ATI: Fundamentals Practice A
Study online at https://quizlet.com/_ctx30o
1. A nurse on a medical-surgical unit is caring for a client who has a new
prescription for wrist restraints. Which of the following actions should the
nurse take?
a) Pad the client's wrist before applying the restraints
b) Evaluate the client's circulation every 8 hours after application
c) Remove the restraints every 4 hr to evaluate the client's status.
d) Secure the restraint ties to the bed's side rails.: A) The use of restraints without
padding can abrade the client's skin, resulting in client injury.
b) The nurse should evaluate the client's circulation, range of motion, vital signs, and
overall status every 15 min after initial application of restraints.
c) The nurse should remove the restraints at least every 2 hr to reposition the client
and assess needs for hygiene and toileting.
d) The nurse should secure the restraint ties to a part of the bed frame that moves
with the client to reduce the risk of injury.
2. A nurse is using an open irrigation technique to irrigate a client's indwelling
urinary catheter. Which of the following actions should the nurse take?
a) Place the client in a side-lying position.
b) Instill 15 mL of irrigation fluid into the catheter with each flush.
c) Subtract the amount of irrigant used from the client's urine output.
d) Perform the irrigation using a 20-mL syringe.: a) For a catheter irrigation, the
nurse should place the client in a supine or dorsal recumbent position for maximal
access to the catheter.
b) Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid.
c) The nurse should calculate the fluid used for irrigation and subtract it from the
client's total urinary output.
d) The nurse should use a 30- to 50-mL syringe to perform open irrigation.
3. A home health nurse is performing a follow-up visit for a client who has a
gastrostomy tube through which they receive intermittent feedings and med-
ications. The client has recently developed diarrhea. Which of the following
findings should the nurse identify as a possible cause of the diarrhea?
a) The client is receiving formula at room temperature.
b) The feedings infuse at a slow, continuous drip over 8 hr each night.
c) The client's caregiver washes out the feeding bag with warm water once
every 24 hr.
d) The client's caregiver flushes the tubing with water before and after admin-
istering medications.: a) Cold formula can cause gastric cramping; therefore, room
1/8
, ATI: Fundamentals Practice A
Study online at https://quizlet.com/_ctx30o
temperature formula is appropriate and is likely not the cause of the client's diarrhea.
b) Diarrhea is more likely to develop with rapid instillation of enteral formula.
c) Feeding bags should be washed out after each feeding and replaced with a
new feeding bag every 24 hr to prevent bacterial contamination. The nurse should
reinforce this information with the client's caregiver to avoid future contamination.
d) It is correct to flush tubing with water before and after administering medications
to prevent clogging of the tube.
4. A nurse is initiating a protective environment for a client who has had an
allogeneic stem cell transplant. Which of the following precautions should the
nurse plan for this client?
a) Make sure the client's room has at least six air exchanges per hour.
b) Make sure the client wears a mask when outside her room if there is
construction in the area.
c) Place the client in a private room with negative-pressure airflow.
d) Wear an N95 respirator when giving the client direct care.: a) A protective
environment requires at least 12 air exchanges per hour.
b) An allogeneic stem cell transplant compromises the client's immune system,
greatly increasing the risk for infection. The client will need protection from breathing
in any pathogens in the environment.
c) The nurse should place the client in a private room that provides positive-pressure
airflow.
d) The nurse should wear an N95 respirator mask when caring for clients who require
airborne precautions, not a protective environment.
5. A nurse is caring for a client who is postoperative and is exhibiting signs
of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to
continue to measure the client's vital signs every 15 min and to report back in
1 hr. Which of the following actions should the nurse take next?
a) Document the provider's statement in the medical record.
b) Complete an incident report.
c) Consult the facility's risk manager.
d) Notify the nursing manager.: a) The nurse should document the provider's
directions in the medical record for later reference; however, another action is the
nurse's priority.
b) The nurse should prepare an incident report detailing the delay in treatment for
later review and action for prevention of future occurrences; however, another action
is the nurse's priority.
