ATI FUNDAMENTALS PROCTORED VERIFIED QUESTIONS AND ANSWERS 2023

ATI FUNDAMENTALS PROCTORED VERIFIED QUESTIONS AND ANSWERS 2023 1) A nurse at a long-term facility is providing a change of shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report? The time for routine vitals and measurements The client's background and health history The type of transmission-based precautions in place The number of visitors the client had during the shift 2) A nurse is caring for a patient who has a new prescription for negative-pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention? The Material Safety Data Sheet The client's plan of care The policy and procedures manual The nurse practice act 3) A nurse is performing a skin assessment on an older client. Which of the following findings should the nurse expect? Reduced sweat production Increased production of oils Increased skin elasticity Thickened outer layer of skin 4) A nurse is preparing to suction a client's tracheotomy. Which of the following actions should the nurse plan to take? Suction the client's airway for 20 seconds with each pass Apply intermittent suctioning during inserting Hyperoxygenate the client manually for 30 to 60 seconds before suctioning Decrease suction pressure to 150 mm hg if the oxygen saturation level drops during suctioning 5) A nurse is teaching a newly licensed nurse about the care of a client with MRSA infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? I will tell the clients visitors to wear a mask when they are within 3ft of the client I will wear an N95 respirator when caring for the client I will remove my gown and gloves after providing care I will place the client in a private room 6) A nurse on a medical-surgical unit is caring for 4 clients. The nurse should identify which of the following is an ethical dilemma? The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she doesn't like him 7) A nurse is caring for a patient who is immunocompromised. Which of the following actions should the nurse take? Have the client wear a mask when children are visiting Use sterile gloves when performing perineal care Place the client in a semi-private room Cleanse hands with an alcohol-based hand rub before client contact 8) A nurse has completed transfusing packed RBCs to a patient. Which of the following should the nurse document? Sterile gloves were used to prime the IV tubing Transfusion of the RBCs started at 0900 Packed RBCs were room temperature 1 hour prior to administration Last IV catheter dressing was 2 days ago 9) A nurse is inserting an NG tube for gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? Place the end of the NG tube in water to observe for bubbling Measure the PH of the gastric aspirate Assess the client for gag reflex Auscultate 2.5 cm above the umbilicus while injecting 15mL of sterile fluid 10) A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect? Distended neck veins Postural hypotension Dependent edema Bradycardia 11) A nurse is caring for a client who has urinary incontinence. Which of the following interventions should the nurse take to prevent skin breakdown? Apply a moisture barrier ointment after perineal hygiene Apply powder to the client's perineal area Restrict the client's fluid intake Request a prescription for an indwelling urinary catheter 12) A nurse is preparing to administer medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity? The client's phone number The clients admitting diagnosis The name of the clients next of kin The client's room number 13) A client is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy? The cephalic vein on the back of the right hand The cephalic vein on the left distal forearm The basilic vein on the right antecubital fossa The radial vein the left wrist 14) A nurse is planning care for a patient that reports insomnia. Which of the following actions should the nurse perform shortly before bedtime? Offer a wet cloth for the client to wash her face Perform range-of-motion exercises Prepare hot cocoa or tea for the client Provide a late supper. 15) A nurse is providing teaching to a client about reducing the effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? I will perform ankle and knee exercises every hour I will have my partner help me change positions every 4 hours I will hold my breath when rising from a sitting position I will remove my anti embolic stockings while I am in bed 16) A nurse is testing a client for conduction deafness by performing a Weber test. Which of the following actions should the nurse take when performing this test? Move a tuning fork in front of the client's ear canals one after the other Place the base of the tuning fork on the top of the client's head Count how many seconds a client can hear a tuning fork after it has been struck Place the base of the tuning fork on the client's mastoid process 17) A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make? I would get a second opinion if I were you I think you would benefit from speaking with our Chaplin It must be difficult for you to receive this news It might seem bad now, but things will get better 18) A nurse is providing education to a 70-year-old client about immunizations. Which of the following statements should the nurse include in the teaching? You should get a tetanus booster every 15 years You should get the pneumococcal vaccine every 5 years You should get the shingles vaccine every 3 year You should get the influenza vaccine every year 19) A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein? Stroke the skin near the vein in an upward direction Dangle the client's arm over the bed Instruct the client to flex their arm with the hand open Apply a cool compress to the vein for 10 minutes 20) A charge nurse is observing a staff nurse performing wound irrigation for a client with a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure? Use a syringe with a catheter to irrigate the wound Refrigerates