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ATI Fundamentals Proctored Exam Questions and Answers
A charge nurse in a long term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include? A. Delirium has an abrupt onset - ANSa A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include? a. "Delirium does not affect a client's perception of her environment." b. "Delirium does not affect a client's sleep cycle." c. "Delirium has an abrupt onset." d. "Delirium has a slow progression." - ANSc A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints? a. If the client is pacing in the hallway b. As a part of a fall prevention program c. At the request of the client's family d. When the client poses a threat to self - ANSd A community health nurse is teaching a group of clients about kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include? A. Contact your pelvic muscle when performing the exercises B.Expect improvement after 2 weeks of performing the exercises C. Hold your breath when performing the exercises D. Tighten your buttocks when performing the exercises - ANSa A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply) a. I will use the bars when getting in and out of the bath tub b. I need to check my medications for expiration dates c. I need to have a fire escape plan with my family
d. I will apply tape over frayed areas of electrical cords e. I need to set my hot water heater to 140 degrees Fahrenheit - ANSa, b, c A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA)
- I need to check my medications for expiration dates
- I will use the grab bars when getting in and out of the bathtub
- I need to have a fire escape plan with my family - ANSa, b, c A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity? a. Provide guided imagery exercises to the client. b. Refrain from discussing the client's prognosis c. Suggest that the client keep a journal. d. Encourage the client to share their life story. - ANSb A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first? a. Move items in the room away from the client b. Turn the client onto their side c. Help the client lie on the floor d. Loosen the client's clothing - ANSc A nurse in a long-term care facility is assessing a client. Which of the following findings should the nurse recognize as an indication a fecal impaction? a. Seepage of liquid stool - ANSa A nurse in a long-term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer? a. A client who is incontinent of urine 1 to 2 times a day b. A client who is receiving enteral tube feedings
B. Confusion C. Coolskin D. Shakiness - ANSa A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take? a. Change the clients position every 4 hours b. Apply petroleum base ointment in the red area c. Assess the red area for blanching d. Use friction when cleansing the client's skin - ANSc A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the following finding is the nurse's priority? a. Last bowel movement was 3 days ago b. Reports pain of 8 on a scale of 0 to 10 c. Distended bladder d. Respiratory rate 7/min - ANSd A nurse is assessing a client's personal hygiene. Which of the following findings indicates that the client might have difficulty with routinely bruising their teeth? A. Theclientsmucosaismoist B. The client gums feel spongy C. The client has a missing tooth D. The Client's tongue is a dull red color - ANSb A nurse is assessing an older adult client. Which of the following findings should the nurse expect? a. Decreased sense of balance - ANSa A nurse is assessing the body temperature of an adult client using a temporal artery thermometer. Which of the following actions should the nurse take? (Select all that apply)
a. Slide the probe across the clients forehead b. Pull the clients pinna up & back c. Hold the client's hair aside while performing the procedure d. Document the client's temperature with "AX" next to the value e. Move the probe in a circular motion - ANSa, c A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority? A. Skin tags noted in the neck region B. A change in appearance of a mole on the shoulder C. A flat, nonpalpable, discovered area of skin on the trunk D. Atrophic wart on the left index finger - ANSb A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use? A. Encourage the client to try to defecate for 20 min while on the fracture pan. B. Keep the bed flat while the client is on the fracture pan. C. Hyperextend the clients back while the fracture pan is in place. D. Place the shallow end of the fracture pan under the clients buttocks. - ANSd A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first? A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to a breast cancer support group C. identify the impact of the mastectomy on the client's body image D. encourage the client to assist with her dressing change - ANSc A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. ( Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse? a. I don't know of if I will be able to meet his physical needs. - ANSa A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take? A cover the client with heavy blankets after shivering subsides B place ice packs on the clients neck and behind the knees C apply a bath blanket between the client and a cooling blanket D give the client a sponge bath using alcohol water solution - ANSc A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her provider. Which of the following is an appropriate response by the nurse? a. You should ask the provider if she recommend traditional Chinese medicine. - ANSa (probs not) A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? a. Develop a list of goals - ANSa. A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A. Complete an incident report B. Obtain the client's vital signs C. Document the fluid infusion in the client's chart D. Report the incident in to the unit manager - ANSb A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? a. Cotton tip applicator to clean the inside of the cannula b. Soak the outer cannula in warm soapy tap water c. Cleanse the skin around the stoma with normal saline
d. Secure the tracheostomy ties to allow one finger to fit snuggly underneath - ANSd a nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect? a. Bradycardia b. Postural hypotension c. Distended neck vein d. Dependent edema - ANSb A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following answers indicates the proper method of cleaning a wound site? a. use a different sterile swab for each stroke - ANSa A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The nurse should identify that which of the following findings indicates a need for restraints? A. The client's family is unable to stay with the client B. The client becomes confused at night C. The client gets out of bed to use the bathroom frequently D. The client is assigned a room near the nurses station - ANSd A nurse is caring for a client who has been treated multiple times for STIs. Which of the following responses should the nurse take? a. "You must have too many sexual partners" b. "Why do you keep letting this happen?" c. "Let's explore why this might be re-occuring" d. "Don't you have access to condoms?" - ANSc A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse? a. "lets discuss your concerns about your father," or anything along those lines that is
a. airborne - ANSa A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Remove one restraint at a time - ANSa A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Tie the restraints to the side rail b. Secure restraints with a square knot c. Remove one restraint at a time d. Remove the restraints every 3 hours - ANSc A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? a. Determine areas of resonance across the abdomen using a systematic approach b. Expose the client's abdomen to look for changes in appearance c. Perform abdominal palpation by pressing gently with the finger pads d. Use the diaphragm of the stethoscope to listen for bowel sounds - ANSb A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts? a. False imprisonment b. Invasion of privacy c. Assault d. Negligence - ANSa A nurse is caring for a client who is immunocompromised which of the following actions should the nurse take? a. Use sterile gloves to provide perineal care b. Cleanse hands with an alcohol based hand rub before client contact
c. Have the client apply a mask when children are visiting d. Place the client in a semi-private room - ANSb A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? A. Petechiae on the client's right anterior thigh B. Flat rash on the client's ankle C. non-palpable macule on the client's left shoulder D. Non Blanching darkened area over the client's trochanter - ANSd A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Plain yogurt - ANSa A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Oatmeal b. Applesauce c. Scrambled eggs d. Plain Yogurt - ANSd A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team. a. Social worker b. Occupational therapist c. Registered Dietician d. Primary care provider - ANSa A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective?
