. Erythema C. Eschar D. Absence of pain Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat. A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) - Report of feeling pressure - Tenderness over the symphysis pubis - Distended bladder - Voiding 30 mL frequently Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understands the teaching? A. "Most of my calories each day should be from fats." B. "I should eat more calories from complex carbohydrates than anything else." C. "Simple sugars are needed more than other calorie sources." D. "Protein should be my main source of calories." The client who has diabetes should consume the majority of calories from complex carbohydrates, such as whole grains, fruits, and vegetables. A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching? A. "I will apply elastic bandages to cuts." B. "I will use dishwashing gloves when cleaning the dishes." C. "I will buy balloons for my son's birthday." D. "I will use ink pens for writing." The client understands pencil erasers contain latex and should use pens for writing instead. A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180 mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift? (Round the answer to the nearest whole number) 1720 mL A charge nurse observes a nurse administer intermittent tube feeding via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A. The nurse initiates the feeding after aspirating 50 mL of gastric residual. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse allows the client to rest in a supine position during feeding. The nurse should elevate the head of the bed to a minimum of 30° to prevent aspiration from reflux during feedings. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication? A. Milk B. Orange juice C. Coffee D. Grapefruit juice Grapefruit juice increases blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of medication can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness. A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report? A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse used a 25-gauge 3/8 inch needle to administer a heparin injection. C. A nurse injected Demerol IM into the vastus lateralis site of adult. D. A client received a crushed bupropion XL tablet mixed with applesauce. Extended or sustained release medications are intended to release medication levels over a long period of time to sustain therapeutic relief. Crushing, breaking, or chewing an extended release medication releases the medication at once into the bloodstream and could be life-threatening. Mixing this medication in applesauce deviates from standard of care and requires the nurse to complete an incident report. A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? (Select all that apply). bid is correct 30 mL is correct A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include? A. "Hold the cane with your left hand." B. "When walking, move your left foot forward first." C. "Move the cane forward 18 inches with each step." D. "Keep your elbow straight when you hold the cane." The client should move her weaker (left) foot with the cane first, then bring her stronger leg forward ahead of the cane and the weaker foot. A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? A. "You can expect fecal output within 24 hours." B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week." D. "You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon. A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a client who is worried about the outcome of a laboratory test. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Justice C. Fidelity D. Nonmaleficence The nurse demonstrates the ethical principle of fidelity by keeping a promise. A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? A. "It is a good idea to use the handrails in the bathroom." B. "I should use chairs without armrests." C."I should place a throw rug over electrical cords." D. "I should get a longer cord for my telephone." Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions. A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will walk briskly for 30 minutes before bedtime." B. "I will no longer have a glass of wine before bedtime." C. "I will have a cup of hot cocoa immediately before bedtime." D. "I will do my muscle relaxation techniques each afternoon." The client should limit or avoid alcohol consumption in the late afternoon and evening. Alcohol can act as a diuretic and cause the client to wake during sleeping hours to urinate. Alcohol also interrupts the sleep cycle and can make it difficult to stay asleep or return to sleep after awakening. A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter. Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.