the solution before irrigation Uses one pair of gloves the dressing removal and irrigation Administers pain medication 5 minutes before starting the irrigation 21) A nurse on a medical-surgical unit is receiving a change of shift report for 4 clients. Which of the following clients should the nurse see first? A client who has pneumonia and 96% oxygen saturation A client who has a new onset of dyspnea 24 hours after a total hip arthroplasty A client who has a urinary tract infection and a low-grade fever A client who has acute abdominal pain of 4 on a scale to 10 22) 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? Express approval of the client's decision Discuss alternative treatments for the client Explain to the client the risks involved with not having the procedure Document the client's decision in the medical record 23) A nurse is assisting an older adult client. Which of the following should the nurse expect? Increased nighttime sleeping Nighttime urinary incontinence Heightened sense of pain Decreased sense of balance 24) A nurse is caring for a client who is scheduled for surgery. While the nurse is witnesses 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? Notify the provider Describe the surgery to the client Complete an incident report Provide brochures about the procedure 25) A nurse is preparing to bathe a client who has dementia. Which of the following action should the nurse take? Use distractions when bathing the client Give detailed instructions for the client to follow Allow the client to select the temperature of the bathe Complete the bath even if the client is in distress 26) A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? SATA Empty the stoma pouch when it becomes 1/3 full Cut the opening of the pouch 1/8 of an inch larger than the stoma Place a piece of gauze over the stoma while changing the pouch Expect the stoma to turn a purple-blue color as it heals Use povidone-iodine to clean around the stoma 27) A nurse is admitting a client that is malnourished. The client states that "My wedding ring is loose, and I am worried I will lose It if it falls off." Which is an appropriate response by the nurse? I can pin it to your hospital gown so you do not lose it I will place it in your drawer so that it won't get lost I will hold onto it until a family member can take it home I can put it in a locked storage unit for you 28) A nurse is preparing to administer otic drops to a school-aged child. Which of the following actions should the nurse take? Have the child lie in a supine position for 1 minute after administration Pull the pinna up and back to straighten the air canal Hold the dropper 5 cm above the air canal Ensure a cotton ball fights tightly into the ear canal 27) A nurse is preparing oral care for a client that is unconscious. Which of the following actions should the nurse take? Place the client in a side-lying position Apply mineral oil to the clients' lips Brush the clients' teeth daily Rinse the client's mouth with an alcohol-based mouthwash 28) A nurse is caring for a client that is postoperative and has a new prescription to advance her diet to full liquids. Which of the following should the nurse consider as a full liquid diet? Scrambles eggs Yogurt Oatmeal Applesauce 29) A nurse is performing postural drainage with percussion and vibration for a client with cystic fibrosis. Which of the following actions should the nurse take? Instruct the client to exhale deeply during vibration Cover the area of percussion with a towel Perform percussion over the lower back Schedule postural drainage after meals 30) A nurse is obtaining a medical history of a client that takes ginkgo Bilboa. The nurse should recognize that which of the following medications can adversely interact with this supplement? Albuterol Atorvastatin Levothyroxine Warfarin 31) 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. 32) A nurse is caring for a client who reports a pain level of 5 on a scale from 0 to 10. The client informs the nurse that pain medications are not an option for managing pain. Which is an appropriate response by the nurse? You may take any herbal remedies that you bring from home Would you like me to give you a back massage? I'm sure it will work if you give it a chance Why do you think pain medication is not going to help you 33) 1) Perform hand hygiene 2) Select injection site port closest to the patient 3) Cleanse the injection port with an antiseptic swab 4) Aspirate for blood 5) Inject medication 34) A charge in a long-term care facility is preparing educational program about delirium for newly licensed nurses. Which of the following statements should the nurse plan include? Delirium has a slow progression Delirium does not affect a clients sleep cycle Delirium has an abrupt onset Delirium does not affect the perception of a client's environment 35) A nurse is caring for a client receiving chemotherapy and reports a loss of appetite. Which of the following instructions should the nurse include? Drink a protein supplement between meals Eat two large meals a day Increase fluids with meals Eat food served at hot temperatures 36) 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 psychomotor history? What medications are you currently taking? Have any of your relatives been diagnosed with cancer? Are you experiencing any pain? What techniques do you use to cope? 37) A nurse is conducting an assessment for a client that takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of supplements? I take Ginkgo Biloba for a headache I take echinacea for my cholesterol I use ginger when I get car sick I use garlic for my menopausal symptoms 38) A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following situations requires the completion of an incident report? An oncoming nurse arrived late for work A client withdrew consent for a procedure A nurse transfused a unit of packed RBCs in 2 hours A client prescribed laboratory testing