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Fundamentals ATI Proctored Exam
Terms in this set (103)
what are the health care regulatory agencies
state boards of nursing
food and drug administration
what would be included in a plan of care for a patient with pertussis
wear a mask when providing care within 3ft of the client
place a surgical mask on the client if being transported to another unit
wear a gown when performing care that involves secretions
a client reports severe sore throat, pain when swallowing and swollen lymph nodes. what stage of infection is this
what are clinical manifestations of localized versus a systemic infection
increase in pulse and respiratory rate
what actions should be taken to reduce risk of falls
call light in reach
provide nonskid footwear
complete fall risk assessment
what are actions for a patient who has had a seizure
place patient on side
administer meds as prescribed
be prepared to insert airway
do not leave client alone during a seizure
what is the priority action for a client with a history of falls
complete a fall risk assessment
what are interventions for seclusion and restraints
assess restraints every 2 hours
assess food, fluids, comfort, and safety and document every 15-30 mins
what should be included in a teaching about carbon monoxide poisoning
carbon monoxide binds with hemoglobin in the body
a client who has a heat stroke will have what
who is at risk for complications from food poisoning
clients as risk for food poisoning are instructed to eat and drink what
only pasteurized milk, yogurt, cheese and other dairy products
what bed position should the bed be in for a client receiving eternal tube feeding due to dysphagia
a client asks to move from the bed to the chair what is the priority action
assess the clients ability to help with the transfer
21 year old with a sore throat tells doctor he has not seen the doctor since highschool. what screening should be done
what should be included in health promotion and primary prevention for a school-aged child
substance use disorder
what is the first sign of maturation in boys
enlargement of the testes and the scrotum
what are expected decreases in physical function of a middle age adult
what should be asked for a older adult who loses weight
do you eat alone or with someone
have you started any new meds
what have you eaten in the last 24 hour
are you on a fixed income
what nutritional interventions are recommended for older adults
increase calcium and fiber
a client who is on bed rest should do what to maintain latency of airways
use incentive spirometer
what interventions should be used to reduce the risk of a dvt for a patient post-op
apply elastic stockings
change position frequently
what are effects of immobility of the cardio vascular system
stasis of blood in legs
increased risk of thrombus
less fluid volume in circulatory system
diminished autonomic response
increased oxygen requirements
decreased cardiac output, poor cardiac effectiveness, increased cardiac workload
what are the immomobility effects of respiratory system
decreased respiratory movement, decreased oxygen and carbon monoxide exchange
stasis of secretions and decreased and weekend respiratory muscles, atelectasis and hypostatic pneumonia
a 82 year old client in ER has temp of 101, pulse 114, respiration of 22. he is restless and skin is warm.. what actions are appropriate?
obtain culture specimen before initiating antimicrobials
assist with oral hygiene frequently
what findings of a skin assessment require immediate intervention
what characteristics should be included when explaining rapid eye movement REM sleep
provides cognitive restoration
it is difficult to awake a person
vivid dreams are common
whole grain such as barley and oats, raw veggies, cabbage, legumes, lentils, black beans are
high in fiber
side effects of opioids
urinary retention, postural hypotension, pruritus, nausea, vomiting and respiratory depression
what are appropriate actions when initiating a bladder training program
have the client record voting times
graduate increase the voiding intervals
remind the client to hold urine until next scheduled time
what are clinical manifestations of infiltration
temperature around the IV site is cooler
The IV dressing is damp
the tissue around the venipuncture site is swollen
what are clinical manifestations fluid overload
distended neck veins
increased blood pressure
shortness of breath
crackles in the lungs
what is the highest priority assessment before performing in enteral feeding to a client with an NG tube
verify the placement of the tube
what are appropriate actions administering enteral feeding via NG tube in a long-term care facility
auscultate bowel sounds
assist the client an upright position
test the pH of gastric aspirate
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with her documentation.
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
Remove the stockings at least once per shift.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds
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 routine screening. What does that involve?" Which of the following responses should the nurse make?
"You should have a fecal occult blood test every year."
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
Use antimicrobial sanitizer for hand hygiene.
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
Wrap monitoring cords with stockinette and tape them in place.
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend?
Use progressive relaxation techniques at bedtime.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
Air into NPH
Air into Regular
Draw up Regular
Draw up NPH
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?
Initiate an enteral feeding through a gastrostomy tube.
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of her body.
A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 mL of sterile water.
A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
Assist the client to an upright position.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 meq/L
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
Stand close to the cabinet when lifting it.
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?
Withhold the blood transfusion.
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?
Select a suction catheter that is half the size of the lumen.
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
Have the client use a trapeze bar when changing position.
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
"Are you able to help with your hygiene care?"
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
Ask another nurse to observe the medication wastage.
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
"The pain is like a dull ache in my stomach."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
Rapid heart rate
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
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?
Tell the client to keep the head of the bed elevated at least 30 degrees.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position.
A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?
A 16 yo client who is married
A 27 yo who has schizophrenia
An adoptive parent who brings in his 8 yo son
A 17 yo mother who brings in her toddler.
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?
Apply intermittent suction when withdrawing the catheter.
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 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?
assess the client for orthostatic hypotension
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
place a client who has tuberculosis in a room with negative-pressure airflow.
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?
bladder scan shows 525mL of urine
a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
wash her hands before and after contact with the client
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?
Compare prescriptions with medications the client received during hospitalization.
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?
Thread the IV catheter so that the hub rests at the insertion site.
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 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?
Check the cord routinely for frays or tearing
Consider purchasing a generator for power backup
Observe for signs of hypoxia
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 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?
Insert the IV catheter without using a tourniquet
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?
elevate the head of the client's bed
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?
"We can talk about advance directives, and I can also give you some brochures about them."
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?
"Is your pain sharp or dull?"
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 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 vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
Notify the nursing manager
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?
albumin level of 3g/dL
A client who is nonambulatory 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?
evacuate the client
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?
Pad the client's wrist before applying the restraints.
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?
Make sure two fingers can fit under the sleeves.
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?
Make sure the client wears a mask when outside her room if there is construction in the area
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
8 oz ice chips
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?
examine personal values about the issue
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?
use tracheostomy covers when outdoors
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)?
Assist the client with a partial bed bath
Measure the client's BP after the nurse administers an antihypertensive medication
Use a communication board to ask what the client wants for lunch
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?
an uneven shape
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?
wrap blankets around all four side rails
A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?
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 client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
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?
The family member washed out the feeding bag with warm water once every 24 hours.
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?
An x-ray shows the end of the tube above the pylorus
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.
Obtain the pronouncement of death from the provider
Remove tubes and indwelling lines
Wash the client's body
Ask the client's family members if they would like to view the body
Place a name tag on the body
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?
administer pain medication 45 min before changing the client's dressing
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