N100: ATI Fundamentals Practice Proctor A Questions
With Complete Solutions
A nurse is caring for a client who is postop and is exhibiting
signs of hemorrhagic shock. The nurse notifies the surgeon, who
tells the nurse to continue to measure the client's vital signs
every 15 min and report back in 1hr. Which of the following
actions should the nurse take next.
A. Document the provider's statement in the medical record.
B. Complete an incident report.
C. Consult the facility's risk manager.
D. Notify the nursing manager.
Document the provider's statement in the medical record.
INCORRECT The nurse should document the provider's
directions in the medical record for later reference;
however, another action is the nurse's priority.
Complete an incident report. INCORRECT The nurse should
prepare an incident report detailing the delay in treatment
for later review and action for prevention of future
occurrences; however, another action is the nurse's priority.
Consult the facility's risk manager. INCORRECT The nurse
should discuss the situation with the facility's risk
management department to help determine the need for
preventive actions; however, another action is the nurse's
priority.
,Notify the nursing manager. CORRECT The greatest risk to
the client is not receiving timely intervention for a
deterioration in physiological status; therefore, the next
action the nurse should take is to activate the chain of
command to ensure that the client receives the necessary
care.
A nurse is discussing the use of herbal supplements for health
promotion with a client. Which of the following client statement
indicates an understanding of herbal supplement use?
A. "I can take echinacea to improve my immune system."
B. "I can take feverfew to reduce my level of anxiety."
C. "I can take ginger to improve my memory."
D. "I can take ginkgo biloba to relieve nausea."
"I can take echinacea to improve my immune system."
CORRECT Echinacea is taken to promote immunity and
reduce the risk of infection.
"I can take feverfew to reduce my level of anxiety."
INCORRECT Feverfew is taken to promote wound healing
and decrease inflammation associated with arthritis.
Valerian and chamomile can be taken to reduce anxiety.
"I can take ginger to improve my memory."
INCORRECT Ginger is taken to relieve nausea and vomiting
and aid in digestion. Ginkgo biloba can be taken to improve
memory and reduce stress.
"I can take ginkgo biloba to relieve nausea."
INCORRECT Ginkgo biloba is taken to improve memory
,and reduce stress. Ginger can be taken to relieve nausea and
vomiting and aid in digestion.
A nurse is caring for a client who is scheduled to be transferred
to a long-term care facility. The client's family questions the
nurse about the reasons for the transfer. Which of the following
responses made by the nurse is appropriate?
A. "The transfer of your family member is being done because
the provider knows what's best."
B. "Would you like it if we discussed the transfer with your
family member?"
C. "Why are you so concerned about this transfer?"
D. "I know how you feel. My parent had to be transferred to a
long-term care facility."
"The transfer of your family member is being done because the
provider knows what's best." INCORRECT This is a defensive
response which can hinder further communication.
"Would you like it if we discussed the transfer with your
family member?" CORRECT This response facilitates
therapeutic communication and provides general leads while
maintaining client confidentiality.
"Why are you so concerned about this transfer?"
INCORRECT Asking a why question can make the recipient
defensive which can hinder further communication.
"I know how you feel. My parent had to be transferred to a
long-term care facility." INCORRECT This is a sympathetic
response, which can interfere with a therapeutic
relationship.
, A nurse enters a client's room and finds them on the floor. The
client's roommate reports that the client was trying to get out of
bed and fell over the side rail onto the floor. Which of the
following statements should the nurse document about this
incident?
A. "Incident report completed."
B. "Client climbed over the side rails."
C. "Client found lying on floor."
D. "Client was trying to get out of bed."
"Incident report completed." INCORRECT An incident report
is an internal document that is part of a facility's risk
management system. The nurse should not document
completion of an incident report in the client's medical
record for the facility's protection in the event of litigation.
"Client climbed over the side rails." INCORRECT Unless the
nurse witnessed the client climbing over the bed's side rails,
this statement is not an objective account of the nurse's
findings.
"Client found lying on floor." CORRECT The nurse should
include documentation of information that is descriptive and
objective concerning what the nurse actually observed,
without including any opinions or judgments about motives
or cause.
"Client was trying to get out of bed." INCORRECT Unless the
nurse witnessed the client trying to get out of bed, this
statement is not an objective account of the nurse's findings.