was not obtained 39) A nurse is assessing a client's ability to swallow. Which of the following actions should the nurse take? Have the client assume the chin down position Position the head of bead at a 45-degree angle Observe the client drink water through a straw Observe the client swallow thickened liquids 40) A nurse is eating a meal tray for a client who follows devout Jewish practices. Which of the following dietary choices should the nurse avoid? Beef Tea Chicken Shellfish 41) A nurse reviews a telephone prescription from a client that is experiencing pain. Which of the following responses should the nurse make? Will you spell the name of the medication for me? Let me clarify that you want the medication given QID, correct? Let me provide you with the client's medical record number for identification. I will sign my name now and leave a space for you to sign your name. 42) A nurse is collecting a sputum specimen from a patient who has a respiratory infection. Which of the following actions should the nurse take? Collect the specimen in the morning Wear sterile gloves while collecting the sample Offer the client oral hygiene after the collection Collect 1 ML of sputum 43) A nurse is teaching a client with diabetes about mixing regular insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? I should roll the bottle of NPH insulin between my hands before drawing it up I should inject air into the regular insulin first I should wait 3 minutes after mixing insulin to inject it I should draw up the NPh insulin before the regular 44) 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? Apply adhesive tape when securing an IV Use plastic syringes for medication administration Cover the blood pressure cuff with a stockinette Wear powdered gloves when providing care 45) A nurse obtains a prescription for wrist restraints for a client that keeps pulling out his NG tube. Which of the following actions should the nurse take? Remove the restraints every 4 hours Apply the restraints to allow as little movement as possible Attach the restraints securely to the sides of the bed rail Allow room for 2 fingers to fit between the client’s skin and the restraints 46) A nurse is caring for a client who has a history of IV drug use and asks that the information not be shared with her provider. Which of the following responses should the nurse make? It's not necessary to keep this information private This information will be kept in your medical records Why do you not want this information to be shared? IV drug use is dangerous, and you should stop using them immediately 47) A charge nurse is conducting an in-service about compliance with HIPPA guidelines for a group of staff members. Which of the following statements by a staff member indicates an understanding of the teaching? I should post the clients diagnosis on a message board in the clients' room I should post only the clients initials on the board in the nursing unit I can discuss the client's condition in the elevator with another nurse I can discuss the client's condition with the client's employer 48) A nurse is caring for a client who has pneumonia. The nurse should recognize that which of the following should be discarded in a biohazard bag. A bedpan containing diarrhea from a client who was receiving antibiotics A disposable tissue containing expectorated sputum An emesis filled with blood from severe coughing A collected toilet insert filled with urine 49) A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula? Encourage the client to take sips of water Check the gastric residual volume Flush the tube with sterile 0.9% sodium chloride irrigation Encourage the client to breathe deeply and cough 50) A nurse is caring for a client who has cancer and states they need to continue working to provide for their family. The nurse should initiate a referral to which of the following health care team members. Occupational therapist Social worker Dietician Respiratory therapist 51) A nurse is assessing the body temperature of an aging adult client using a temporal artery thermometer. Which of the following actions should the nurse take? SATA Pull the client's pinna up and back Slide the probe across the client's forehead Move the probe in a circular motion to obtain the reading Document the client's temperature with an "AX" next to the value Hold the client's hair aside while performing the procedure 52) A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse priority? Respiratory rate 7/min Reports pain of 8 on a scale of 0 to 10 Distended bladder Last bowel movement was 3 days 53) A nurse is preparing to transfer a client who is partially weight-bearing from the bed to a chair. Which of the following actions should the nurse take? Have the client bear weight on her stronger leg Position the chair next to the beg at 90 angles Stand with his feet together when lifting the client Keep his knees straight when moving the client 54) 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 by the nurse? I think that you should discuss this with the hospice nurse Let's talk more about your dad's condition Try to help your dad enjoy his life as much as possible The social worker will help you answer those questions 55) A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? Airborne Droplet Protective environment Contact 56) A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence? A nurse administers medication without first identifying the client An assistive personal prevents a client from leaving the facility A nurse begins a blood transfusion without obtaining a consent form An AP discusses client care in the facility cafeteria with visitors present 57). To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning? Client educator Case Manager Client advocate Client Care provider 58) A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Offer written information in the client's language Request that an AP interpret the