ATI RN Fundamentals Online Practice 2023 B FINAL EXAM UPDATED

A nurse in a medical-surgical unit is caring for six clients. Complete the following sentence by using the list of options. The first client the nurse should assess is _____ followed by _____. Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is admitted with a new diagnosis of diabetes mellitus. - ANSWERSCorrect Answer (1): Client 3 When using the airway, breathing, circulation approach to client care, the nurse should determine 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. Correct Answer (2): 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. Incorrect Answers (1): Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein is greater than the expected reference range, which is an indication of inflammation. However, there is another client the nurse should assess first. Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level is greater than the expected reference range, which places them at risk for coronary heart disease. However, there is another client the nurse should assess first. Incorrect Answers (2): Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less than the expected reference range, which places them at risk for delayed wound healing. However, this client is not the next priority client to assess. Client 6 is incorrect. The nurse should assess this client because their glycosylated hemoglobin level is greater than the expected reference range, which indicates poor diabetic control. However, this client is not the next priority client to assess. A nurse is caring for a client who has COPD. Select the 3 findings that require follow-up. Breath sounds Blood pressure Oxygen saturation Temperature Heart rate - ANSWERSCorrect Answer: Breath Sounds Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Oxygen Saturation The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. Temperature The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse. Incorrect Answer: Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not require follow-up by the nurse. Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to 100/min and does not require follow-up by the nurse. A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply. Assist the client to a left side-lying position with the right knee flexed. Prepare the client for a chest x-ray. Administer a cleansing enema. Auscultate the client's bowel sounds. Perform a manual digital examination of the client's rectum. Administer oxycodone extended-release tablets. Prepare the client for NG tube placement. - ANSWERSCorrect Answer: 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. 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. 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. 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. Incorrect Answer: Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary. Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client for placement of an NG tube because there is no indication or prescription to do so. Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract and peristalsis is absent. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? "They allow the court to overrule an adult client's refusal of medical treatment." "They indicate the form of treatment a client is willing to accept in the event of a serious illness." "They permit a client to withhold medical information from health care personnel." "They allow health care personnel in the emergency department to stabilize a client's condition." - ANSWERSCorrect Answer: "They indicate the form of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness. Incorrect Answer: "They allow the court to overrule an adult client's refusal of medical treatment." A court can only overrule an adult client's refusal of medical treatment if the client is legally incompetent. "They permit a client to withhold medical information from health care personnel." The Americans with Disabilities Act, not advance directives, protects the privacy of a client who chooses not to disclose a medical disability. "They allow health care personnel in the emergency department to stabilize a client's condition." The Emergency Medical Treatment and Active Labor Act, not advance directives, directs emergency personnel to provide screening and stabilizing care before discharging or transferring clients to another facility. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of NPH insulin from the bottle Inject 10 units of air into the bottle of NPH insulin Withdraw the correct dose of regular insulin from the bottle - ANSWERSCorrect Answer: Inject 10 units of air into the bottle of NPH insulin Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle Withdraw the correct dose 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 performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball. Apply a vibrating tuning fork to the client's forehead. Have the client stand with their arms at their sides and their feet together. Perform direct percussion over the area of the kidneys. - ANSWERSCorrect Answer: Have the client stand with their arms at their sides and their feet together. A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance. Incorrect Answer: Touch the face with a cotton ball. The nurse should touch the client's corneas with a wisp of cotton and measure light touch and pain across the client's face to test cranial nerve V, the trigeminal nerve. Apply a vibrating tuning fork to the client's forehead. The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to identify sound lateralization when assessing hearing. Perform direct percussion over the area of the kidneys. The nurse should perform direct percussion over the area of the kidneys to evaluate them for inflammation. A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and their family. Check the cord routinely for frays or tearing. Keep the unit at least 1.2 m (4 ft) away from a gas stove. Consider purchasing a generator for power backup. Observe for signs of hypoxia. Select synthetic clothing and bedding. - ANSWERSCorrect Answer: Check the cord routinely for frays or tearing. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Consider purchasing a generator for power backup. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. Observe for signs of hypoxia. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia. Incorrect Answer: Keep the unit at least 1.2 m (4 ft) away from a gas stove. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources. Select synthetic clothing and bedding. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton. A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet. Cucumbers Corn Asparagus Avocados - ANSWERSCorrect Answer: Avocados The nurse should suggest the client eat avocados, which are an excellent dietary source of potassium. Incorrect Answer: Cucumbers This food is low in potassium. Corn This food is low in potassium. Asparagus This food is low in potassium. A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches in the inner ear? Press gently on the tragus of the client's ear. Pack a small piece of cotton deep into the client's ear canal. Move the client's auricle down and back toward their head. Tilt the client's head backward for 5 min. - ANSWERSCorrect Answer: Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into the inner ear. Incorrect Answer: Pack a small piece of cotton deep into the client's ear canal. Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward. Move the client's auricle down and back toward their head. For an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal. Tilt the client's head backward for 5 min. The client should lie on one side with the ear that received the instillation facing upward for 2 to 5 min. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage. Notify the pharmacy when wasting the medication. Lock the remaining medication in the controlled substances cabinet. Dispose of the vial with the remaining medication in a sharps container. - ANSWERSCorrect Answer: Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance. Incorrect Answer: Notify the pharmacy when wasting the medication. Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. Lock the remaining medication in the controlled substances cabinet. The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. Dispose of the vial with the remaining medication in a sharps container. The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act. 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? Auscultate lung sounds. Measure urine output. Monitor blood pressure readings. Monitor electrolyte levels. - ANSWERSCorrect Answer: 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. Incorrect Answer: Measure urine output. The nurse should measure urine output to monitor the renal function of a client who is receiving IV fluid; however, it is not the priority assessment. Monitor blood pressure readings. The nurse should monitor blood pressure readings to evaluate the hemodynamic stability of a client who is receiving IV fluids; however, it is not the priority assessment. Monitor electrolyte levels. The nurse should monitor electrolyte levels, especially sodium, to guide the planning of interventions to correct any imbalances in a client who is receiving IV fluids; however, it is not the priority assessment. A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which of the following actions should the nurse take? Discuss the risk factors for colon cancer. Focus teaching on what the client will need to do in the future to manage their illness. Provide the client with written information about the phases of loss and grief. Reassure the client that this is an expected response to grief. - ANSWERSCorrect Answer: Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. Incorrect Answer: Discuss the risk factors for colon cancer. The client might perceive this as challenging or argumentative and react defensively. Instead, the nurse should listen to the client's concerns and should avoid challenging them. Focus teaching on what the client will need to do in the future to manage their illness. During the anger stage of the client's psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face the future. Provide the client with written information about the phases of loss and grief. Unless the client requests reading materials about loss, this is not an optimal time to provide them. At this stage, the client needs to express their feelings without any expectations for learning. 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? Walking briskly Riding a bicycle Performing isometric exercises Engaging in high-impact aerobics - ANSWERSCorrect Answer: 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. Incorrect Answer: Riding a bicycle Cycling has no weight-bearing advantages; therefore, it does not help prevent osteoporosis. Performing isometric exercises Isometric exercises have no weight-bearing advantages; therefore, they do not help prevent osteoporosis. Engaging in high-impact aerobics High-impact aerobics can injure bones that have lost density; therefore, the nurse should not recommend these exercises for a client who is at risk for developing osteoporosis. 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 developin