c) The nurse should discuss the situation with the facility's risk management depart-
2/8
Study online at https://quizlet.com/_ctx30o
1. A nurse on a medical-surgical unit is caring for a client who has a new
prescription for wrist restraints. Which of the following actions should the
nurse take?
a) Pad the client's wrist before applying the restraints
b) Evaluate the client's circulation every 8 hours after application
c) Remove the restraints every 4 hr to evaluate the client's status.
d) Secure the restraint ties to the bed's side rails.: A) The use of restraints without
padding can abrade the client's skin, resulting in client injury.
b) The nurse should evaluate the client's circulation, range of motion, vital signs, and
overall status every 15 min after initial application of restraints.
c) The nurse should remove the restraints at least every 2 hr to reposition the client
and assess needs for hygiene and toileting.
d) The nurse should secure the restraint ties to a part of the bed frame that moves
with the client to reduce the risk of injury.
2. A nurse is using an open irrigation technique to irrigate a client's indwelling
urinary catheter. Which of the following actions should the nurse take?
a) Place the client in a side-lying position.
b) Instill 15 mL of irrigation fluid into the catheter with each flush.
c) Subtract the amount of irrigant used from the client's urine output.
d) Perform the irrigation using a 20-mL syringe.: a) For a catheter irrigation, the
nurse should place the client in a supine or dorsal recumbent position for maximal
access to the catheter.
b) Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid.
c) The nurse should calculate the fluid used for irrigation and subtract it from the
client's total urinary output.
d) The nurse should use a 30- to 50-mL syringe to perform open irrigation.
3. A home health nurse is performing a follow-up visit for a client who has a
gastrostomy tube through which they receive intermittent feedings and med-
ications. The client has recently developed diarrhea. Which of the following
findings should the nurse identify as a possible cause of the diarrhea?
a) The client is receiving formula at room temperature.
b) The feedings infuse at a slow, continuous drip over 8 hr each night.
c) The client's caregiver washes out the feeding bag with warm water once
every 24 hr.
d) The client's caregiver flushes the tubing with water before and after admin-
istering medications.: a) Cold formula can cause gastric cramping; therefore, room
1/8
, ATI: Fundamentals Practice A
Study online at https://quizlet.com/_ctx30o
temperature formula is appropriate and is likely not the cause of the client's diarrhea.
b) Diarrhea is more likely to develop with rapid instillation of enteral formula.
c) Feeding bags should be washed out after each feeding and replaced with a
new feeding bag every 24 hr to prevent bacterial contamination. The nurse should
reinforce this information with the client's caregiver to avoid future contamination.
d) It is correct to flush tubing with water before and after administering medications
to prevent clogging of the tube.
4. A nurse is initiating a protective environment for a client who has had an
allogeneic stem cell transplant. Which of the following precautions should the
nurse plan for this client?
a) Make sure the client's room has at least six air exchanges per hour.
b) Make sure the client wears a mask when outside her room if there is
construction in the area.
c) Place the client in a private room with negative-pressure airflow.
d) Wear an N95 respirator when giving the client direct care.: a) A protective
environment requires at least 12 air exchanges per hour.
b) An allogeneic stem cell transplant compromises the client's immune system,
greatly increasing the risk for infection. The client will need protection from breathing
in any pathogens in the environment.
c) The nurse should place the client in a private room that provides positive-pressure
airflow.
d) The nurse should wear an N95 respirator mask when caring for clients who require
airborne precautions, not a protective environment.
5. A nurse is caring for a client who is postoperative and is exhibiting signs
of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to
continue to measure the client's vital signs every 15 min and to report back in
1 hr. Which of the following actions should the nurse take next?
a) Document the provider's statement in the medical record.
b) Complete an incident report.
c) Consult the facility's risk manager.
d) Notify the nursing manager.: a) The nurse should document the provider's
directions in the medical record for later reference; however, another action is the
nurse's priority.
b) The nurse should prepare an incident report detailing the delay in treatment for
later review and action for prevention of future occurrences; however, another action
is the nurse's priority.
c) The nurse should discuss the situation with the facility's risk management depart-
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