information for the client Use proper medical terms when giving information to the client Avoid using gestures when speaking to the client 59) During a change of shift report, a nurse discovers she overlooked a prescription for a type and cross match of a client who is to have surgery the next day. Which of the following actions should the nurse take? Prepare an incident report for risk management Inform the provider of the delay in obtaining the cross match Obtain the clients cross match and type Document the incident in the client's medical record 60) A nurse is teaching a client about home care of oxygen equipment. Which of the following information should the nurse include in the teaching SATA Lay the oxygen tank flat Avoid using wool blankets when using oxygen Align the middle ball in the flow meter with the line of the prescribed low rate Keep the oxygen delivery system 0.6 meters from heat source Check the oxygen delivery rate at least once a day 61) A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to have a seizure. Which of the following actions should the nurse take first? Turn the client on her side Help the client lie on the floor Loosen the clients' clothes Move items in the room away from the client 62) A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take? Use the clients first and last name when initially meeting the client Avoid documenting direct quotes from the client as part of subjective data Explain to the client the necessity of full disclosure of information Tell the client the purpose of collecting the information 63) A nurse is caring for a client who has influenza and isolation precautions. Which of the following actions should the nurse take to prevent the spread of infection? Wear a mask within 3ft of the client Administer metronidazole Place the client in a negative airflow room Don protective eyewear before entering the room 64) A nurse is teaching a client about self-breast examination. Which of the following statements by the client shows an understanding of the teaching? I should make different patterns on each breast when I do my self-exams I should use the palms of my hands to apply pressure to each breast I should make circular motions with my fingertips under my arms I should perform my self-exams the week my period starts. 65) A nurse is documenting in a client's medical record. Which of the following should the nurse record? Oral temperature slightly elevated at 0800 Incision without redness or drainage Drank adequate amounts of fluid with meals Administered pain medication 66) A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." Which stage of grief is the client experiencing? Bargaining Anger Denial Acceptance 67) A nurse is caring for a client that has 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 health care teams? Occupational therapist Social worker Primary care provider Registered dietician 68) A nurse is preparing to apply a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse plan to take? Allow 2.5-5 cm between the end of the catheter and the tip of the penis Change the condom catheter every 3 days Keep foreskin in a retracted position after application of the catheter Place adhesive tape directly on the penis. 69) A nurse is at an assisted living facility is preparing an in-service for residents about electrical safety, which of the following instructions should the nurse include. Clean electrical equipment prior to disconnecting Avoid taping electrical cord to the floor Disconnect electrical equipment by grasping the plug Cover exposed wires with tape before use 70) A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personal? Assist the client to select food choices from the menu Evaluate the client's response to pain medication Teach deep breathing and coughing to the client Monitor the characteristics of the client's chest tube drainage 71) A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity? Continuous passive motion machine Abduction splint Ankle-foot orthotic Sequential compression device 72) A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take first? Place the wasted portion of the controlled substance in the sharp's container Verify the count total of the controlled substance after removing the amount needed Report any discrepancy in the count total of the controlled substance after administration Ask a second nurse to record her signature when wasting any used portion of the controlled substance 73) A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching? Instruct the client to stop drinking clear liquids 1 hour before the surgery Explain the need to have another adult drive the client home after surgery Inform the client they can wear makeup during surgery Ask the client to shower three times the day before the surgery 74) A nurse is conducting an in-service for staff members about the Emergency Medical Treatment and Active Labor act. Which of the following statements by a staff member indicates an understanding of the teaching? A client can be discharged to another facility their condition stabilizes A client can be discharged to another facility if their behavior is unsafe and inappropriate A client can be discharged to another facility if their condition is terminal A client can be discharged to another facility if they are unable to pay for services received 75) A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuff to the client's arm, Identify the sequence of steps the nurse should follow. Palpate the brachial pulse, deflate the cuff until the brachial pulse is no longer felt, discontinue palpation of the brachial artery, Inflate the pressure cuff to 30 mm hg beyond where the brachial pulse was last felt 76) A nurse is caring for a group of clients whose primary languages are different from the nurses. For which of the following clients should the nurse provide written material in the client's primary language? A client who is learning to use an incentive spirometer A client who requires administration of a prescription medications A client watching a video about the meal services at the facility in their primary language A client who requires teaching prior to discharge. 