client is saying I trust my doctor, but I don't understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take? a. Provide brochures about the procedure b. Notify the provider c. Complete an incident report d. Describe the surgery to the client - ANSb A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, " I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take? a. Describe the surgery to the client. b. Notify the Provider. c. Complete an incident report d. Provide brochures about the procedure. - ANSb A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, I trust my doctor, but I don't understand what is meant by resecting my intestine. Which of the following actions should the nurse take? a. notify the provider - ANSa A nurse is caring for a client who is scheduled to have his alanine amino transferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? A. This test will determine if your heart is performing properly B. This test will indicate if you are at risk for developing blood clots C. This test is used to check how your kidneys are working D. This test will provide information about the function of your liver - ANSd A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statement by the client partner indicates maladaptive coping? a. I don't know of if I will be able to meet his physical needs. - ANSa
A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts? a. Libel b. Defamation of character c. Assault d. Battery - ANSc A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain meds are not an option for managing pain. Which of the following is an appropriate response by the nurse? a. Would you like to get you a back massage? b. Why do you think pain med is not going to help you? c. You may take any herbal remedies you bring from home d. I'm sure it will work if you just give it a chance - ANSa A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? a. Eat a light carbohydrate snack before bedtime b. Exercise 1 hour before bedtime c. Drink a cup of hot cocoa before bedtime d.Take a 30 min nap daily - ANSa A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the clients room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first? A. Gloves B. Eyewear C. Gown D. Mask - ANSa
delegate to the AP? a. obtain input & output for the patient that was stable, ADLs, specimen collection, I&O, vital signs if stable
- ANSa A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage? A. Dilated pupils B. Physical exhaustion C. Bradycardia D. Depression - ANSa A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation? A. No changes noted to the wound from previous nursing notes B. Client pre-medicated with MSO4 sunq prior to dressing change C. The wound seems clean and does not appear to be infected D. New dressing applied as prescribed, no drainage on old dressing - ANSb A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. " SQ" for subcutaneous b. "SS" for sliding scale c. "BRP" for bathroom privileges d. "OJ" for orange juice - ANSc A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. BRP for bathroom privileges - ANSa A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside?
a. Oral suction equipment and oral airway. - ANSa A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a. Assess the client for a gag reflex b. Measure the pH of the gastric c. Place the end of the NG tube in the water to observe for bubbling d. Asculatate 2.5 cm above the umbilicus while injecting 15 ml of water - ANSb A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first? a. Inject air into the short acting insulin vial. - ANSa. A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take? a. Discuss alternative treatments with the client b. Explain to the client the risks involved with not having the procedure c. Express approval of the client's decision to not have the procedure d. Document the client's decision in the medical record - ANSd A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify which of the following medications can interact adversely with this supplement? a. Warfarin b. Albuterol c. Levothyroxine d. Atorvastatin - ANSa A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect? a. Thickened outer layer of skin b. Increased skin elasticity
a. Toilet the client every 4hr while the client is awake b. Apply a moisture barrier in a thick layer to vulnerable skin areas c. Cleanse the skin with antibacterial soap and hot water after each incontinence episode d. Reduce the clients daily fluid intake - ANSb A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage? A. Assist the client in setting goals to make the change B. Develop a plan for the client to integrate the change into her lifestyle C. Present information about the benefits of quitting smoking D. Recommend small changes for the client to make to change her behavior overtime - ANSc A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan? a. Cover the blood pressure cuff with a stockinette. b. Wear powdered gloves when providing care to the client. c. Apply adhesive tape when securing an IV insertion site. d. Use plastic syringes for medication administration. - ANSa A nurse is planning care for a female client who has an indwelling urinary catheter.Which of the following actions should the nurse include in the plan? A. Tape the catheter to the lower abdomen B. Attach the drainage bag to the side rails of the bed C. Keep the drainage bag below the level of the bladder D. Empty the drainage bag when it is three quarters full - ANSc A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? a. Ensure the client is free of metal objects b. Administer 240 ml (8oz) oral contrast before the procedure
c. Monitor the client for pain in the suprapubic region d. Assist the client with a bowel cleansing - ANSa A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care. a. request a prescription for an indwelling urinary cath - ANSa A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first? a. Provide the client with a contact number for a diabetes education specialist b. Make a copy of the medication record of the reconciliation for the client c. Determine whether the client can afford the insulin administration supplies d. Obtain printed information about self-administration - ANSc A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first? A. Makeacopyofthemedicationreconciliationformfortheclient B. Providetheclientwiththecontactnumberforadiabeteseducationspecialist C. Determine whether the client can afford the insulin administration supplies D. Obtain printed about insulin self administration - ANSc A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. Which of the following should the nurse take to obtain the sample? a. The pad of the finger tip b. The lateral aspect of the finger c. The pinna of the ear d. The side of the wrist - ANSb A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history? a. " What medications are you currently taking?"
