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ATI RN Fundamentals Online Practice
2019 B with NGN 100% VERIFIED
ANSWERS 2024/2025 CORRECT
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? A. Client flow sheet B. Acuity ratings C. Current medications D. Incident reports C. Current medications The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care. 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? A. Use a resuscitation bag with 80% oxygen prior to the procedure. B. Select a suction catheter that is half the size of the lumen. C. Place the end of the suction catheter in water-soluble lubricant. D. Adjust the wall suction apparatus to a pressure of 170 mm Hg. B. Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? A. Place a pillow under the client's knees.
B. Position a trochanter roll under each of the client's hips. C. Advise the client to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the client's feet. D. Apply an ankle-foot orthotic device to the client's feet. The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. B. A nurse asks a nurse from another unit to assist with documentation for a client. C. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. D. A nurse discusses a client's status with the physical therapist who is caring for the client. B. A nurse asks a nurse from another unit to assist with documentation for a client. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the container of medication prior to administration. B. Transfer the medication to a medicine cup. C. Place the client in a semi-Fowler's position prior to medication administration. D. Verify the dosage by measuring the liquid before administering it. A. Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure that the medication is mixed.
C. Inject 10 units of air into the bottle of NPH insulin. D. Withdraw the correct does of regular insulin from the bottle. C. Inject 10 units of air into the bottle of NPH insulin. A. Inject 5 units of air into the bottle of regular insulin. D. Withdraw the correct does of regular insulin from the bottle. B. Withdraw the correct does of NPH insulin from the bottle. The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 1. C. Rapid heart rate D. Blood pressure 144/82 mm Hg C. Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. 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? A. Rock the client up to a standing position. B. Pivot on the foot that is the farthest from the chair. C. Assess the client for orthostatic hypotension. D. Apply a gait belt to the client. C. Assess the client for orthostatic hypotension.
The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair. A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Nurses' Notes 1000: Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs 1000: Blood pressure 132/68 mm Hg, Heart rate 99/min, Respiratory rate 20/min, Temperature 38.3° C (101° F), Oxygen saturation 96% on room air Diagnostic Results 1100: Positive throat culture for streptococci bacteria. A. Request a prescription for an antibiotic medication. B. Apply oxygen at 2 L/min via nasal cannula. C. Initiate droplet precautions. D. W
nurse responds affirmatively. B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. C. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. D. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer. A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. Auscultate lung sounds. B. Measure urine output. C. Monitor blood pressure readings. D. Monitor electrolyte levels. A. Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding
C. Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration. A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A. A client who has a history of physical abuse B. A client who has a permanent pacemaker C. A client who has ulcerative colitis D. A client who has asthma D. A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma. A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? A. The caregiver is the client's financial power of attorney. B. The client is in a wheelchair with the wheels locked. C. The client reports receiving a full bath twice each week. D. The caregiver insists on remaining in the room. D. The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? A. Assign a staff member to feed the client.
that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Followed by A. Client 4 When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias. A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg B. 0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. 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 a routine screening. What does that involve?" Which of the following responses should the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "Beginning at age 60, you should have a colonoscopy." C. "You should have a fecal occult blood test every year." D. "The recommendation is to have a sigmoidoscopy every 10 years." C. "You should have a fecal occult blood test every year."
Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually. A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? A. Admitting diagnosis B. Breath sounds C. Body temperature D. Diagnostic test results B. Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. Nurses' Notes Day 1: Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. + peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to
- Client repositioned every 2 hr while in bed. Day 4: Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Vital Signs Day
an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics A. Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. A nurse is caring for a client who had a spinal cord injury and has paraplegia. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. Nurses' Notes Day 1: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Day 5: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.
A. Client is repositioned every 2 hr. B. Passive range-of-motion exercises to lower extremities performed once each day. C. Feet warm. Pedal pulses 2+ bilaterally. D. Pl B. Passive range-of-motion exercises to lower extremities performed once each day. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. D. Plantar flexion contractures noted bilaterally. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. E. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing. 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? A. Insert an implanted port. B. Close a laceration with sutures. C. Place an endotracheal tube. D. Initiate an enteral feeding through a gastrostomy tube. D. Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. 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? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30°.
suspension. Client reports that neither therapy initiated defecation. 1230: Client transported for abdominal x-ray. 1245: Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300: Procedure explained to client who verbalized understanding. Diagnostic Results 1245: Abdominal x-ray indicates a large A. Assist the client to a left side-lying position with the right knee flexed. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. C. Administer a cleansing enema. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. D. Auscultate the client's bowel sounds. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. E. Perform a manual digital examination of the client's rectum. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract. 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?
A. "I'm having mild pain." B. "The pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "The pain makes me feel nauseous." B. "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in the client's own words. A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 8 mL/hr 800 units/hr x 250 mL = 200,000 units/mL/hr 200,000 / 25,000 units = 8 mL/hr A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? A. Describe the procedure to the client. B. Witness the client's signature on the consent form. C. Inform the client of alternatives to the procedure. D. Tell the client which team members will assist with the procedure. B. Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in a room with negative-pressure airflow. B. Wear gloves when assisting the client with oral care.
The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Nurses' Notes 0930: Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. 1030: Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs 1030: Blood pressure 110/68 mm Hg, Heart rate 110/min, Respiratory rate 24/min, Temperature 38.6° C (101.5° F), Oxygen saturation 91% on room air A. Place the client on droplet isolation precautions. B. Apply oxygen at 2 L/min via nasal cannula. C. Request a prescription for an antipyretic medication. D. Wear an N-95 mask when providing care to the client. E. Request a prescription for an A. Place the client on droplet isolation precautions. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. B. Apply oxygen at 2 L/min via nasal cannula. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. C. Request a prescription for an antipyretic medication.
The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. F. Remain 1 m (3 feets) from the client. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client. 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? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the test quickly." C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? A. Instruct the family to refrain from pushing the button for the client while she is asleep. B. Inform the client that because she is on PCA, vital signs will be taken every 8 hr. C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. D. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high. A. Instruct the family to refrain from pushing the button for the client while she is asleep. The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain. A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