77) 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. The situation represents which of the following torts? False imprisonment Invasion of privacy Assault Negligence 78) A nurse is assessing an older adult client who lives with a caregiver. Which of the following findings should lead the nurse to further assess the client for elder maltreatment? The client is confused at times during the day The client is incontinent of urine The client is unable to stand for long periods of time The client has not had a bath in several weeks 79) A nurse is caring for an older adult client who tells the nurse, "I have smoked one pack of cigarettes a day for the last 60 years." Which of the following actions should the nurse take first? Suggest that the client use a nicotine gun to facilitate quitting Refer the client to a local smoking cessation program Ask what the client knows about the effects of smoking Work with the client to establish a quit date 80) A nurse on a medical-surgical unit is caring for a client who reports difficult sleeping at night. Which of the following should indicate to the nurse that the client has sleep deprivation? Increased reflexes Increased auditory alertness Decreased judgment Decreased activity 81) A nurse says to their manager that "I'm the only one on my team who is working hard." Which of the following responses should the nurse manager make? Why do you feel upset about this? I will reprimand your team members You must feel frustrated You should be working harder 82) A nurse is planning to admit a client who is at risk for sensory overload. Which of the following actions should the nurse take? Keep the client's room brightly lit Encourage the clients' friends to visit frequently Spread out client care throughout the shift Place the client in a private room 83) A nurse is caring for a client who is scheduled to have his ALT level checked. The client asked to explain the laboratory test. Which of the following is an appropriate response by the nurse? The test will indicate if you are at risk for developing blood clots The test will determine if your heart is functioning properly This test is used to check how your kidneys are working The test will provide information about the function of your liver 84) A nurse is providing teaching about preventing back strains to the caregiver of a client that is immobile and requires assistance. Which of the statements by the caregiver indicates an understanding of the teaching? I will keep my legs straight to provide more power with the lift I will place the bed in the lowest possible position I will tighten my abdominal muscle prior to moving I will twist at the waist while pulling the draw sheet 85) A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? Ask a family member to translate for the client Speak to the client while indicating printed instructions in the client's language Find an assistive personal who speaks the client's language Arrange for a video conference with an interpreter who speaks the client's language 86) A nurse is monitoring a client receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site? Pitting edema at the insertion site Erythema along the path of the vein Coolness of the clients left forearm Pallor of the clients left forearm 87) A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving the client to a safe location, which of the following actions should the nurse take next? Close the doors to the client's rooms Use an extinguisher to put out the fire Turn off any electrical equipment Pull the fire alarm 88) A nurse hangs a bag of dextrose 5% in water 1000 ml at 0800 to run at 125 ml/hr. At 1200, the nurse notices that the client's IV is empty. Which of the following actions should the nurse take first? Notify the primary care provider Calculate the infused volume Assess the client's vital signs Complete an incident report 89) A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate order in place. The client requests that CPR be performed if necessary. Which of the following responses should the nurse make? I understand how you feel because I recently lost a family member You should call your partners provider to change the DNR Let's discuss other areas of your partner's care It must be very difficult for you to accept your partner's wishes 90) A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin. Which of the following actions should the nurse take prior to the start of the infusion? Check that the client has a small gauge IV catheter in place Prime the client's IV tubing with lactated ringer Check the blood products compatibility with the client's blood type Confirm the identity of the client with the blood bank technician 91) A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier? Bed number Photograph Age Room Number 92) A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? Discuss the client's prior coping mechanisms. Help the client to find a local support group Teach the client to use progressive relaxation techniques Develop a list of goals with the client 93). A nurse is preparing a sterile field to assist with suturing a client's laceration. Which of the following actions should the nurse plan to take? Hold the bottle of a sterile solution so that the label is facing the palm of the hand. Pour the sterile solution with the bottle held 20cm above the sterile bowl Place the lid of the bottle face down on the sterile drape Apply sterile gloves before opening the bottle of sterile solution 94) A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? Write down the complete prescription Ensure that the provider signs the prescription Read back the prescription to the provider Document the prescription as a telephone in the medical record 95) A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600 ml IV infusion, cefazolin 250 mg in dextrose 5% in water 100 ml intermittent IV bolus, 200 ml emesis, 40 ml voided urine, and 20 ml urine from straight catheterization. The nurse should record the client's net fluid intake as how many ml? