Virtual ATI Fundamentals Pre-Assessment graded A+ 2024exam.

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - correct answer - Remove the clients from the room - Activate the fire alarm - Close the door - Extinguish the fire A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? A. Blistering B. Erythema C. Eschar D. Absence of pain - correct answer B. Erythema Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat. A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) - correct answer - Report of feeling pressure - Tenderness over the symphysis pubis - Distended bladder - Voiding 30 mL frequently Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understands the teaching? A. "Most of my calories each day should be from fats." B. "I should eat more calories from complex carbohydrates than anything else." C. "Simple sugars are needed more than other calorie sources." D. "Protein should be my main source of calories." - correct answer "I should eat more calories from complex carbohydrates than anything else." The client who has diabetes should consume the majority of calories from complex carbohydrates, such as whole grains, fruits, and vegetables. A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching? A. "I will apply elastic bandages to cuts." B. "I will use dishwashing gloves when cleaning the dishes." C. "I will buy balloons for my son's birthday." D. "I will use ink pens for writing." - correct answer "I will use ink pens for writing." The client understands pencil erasers contain latex and should use pens for writing instead. A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180 mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift? (Round the answer to the nearest whole number) - correct answer 1720 mL A charge nurse observes a nurse administer intermittent tube feeding via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A. The nurse initiates the feeding after aspirating 50 mL of gastric residual. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse allows the client to rest in a supine position during feeding. - correct answer The nurse allows the client to rest in a supine position during feeding. The nurse should elevate the head of the bed to a minimum of 30° to prevent aspiration from reflux during feedings. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication? A. Milk B. Orange juice C. Coffee D. Grapefruit juice - correct answer Grapefruit juice Grapefruit juice increases blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of medication can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness. A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report? A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse used a 25-gauge 3/8 inch needle to administer a heparin injection. C. A nurse injected Demerol IM into the vastus lateralis site of adult. D. A client received a crushed bupropion XL tablet mixed with applesauce. - correct answer A client received a crushed bupropion XL tablet mixed with applesauce. Extended or sustained release medications are intended to release medication levels over a long period of time to sustain therapeutic relief. Crushing, breaking, or chewing an extended release medication releases the medication at once into the bloodstream and could be life-threatening. Mixing this medication in applesauce deviates from standard of care and requires the nurse to complete an incident report. A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? (Select all that apply). - correct answer bid is correct 30 mL is correct A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include? A. "Hold the cane with your left hand." B. "When walking, move your left foot forward first." C. "Move the cane forward 18 inches with each step." D. "Keep your elbow straight when you hold the cane." - correct answer "When walking, move your left foot forward first." The client should move her weaker (left) foot with the cane first, then bring her stronger leg forward ahead of the cane and the weaker foot. A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? A. "You can expect fecal output within 24 hours." B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week." D. "You may experience a small amount of bleeding around the stoma." - correct answer "You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon. A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a client who is worried about the outcome of a laboratory test. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Justice C. Fidelity D. Nonmaleficence - correct answer Fidelity The nurse demonstrates the ethical principle of fidelity by keeping a promise. A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? A. "It is a good idea to use the handrails in the bathroom." B. "I should use chairs without armrests." C."I should place a throw rug over electrical cords." D. "I should get a longer cord for my telephone." - correct answer "It is a good idea to use the handrails in the bathroom." Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions. A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will walk briskly for 30 minutes before bedtime." B. "I will no longer have a glass of wine before bedtime." C. "I will have a cup of hot cocoa immediately before bedtime." D. "I will do my muscle relaxation techniques each afternoon." - correct answer "I will no longer have a glass of wine before bedtime." The client should limit or avoid alcohol consumption in the late afternoon and evening. Alcohol can act as a diuretic and cause the client to wake during sleeping hours to urinate. Alcohol also interrupts the sleep cycle and can make it difficult to stay asleep or return to sleep after awakening. A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter. - correct answer Apply a moisture barrier ointment to the client's skin. Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine. A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infection (STIs). Which of the following statements should the nurse include in the teaching? A. "Use a natural membrane condom rather than a polyurethane condom." B. "You may use a condom more than once." C. "Use an oil-based lubricant when you use a condom." D. "Female condoms can help prevent transmission of sexually transmitted viruses." - correct answer "Female condoms can help prevent transmission of sexually transmitted viruses." The client who uses a female condom can prevent sexually transmitted viruses when the polyurethane or nitrile sheath is placed in the vagina. A nurse is caring for client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use? A. Ask the client to perform a return demonstration of insulin injection. B. Review the action of insulin therapy. C. Explore the client's feelings about dietary modifications. D. Have the client practice blood-glucose monitoring using a glucometer. - correct answer Explore the client's feelings about dietary modifications. This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning. A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? A. "You will do special exercises in advance of getting your prosthesis." B. "You will be fitted for your prosthesis at the time of surgery." C. "A special pressure dressing will remain on to cushion your prosthesis." D. "The prosthesis will be adjustable depending on what shoe you are wearing." - correct answer "You will do special exercises in advance of getting your prosthesis." The physical therapist will teach muscle strengthening exercises to prepare the client for prosthesis use. A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. B. Administer prescribed analgesic medication. C. Encourage coughing and deep breathing. D. Raise the head of the bed. - correct answer Raise the head of the bed. Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive. A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? A. Check that the client lifts the walker and then places it down in front of her. B. Walk in front of the client to guide her in moving the walker. C. Have the client move one leg forward with the walker. D. Make sure that the upper bar of the walker is level with the client's waist. - correct answer Check that the client lifts the walker and then places it down in front of her. The client should lift the walker and advance it about 15 cm (6 in), then set it down. This allows her a wide base of support while she moves forward. A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle? A. Locate the center of the arm between the elbow and the shoulder. B. Find the center of the anterior aspect of the thigh. C. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. D. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. - correct answer Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. This identifies the deltoid muscle, into which the nurse should inject the vaccine. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? A. Deflate the catheter balloon using a sterile syringe. B. Measure and document the urine in the drainage bag. C. Remove the tape or device securing the catheter to the client's thigh. D. Position the client supine. - correct answer Position the client supine. The first action the nurse should take using the nursing process is to place the client in a supine position. This permits adequate A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? A. Eat plenty of fresh fruits and vegetables. B. Avoid crowds. C. Perform mild exercise, such as gardening. D. Take temperature weekly. - correct answer Avoid crowds. The nurse should inform the client to avoid crowds due to his suppressed immune system. A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include? A. "The client attempted to climb over the side rails and fell." B. "The client was lying on the floor next to his bed." C. "The client was restless and trying to get out of bed all evening." D. "The presence of a bed alarm could have prevented the client from falling." - correct answer "The client was lying on the floor next to his bed." In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mmHg, and temperature 36.8 C (98.2 F). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin. - correct answer Complete a neurological check. Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being. A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - correct answer 1. Adjust the suction 2. Don Sterile gloves 3. Check the function of the catheter 4. Hyperoxygenate the client 5. Insert the catheter without suction 6. Apply suction while rotating the catheter 7. Assess for secretion clearance A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the client's diet? A. Creamed chicken B. Roast turkey C. Ice cream D. Macaroni and cheese - correct answer Roast turkey Roast turkey is a low-fat protein that is an appropriate choice for inclusion in the client's diet. Low-fat food decreases stimulation of the gallbladder, thereby reducing associated symptoms. A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens client care? A. Properly disposing of contaminated equipment B. Discarding used syringes in appropriate containers C. Changing soiled linens daily for clients who have draining wounds D. Performing hand hygiene frequently and consistently - correct answer Performing hand hygiene frequently and consistently The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care. A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant - correct answer Encourage the use of an incentive spirometer Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.