ATI RN Fundamentals Practice Tests A & B proctored Exam

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I am having mild pain" "The pain is like a dull ache in my stomach" "I notice that the pain gets worse after I eat" "The pain makes me feel nauseous" - ANSWERS"The pain is like a dull ache in my stomach" A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm Extinguish the fire Evacuate the client Confine the fire - ANSWERSEvacuate the client A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distention Urine specific gravity 1.010 Rapid Heart rate Blood pressure 144/82 mmHg - ANSWERSRapid heart rate A nurse has accepted a verbal prescription for "thee tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? .3 mg 0.3 mg 0.30 mg 3/10 mg - ANSWERS0.3 mg A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 ml to infuse at 800 units/hour. At what rate should the nurse set the infusion pump? - ANSWERS8 ml/hour A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5 C (105 F) Cleanse the wound from the center outward Use a 20 ml syringe to irrigate the wound - ANSWERSCleanse the wound from the center outward A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? Purulent exudate Warmth Skin blanching Bleeding - ANSWERSSkin blanching A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "When descending the stairs, I will first shift my weight to my right leg" "I should place my crutches 12 inches in front and to the side of each foot" "As I sit down, I will hold one crutch in each hand" "I will make sure the shoulder rests are snug against my armpits" - ANSWERS"When descending the stairs, I will first shift my weight to my right leg" A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Rinse the feeding back with water between feedings Tell the client to keep the head of the bed elevated at least 30 degrees Make sure the enteral formula is at room temperature Wipe the top of the formula can with alcohol - ANSWERSTell the client to keep the head of the bed elevated at least 30 degrees A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse verify with the provider? Medication name Route of administration Medication dose Frequency of administration - ANSWERSMedication dose A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume" "I shouldn't have trouble keeping the hearing aid in place during exercise" "I expect to hear a whistling sound when I first insert the hearing aid" "I will be sure to remove my hearing aid before taking a shower" - ANSWERS"I will be sure to remove my hearing aid before taking a shower" A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? "Incident report completed" "Client climbed over the side rails" "Client found lying on the floor" "Client was trying to get out of bed" - ANSWERS"Client found lying on the floor" A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Seal unused medications from the facility in a plastic bag Evaluate the client's ability to self administer medications Report an identified discrepancy to The Joint Commission Compare prescriptions with medications the client received while at the facility - ANSWERSCompare prescriptions with medications the client received while at the facility A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? Describe the procedure to the client Witness the client's signature on the consent form Inform the client of alternatives to the procedure Tell the client which team members will assist with the procedure - ANSWERSWitness the client's signature on the consent form A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? "You should have an eye examination every 2 years" "You should receive a tetanus booster every 5 years" "You should receive a shingles vaccine when you are 70 years old" "You should receive a pneumococcal vaccine when you are 65 years old" - ANSWERS"You should receive a pneumococcal vaccine when you are 65 years old" A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Ask the client to consider a direct donation Withhold the blood transfusion Request a consultation with the ethics committee Ask the client's family to intervene - ANSWERSWithhold the blood transfusion A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? droplet airborne contact protective environment - ANSWERSdroplet 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 - ANSWERSMeasure urine output A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? "Most people are happy when their children grow up and leave home" "You should be proud that your children are becoming independent" "Maybe you should consider why you are feeling useless" "People in middle adulthood often find satisfaction in nurturing and guiding young people" - ANSWERS"People in middle adulthood often find satisfaction in nurturing and guiding young people" 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 his family? (select all that apply) Check the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove Consider purchasing a generator for power backup Observe for signs of hypoxia Select synthetic clothing and bedding - ANSWERSCheck the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove Observe for signs of hypoxia A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? Use a resuscitation bag with 80% oxygen prior to the procedure Select a suction catheter that is half the size of the lumen Place the end of the suction catheter in water soluble lubricant Adjust the wall suction apparatus to a pressure of 170 mmHg - ANSWERSSelect a suction catheter that is half the size of the lumen A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. Which of the following actions should the nurse take? Instruct the family to refrain from pushing the button for the client while she is asleep Inform the client that because she is on PCA, vital signs will be taken every 8 hours Teach the client to avoid pushing the button until the pain is above 7 on a scale of 0 to 10 Increase the basal rate and shorten the lock out interval time if the client's pain level is too high - ANSWERSInstruct the family to refrain from pushing the button for the client while she is asleep A nurse is admitting a client who has been having frequent tonic clonic seizures. Which of the following actions should the nurse add to the client's plan of care? Wrap blankets around all 4 sides of the bed Apply restraints during seizure activity Place the client in a supine position during seizure activity Have a tongue depressor at the client's bedside - ANSWERSWrap blankets around all 4 sides of the bed A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manage intervene due to a violation of HIPPAA guidelines? A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse A nurse asks a nurse from another unit to assist with documentation for a client A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care A nurse discusses a client's status with the physical therapist who is caring for the client - ANSWERSA nurse asks a nurse from another unit to assist with documentation for a client A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficle infection. Which of the following information should the nurse include in the teaching? Assign the client to a room with a negative airflow system Use alcohol based hand sanitizer when leaving the client's room Clean contaminated surfaces in the client's room with a phenol solution Have family members wear a gown and gloves when visiting - ANSWERSHave family members wear a gown and gloves when visiting A nurse is preparing to administer 0.5 ml of oral single dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration Transfer the medication to a medicine cup Place the client in a semi fowler's position prior to medication administration Verify the dosage by measuring the liquid before administering it - ANSWERSGently shake the container of medication prior to administration A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high fowler's position Increase the client's intake of carbohydrates Massage reddened areas with unscented lotion Have the client use a trapeze bar when changing position - ANSWERSHave the client use a trapeze bar when changing position A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate? Ambulating a client who is postoperative Inserting an indwelling urinary catheter for a client Demonstrating the use of an incentive spirometer to a client Confirming that a client's pain has decreased after receiving an analgesic - ANSWERSAmbulating a client who is postoperative A nurse is an acute care facility preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include? Client flow sheet Acuity ratings Current medications Incident reports - ANSWERSCurrent medications A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" "I blame medical science for not curing me" "Where is my daughter at a time like this?" "Will I ever begin to fell in charge of my life again?" - ANSWERS"What could