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ATI FUNDAMENTALS (dynamic
quizzes)
A nurse is discussing with a client who has a sudden onset of severe back pain from unknown origin. What question should the nurse ask to encourage discussion with the client? - ~ANSWER "What do you think caused the onset of your pain?" A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers that the patient is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. What action should the nurse take first? - ~ANSWER start chest compressions A nurse is admitting a client who has measles. What type of transmission-based precautions should be taken? - ~ANSWER Airborne A nurse is providing teaching about crutches for a client with a fracture of the right foot. What instruction should the nurse include? - ~ANSWER keep the rubber crutch tips securely in place
A nurse manager is providing training to a group of newly licensed nurses about ways that clients acquire healthcare-related infections. Which route of infection should the nurse as iatrogenic? - ~ANSWER infection acquired from a diagnostic procedure A nurse is performing a straight catheterization of a female client who has urinary retention. Which action indicates the nurse is following sterile technique? - ~ANSWER wiping the labia minora in an anteroposterior direction A nurse is caring for a client who is set to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks how the TENS unit helps relieve pain. How should the nurse respond? - ~ANSWER it modulates the transmission of the pain impulse A nurse is administering medication to a client that asks the nurse to leave the medication at the bedside to be taken at a later time. How should the nurse respond? - ~ANSWER "Call me when you are ready, and I will return with the medication."
A nurse is preparing to instill a vaginal medication in suppository form to a client. Which action should the nurse take during this procedure? - ~ANSWER use the index finger to insert the suppository A nurse is caring for a group of clients in a long-term care facility. The nurse should admit that which client is eligible for hospice services? - ~ANSWER A client who has end-stage cirrhosis A nurse is caring for an adult client who has an unmet spiritual need. Which of the following statements should indicate to the nurse that the client is in spiritual distress? - ~ANSWER "God is punishing me for something." A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which action should the nurse take? - ~ANSWER Provide more water with feedings A nurse is collecting a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger but does not collect enough blood for the sample. Which action should the nurse take? - ~ANSWER Wash the client's finger in a warm washcloth
A nurse is measuring a client's vital signs. The client's heart rate is 105 bpm. How should the nurse document this finding? - ~ANSWER tachycardic A nurse is caring for a client who has injuries from a motor-vehicle crash. What statement should the nurse address first? - ~ANSWER "I can't sleep well because whenever I fall asleep, the pain wakes me back up." A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. What finding should the nurse expect? - ~ANSWER increased blood pressure A nurse is preparing to administer an intramuscular injection to a client who is overweight. What site should the nurse choose for this injection? - ~ANSWER side hip between iliac crest and anterior iliac spine
A nurse is caring for a client who has peripheral edema. The nurse should identify that which nutrient regulates extracellular volume? - ~ANSWER sodium A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which action should the nurse take first? - ~ANSWER remove the sleeve of the gown without the IV line A nurse is discussion fire safety with newly hired nurses. What action is the priority if fire occurs in a health care facility? - ~ANSWER Evacuate clients from unit A nurse is caring for a client who has MRSA. An assistant asks the nurse what precautions are required for entering the client's room with a lunch tray. What instruction should the nurse give to the assistant? - ~ANSWER don gloves when entering the room and use hand sanitizer when exiting A nurse is caring for a client who has MRSA. What precautions should the nurse implement? - ~ANSWER Wear a gown when in the client's room?