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 590 ml. 96). A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Provide adequate lighting to inspect the abdomen. Listen to the abdominal arteries using the bell of the stethoscope. Percuss all four quadrants of the abdomen to measure sound quality. Check for access of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen. Locate the liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen. 97) A nurse is teaching a group of newly licensed nurses about the Braden scale; which of the following responses by a newly licensed nurse indicates an understanding of the teaching? The scale measures six elements. 98) 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? Determine whether the client can afford the insulin 99) 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? Contract your pelvic muscle when performing the exercise 100) 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 change in the appearance of the mole on the shoulder. 101) A nurse is caring for a patient who has a high fever. Which of the following actions should the nurse take? Apply a bath blanket between the client and the cooling blanket. 102) A nurse is caring for an infant who is to undergo surgery. The nurse should identify that which of the following should sign the consent form? The infant's 17-year-old mother. 103) 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 should the nurse take? Place the shallow end of the fracture pan under the client's buttocks. 104) A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? SATA Stop the transfusion Administer oxygen to the client Obtains a prescription for a diuretic Administer epinephrine to the client Place the client in a high-fowlers position 105) A nurse is calculating a prescribed dose of a narcotic to be given to a client and has determined that half of the tablet should be administered. Which of the following actions should the nurse take? Document the time the calculation was performed Document that half the dose was administered Placed the unused portion in a sharp's container Have a second nurse witness the disposal of the unused portion 106) A nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples is a violation of HIPPA? Teaching the client discharge instructions with the client's partner present Discussing the patient's transfer to a long-term facility with a nurse from another unit Giving a telephone report to a surgical nurse when sending the client to the surgical unit Faxing medical information to the clients' provider's office. 107) A nurse is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the nurse include? Obtain a herpes zoster vaccine by the age of 50 Obtain a tetanus booster every 5 years Have a dental examination every 6 months Have a testicular examination every 2 years 108) A nurse is teaching a client who requires maximal assistance about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching? The client picks up the walker which each step The client stoops slightly forward when moving the walker The client moves the walker ahead 25.4 cm (10 inches) with each step The client stands with her elbow slightly flexed while holding the walker 109) 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? Apply cornstarch to the client's skin Arrange for an alternating pressure mattress Request a prescription for an indwelling urinary catheter Reposition client every 4 hours 110) A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following finding indicates to the nurse that the client is experiencing fluid volume overload? Crackles in the lungs Bradycardia Flattened neck veins Fever 111) A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home". Which of the following statements should the nurse make? Do you understand without treatment, you will die? Don't you think you are giving up too soon? I can refer you to hospice care, and they can help you at home You should discuss this with your family before making a decision? 112) A nurse is providing instructions for a client who has diabetes about foot care. Which of the following statements by the client indicates an understanding of the instructions? I can use a heating pad when my feet are cold I can apply lotion to my feet if I avoid between my toes I will use a pumice stone to soften the callus on my feet I will just go barefoot in the house 113) A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take? Don clean gloves before cleaning the wound Cut a 4X4 piece of gauze to place around the drain site Use a separate, sterile swab for each stroke when cleaning the wound First, clean the drain site and then clean the incision 114) A nurse is planning the care of a client who has Parkinson's disease and requires assistance with managing their quality of life. Which of the following referrals should the nurse plan to take? Social worker Group Therapy Palliative Care Hospice 115) A nurse is planning an educational conference about informed consent. Which of the following information should the nurse include? Informed Consent includes information about the potential risks of the procedure A nursing student can witness informed consent After signing the informed consent, the client can no longer refuse the procedure The nurse is responsible for explaining the procedure when obtaining the informed consent 116) A nurse is planning care to delegate client care to assistive personnel. Which of the following tasks should the nurse plan to delegate? Suctioning a client's tracheotomy that has been in place for three days Reinserting an NG tube that was pulled out by the client Recording output for a client who has