With Complete Solutions
A nurse is caring for a client who is postop and is exhibiting
signs of hemorrhagic shock. The nurse notifies the surgeon, who
tells the nurse to continue to measure the client's vital signs
every 15 min and report back in 1hr. Which of the following
actions should the nurse take next.
A. Document the provider's statement in the medical record.
B. Complete an incident report.
C. Consult the facility's risk manager.
D. Notify the nursing manager.
Document the provider's statement in the medical record.
INCORRECT The nurse should document the provider's
directions in the medical record for later reference;
however, another action is the nurse's priority.
Complete an incident report. INCORRECT The nurse should
prepare an incident report detailing the delay in treatment
for later review and action for prevention of future
occurrences; however, another action is the nurse's priority.
Consult the facility's risk manager. INCORRECT The nurse
should discuss the situation with the facility's risk
management department to help determine the need for
preventive actions; however, another action is the nurse's
priority.
,Notify the nursing manager. CORRECT The greatest risk to
the client is not receiving timely intervention for a
deterioration in physiological status; therefore, the next
action the nurse should take is to activate the chain of
command to ensure that the client receives the necessary
care.
A nurse is discussing the use of herbal supplements for health
promotion with a client. Which of the following client statement
indicates an understanding of herbal supplement use?
A. "I can take echinacea to improve my immune system."
B. "I can take feverfew to reduce my level of anxiety."
C. "I can take ginger to improve my memory."
D. "I can take ginkgo biloba to relieve nausea."
"I can take echinacea to improve my immune system."
CORRECT Echinacea is taken to promote immunity and
reduce the risk of infection.
"I can take feverfew to reduce my level of anxiety."
INCORRECT Feverfew is taken to promote wound healing
and decrease inflammation associated with arthritis.
Valerian and chamomile can be taken to reduce anxiety.
"I can take ginger to improve my memory."
INCORRECT Ginger is taken to relieve nausea and vomiting
and aid in digestion. Ginkgo biloba can be taken to improve
memory and reduce stress.
"I can take ginkgo biloba to relieve nausea."
INCORRECT Ginkgo biloba is taken to improve memory
,and reduce stress. Ginger can be taken to relieve nausea and
vomiting and aid in digestion.
A nurse is caring for a client who is scheduled to be transferred
to a long-term care facility. The client's family questions the
nurse about the reasons for the transfer. Which of the following
responses made by the nurse is appropriate?
A. "The transfer of your family member is being done because
the provider knows what's best."
B. "Would you like it if we discussed the transfer with your
family member?"
C. "Why are you so concerned about this transfer?"
D. "I know how you feel. My parent had to be transferred to a
long-term care facility."
"The transfer of your family member is being done because the
provider knows what's best." INCORRECT This is a defensive
response which can hinder further communication.
"Would you like it if we discussed the transfer with your
family member?" CORRECT This response facilitates
therapeutic communication and provides general leads while
maintaining client confidentiality.
"Why are you so concerned about this transfer?"
INCORRECT Asking a why question can make the recipient
defensive which can hinder further communication.
"I know how you feel. My parent had to be transferred to a
long-term care facility." INCORRECT This is a sympathetic
response, which can interfere with a therapeutic
relationship.
, A nurse enters a client's room and finds them on the floor. The
client's roommate reports that the client was trying to get out of
bed and fell over the side rail onto the floor. Which of the
following statements should the nurse document about this
incident?
A. "Incident report completed."
B. "Client climbed over the side rails."
C. "Client found lying on floor."
D. "Client was trying to get out of bed."
"Incident report completed." INCORRECT An incident report
is an internal document that is part of a facility's risk
management system. The nurse should not document
completion of an incident report in the client's medical
record for the facility's protection in the event of litigation.
"Client climbed over the side rails." INCORRECT Unless the
nurse witnessed the client climbing over the bed's side rails,
this statement is not an objective account of the nurse's
findings.
"Client found lying on floor." CORRECT The nurse should
include documentation of information that is descriptive and
objective concerning what the nurse actually observed,
without including any opinions or judgments about motives
or cause.
"Client was trying to get out of bed." INCORRECT Unless the
nurse witnessed the client trying to get out of bed, this
statement is not an objective account of the nurse's findings.
