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ATI Fundamentals nursing exam latest

updated 2024 by an expert

A nurse is teaching a client with lower extremity weakness to use a 4 point crutch gait. Which of the following instructions should the nurse include in the teaching? a. support the weight on your axillae b. keep your elbows extended c. bear weight on both of your legs d. move both crutches forward at the same time - answers Answer: C b/c need 3 points of contact with ground at all times Which client can have an MRI? a. coronary artery stents b. aneurysm clip c. hearing aids d. automated internal defibrillator - answers C. b/c hearing aids can be removed A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which action should nurse take? a. maintain suction while removing NG tube b. instill 100mL of air into NG tube before removal c. pinch NG tube while removing tube d. instruct client to breath in and out during removing - answers Answer: C Pinch, instill 50mL of air into tube to clear drainage contents, take +hold deep breath --> decreases risk of aspiration of gastric contents Disconnect from suction Older adult with dysphagia. What action is appropriate? a. encourage client to drink fluids before swallowing food b. offer client tart or sour foods first

Islam: body washed, wrapped, buried ASAP Hindu: head faces N, but cremation more common Buddhist: Male family members prep body Perioperative pt concerned about infection from blood transfusion. What should nurse say? a. ask HCP to prescribe epoetin b. ask HCP abt taking iron supplements c. ask family member to donate blood for your surgery d. Donate autologous blood before surgery - answers Answer: D b/c collection & re- infusion of client's own blood (3-5weeks before elective surgery) Epoetin to boost hematocrit for anemic pt Iron for low hemoglobin pt A nurse is administering a cleansing enema to a client who is scheduled to have a diagnostic procedure. Which of the following actions should the nurse take? a. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube b. Position client on right side c. Insert Tip of tubing 8cm (3.1 in) d. Hold enema container 61 cm (24 in) above the rectum - answers Answer: C a -->lubricate 5 - 8cm (2- 3 in) b --> left Sim's to promote retention of enema d --> max of 45 cm (18 in) above rectum to prevent painful distention of colon A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect? a. BUN 18 mg/dL

b. Cap refill 1.5 seconds c. Hct 55% d. Urine specific gravity 1.001 - answers Answer: C A & B normal Hypovolemic Shock: elevated hematocrit, weak pulse, tachycardia, hypotension, tachypnea, slow cap refill, elevated BUN, increased urine specific gravity, decreased urine output this is a low urine specific gravity indicating hypervolemia (normal 1.005 - 1.030) A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? a. Hyperoxygenate the client before suctioning b. Insert the catheter during exhalation c. Apply suction during insertion of catheter d. Apply suction for no more than 15 sec - answers Answer: A b/c nurse should use manual resuscitation bag to hyperoxygenate client for several minutes prior to suctioning b--> insert during inhale c --> no suction during insertion d --> suction for no more than 10 sec According to ATI, how far above last palpated pulse should nurse inflate bp cuff? - answers 30 mmHg A nurse is caring for client who has 24 hour urine collection. Which statement indicates understanding of teaching? a. I had a bm but was able to save the urine b. I have specimen in bathroom from 30 minutes ago c. I flushed what I urinated at 7:00 am and have saved all urine since d. I drink a lot, so I will fill up the bottle and complete the test quickly - answers Answer: c

flush w/ 30 - 60mL after last admin of med dissolve meds in 30mL of water