multiple drains and tubes Teaching a family member how to change a simple dressing at home 117) A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? Ensure the provider signs the prescription Read back the prescription to the provider Document the prescription as a telephone prescription in the medical record Write down the complete prescription 118) A nurse is caring for a hospitalized client who states, "I cannot sleep at night because of so many interruptions by health care team members." Which of the following interventions should the nurse initiate? Cluster client care with other members of the health care team Instruct assistive personnel to provide routine hygiene at night Encourage the client to sleep during the day Withhold any medications due overnight 119) A nurse is performing hand hygiene at the beginning of his shift. Which of the following actions should the nurse take? Keep his hands above elbow level when washing Turn off the faucet with a clean, dry paper towel Rub his hands together to cause friction for 10 seconds Dry his hands by working from forearms down to fingertips 120) A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Use a cuff that is 60% of the client arm circumference Apply the cuff above the client's antecubital fossa Release the pressure on the clients arm 5 to 6 mm per second Have the client sit with their arm resting above the level of the heart 121) A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take? Suction the client's airway every hour Offer the client sips of flavored soda Position the client supine in bed Encourage the client to make choices about personal hygiene 122) A nurse is preparing teaching to a client about the administration of Clotrimazole vaginal suppositories. Which of the following statements by the client indicates an understanding of the teaching? I will lie on my left side to insert the suppository I can discontinue the medications once my symptoms are gone I will place the suppository as far inside my vagina as it can reach I will put some lubricant on the flat end of the suppository 123) A hospice nurse is visiting a client who has terminal cancer. Which of the following statements by the client's partner should the nurse recognize as an indication of anticipatory grief? I miss him so much already We are planning a trip next spring I am so angry that this is happening to us We haven't discussed funeral arrangements 124) A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury but is walking with a slight limp. Which of the following actions should the nurse take? Send the visitor to the risk management office Document the occurrence in the client's medical record Complete an incidence report Administer acetaminophen to the client 125) A nurse in an acute care facility is preparing to transfer to a long care facility. Which of the following information should the nurse include in the hand-off report? Effectiveness of the last dose of pain medication Time of the client's last bath Frequency of previous vital measurements Number of family members that have visited 126) A nurse is caring for a client who consumes 3 OZ of milk, 2 OZ of orange juice, 4 OZ of water over a 4-hour period. The client is also receiving dextrose 5% in 0.45 sodium chloride 30 mL/hr by continuous IV infusion. Calculate the client's intake for the 4- hour period. 490ml 127) A nurse is caring for a client with dysphagia. Which of the following actions should the nurse take? Have suctioning equipment at bedside Use a syringe to feed the client Instruct the client to tile their head back when swallowing Give the client a 15- minute time period to finish meals 128) A nurse is caring for a client that has chronic back pain and asks about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment? Hypertension Migraines Obesity Cellulitis 128) A nurse is caring for a client who is postoperative and asks the nurse, "When will I get to go home? I'm not sure what happens next." Which of the following actions should the nurse take? Assure the client that the provider will come to talk to them when they get the chance Explain that the client should trust the provider because she has an excellent reputation Inform the provider that the client is requesting information regarding his treatment plan Tell the client that the provider will discharge him when she feels he is ready to leave 130) A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea. Put in order Determine the probability of intervention-related complications Review the potential benefit and consequences of each intervention Select an intervention that provides the greatest benefit with least risk Identify possible nursing interventions that address the client's nausea 131) A nurse is assessing visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take? Document the largest line that the client can read Position the client 3.3 M away from the client Instruct the client to begin the exam with both eyes open Begin the testing while they are wearing glasses 132) A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory finding should the nurse expect? Regular respirations fewer than 12 breaths/min Irregular respirations with frequent periods of apnea Regular, rapid, shallow respirations Irregular respirations greater that 20/Min 133) A nurse manager is preparing a quality improvement assessment to determine the source of Clostridium Difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infections? Cleansing visibly fecal-soiled hands with alcohol-based hand sanitizer Failing to don a mask when entering a client's room Putting on a protective gown before entering a client's room Wearing gloves when performing perianal care 134) A nurse teaches a client self-administering an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching? I will press the inner corner of my eye after I insert eye drops I will keep my eyes closed after inserting the eye drops I will insert the eye drops