A middle-aged adult client is discussing future plans with the nurse. Which statement by the client should indicate that he is having difficulty achieving Erikson's developmental task for his age group? - ~ANSWER "we miss our daughter so much that we are going to move closer to her" A nurse is planning an in-service training session about nutrition. What statement should the nurse include in the teaching? - ~ANSWER "Fats provide energy" A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly lost interest in certain foods." What statement should the nurse make? - ~ANSWER "Keep a diary of the foods your child eats every day" A nurse is teaching a client how to self-administer insulin. What action should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? - ~ANSWER Have the client demonstrate the procedure
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. What response should the nurse provide? - ~ANSWER What worries you about being without your teeth? A nurse is caring for a client who is receiving fluid infusion through a peripheral IV catheter. The nurse notes that the area immediately surrounding the site is red and feels warm. What action should the nurse take? - ~ANSWER remove the IV catheter A nurse on a medical unit is caring for a client who has difficulty sleeping. What action should the nurse take to improve the client's ability to sleep? - ~ANSWER Allow the client to maintain the same night-time routine as he did at home A nurse is caring for a client who is post-operative following an abdominal surgery. What action should the nurse take first after observing that the client's wound has eviscerated? - ~ANSWER cover the incision with a moist sterile dressing
A nurse is assessing a client who has an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which eye disorder? - ~ANSWER glaucoma A nurse is providing oral care for a client who is unconscious. What action should the nurse take? - ~ANSWER place the client in a lateral position with the head turned to the side before beginning the procedure A nurse is caring for a client who has a gastric ulcer. The nurse should remind the client that prolonged exposure to stress can also cause what? - ~ANSWER hyperglycemia A nurse is performing an abdominal assessments of a client. What position should the client assume for the examination? - ~ANSWER supine A nurse is teaching a middle-aged female client about disease prevention and health maintenance. What diagnostic tests should the nurse recommend screening for? - ~ANSWER eye examination every two years
hand hygiene? - ~ANSWER there are times when I should use soap and water to wash my hands instead of hand sanitizer A nurse is planning care for a group of clients receiving oxygen therapy. What client should the nurse see first? - ~ANSWER A client with heart failure who is receiving 100% oxygen via partial rebreather mask A nurse is caring for a client who has an NG tube with intermittent enteral feedings. What action should the nurse take before feedings? - ~ANSWER Elevate the head of the bed to 45 degrees before feedings A nurse is preparing to perform tracheostomy care for a client. What action should the nurse perform first? - ~ANSWER perform hand hygiene A nurse is cleaning a client's wound by swabbing from areas of greatest contamination to areas of least contamination. What rationale should the nurse use for completing this task? - ~ANSWER keeping microorganisms from entering the wound
A nurse is preparing to administer eye drops to a patient with glaucoma. While instilling the medication, what action should the nurse take? - ~ANSWER apply pressure to the puncta after instillation A nurse is caring for a client with a stroke that has a risk for falls. What action should the nurse take? - ~ANSWER monitor the client at least once every hour A nurse is caring for a client who is receiving mechanical ventilation via tracheostomy tube and has a gastrostomy tube for enteral feedings. What pieces of information are critical to communicate to the next nurse who will be caring for this client? - ~ANSWER new prescriptions, arterial blood gas results, tracheal secretion characteristics The nurse is reviewing the correct use of a fire extinguisher with a client. What action should the nurse direct the client to take first? - ~ANSWER remove the safety pin form the extinguisher
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? - ~ANSWER absent bowel sounds with distention A nurse is explaining Piaget's theory for cognitive development to a group of daycare providers at an acute care facility. What activity should the nurse include as an example of concrete operational thinking? - ~ANSWER collecting and trading game cards A nurse is caring for a client who is violent and attempting to pull out her IV lines. The provider prescribes soft wrist restraints. What action should the nurse take while the client is on restraints? - ~ANSWER remove the restraints one at a time A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? - ~ANSWER the signature on the pre- operative consent form is the client's
A nurse is preparing to assess the function of the client's trigeminal nerve. What items should the nurse collect for the test? - ~ANSWER cotton wisps a home health nurse enters a client's home and notices a used insulin syringe without a cap on the table, What action should the nurse take? - ~ANSWER place the syringe in a puncture-proof sealed container A nurse is assessing a client. What is a sign protein-calorie malnourishment? - ~ANSWER spoon-shaped nails, poor wound healing, dry and brittle hair A nurse documents the presence of clubbing on fingernails for a client who has emphysema. What is the underlying cause of this finding? - ~ANSWER chronic hypoxemia A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are swollen. Which of the findings is another manifestation of fluid volume excess. - ~ANSWER bounding pulse
A nurse is preparing to administer eye drops to a client following surgery. What action should the nurse take during application? - ~ANSWER drop the eye drops into the lower conjunctival sac A nurse on a med-surg unit is washing her hands prior to assisting with a surgical procedure. What actions by the nurse demonstrates proper surgical handwashing technique? - ~ANSWER the nurse holds her hands higher than elbows while washing a nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend which team member to assess for dysphagia? - ~ANSWER Speech-language pathologist A nurse is caring for a client who is post-op and has a history of poor nutrition. What action should the nurse include to promote wound healing? - ~ANSWER provide a protein intake of 1.5 mg/kg per day
A nurse is assessing a client's thyroid gland. What instruction should the nurse give before assessing and palpating this gland? - ~ANSWER tilt your head back and swallow A nurse is caring for an older adult client who has an in-canal hearing aide. The client states that it is making a whistling sound. The nurse should identify that what factor is the source for this sound? - ~ANSWER excessive wax in the ear canal A nurse is teaching a client about the use of a straight-legged cane. What client action indicates an understanding of the teaching? - ~ANSWER The client holds the cane on the unaffected side A nurse is changing the dressings for a client who is 3 days post-op following a cholecystectomy. The nurse observes yellow, thick drainage from the dressing. The nurse should document what type of drainage? - ~ANSWER purulent A nurse on a med-surg unit is caring for a client. What actions should the nurse prioritize when using the nursing process? - ~ANSWER obtain client information