into the center of the eye I will raise my eyelid up while looking down to insert the eye drop 135) A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? SATA Secure restraints to allow three finger breaths to slide under the restrains Attach the restraints to the bed rail Ensure that the bed is in the lowest possible position Pad bony prominences before applying wrist restraints Assess skin temperature and color before applying restrains -A nurse is reviewing the medical record of a client who asks about the use of magnet therapy for pain relief. The nurse should identify that which of the following findings is a contraindication for receiving this type of therapy? The client has an implanted defibrillator. -A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn? The client's belief that his needs will be met through education. -A nurse is planning to insert an IV catheter for an adult client. Which of the following actions should the nurse take? Apply a cool compress for several minutes before insertion of the IV catheter. -A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching? You will receive written information about advance directives prior to signing. -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? Secure restraints with a square knot. -A home health nurse is teaching a client about home safety. Which of the following statements by the client indicate an understanding of the teaching? (select all that apply) 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. I need to check my medications for expiration dates. -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. Dilated pupils. -A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? Unplug the pump. -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? The client's skin on the lower back is intact without redness. -A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care? Obtain a random blood glucose daily. -A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicate an understanding of the teaching? I should gradually increase the time that I wear the hearing aid. -A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? Ensure the client is free of metal objects. -A nurse is assessing a client who diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia? Thirst. -A nurse is caring for a patient who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, "I'm worried about the bag." Which of the following is an appropriate response by the nurse? The surgeon will only place the colostomy if it is necessary. -A nurse is caring for a client who had a stroke and requires assistance with morning ADL's. Which of the following inter-professional team member should the nurse consult? Occupational therapist. -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 should the nurse plan to take during this stage? Present information about the benefits of quitting smoking. -A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate? Performing a simple dressing change. -A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching? I should limit the time I spend sitting in a chair. -A nurse is caring for a client who refuses to follow the provider's prescriptions for strict bed rest. The nurse overhears assistive personnel (AP) tell the client, "if you do not remain in bed, I will place you in restraints." The nurse should identify that the AP is committing which of the following torts? Assault. -A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first? Skin integrity. -A nurse is planning care for a female who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan? Keep the drainage bag below the level of the bladder. -A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse provide to the provider? Potassium 5.8mEq/l. -A nurse is preparing to administer gentamicin 2mg/kg IV to a client who weighs 220 lb. how many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 200. -A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority? Review the use of an artificial larynx with the client. -A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation? "Client predetermined with MSO4 substances prior to dressing change." -A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take? Cleanse the skin around the stoma with normal saline. -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? (Select all that apply.) Blood glucose monitor, oral suction equipment, Supplemental oxygen supplies. -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? Eat a light carbohydrate snack before bedtime. -A nurse is preparing to obtain informed consent from a client who speaks different languages than the nurse and is scheduled for surgery. Which of the following actions should the nurse take? Recommend an interpreter who is the same gender as the client. -A nurse is caring for a client who is postoperative and asks the nurse, "When will I get to go home? I'm not sure what happens next." Which of the following actions should the nurse take? Inform the provider that the client is requesting information about his treatment plan. -A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include? "You will be placed in a semi-private room." -A nurse is preparing a medication from a vial for a subcutaneous injection for a client. Which of the following actions should the nurse take? Hold the vial with the top facing upward while injecting air into the vial. -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? Expose the client's abdomen to look for changes in appearance. -A nurse is mixing a short-acting insulin and an intermediate-acting insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first? Inject air into the intermediate-acting insulin vial. -A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take? Change the tubing set every 72hours. -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? Plain yogurt. -A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care? Remove the stopcocks from IV tubing.