ATI Fundamentals Exam Prep./Review (Complete Updated 2022) 100% CORRECT Distinction Level Assignment Has everything GUARANTEED GRADE A+

1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements indicates an understanding of the teaching? a. I had a bowel movement, but I was able to save the urine – should be free of feces b. I have a specimen in the bathroom from about 30 minutes ago- Client should place any urine in the container immediately and keep it on ice or in the fridge. c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24 hr urine collection, the client should discard the first voiding and save all subsequent voiding. d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified amount 2. A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention – urinary retention which causes bladder distension is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles b. Decreased blood pressure – client on bed rest can develop postural hypotension. Drop in BP when the client moves from a lying to a sitting position. Nurse should assess for pulse rate and dizziness. c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations of thrombophlebitis, a common complication of immobility d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis. Constipation is common complication of immobility. 3. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse – any healthcare professional directly caring for a client has access to the medical information. b. A nurse asks a nurse from another unit to assist with her documentation – only health care professionals directly caring for a client may access medical information. c. A nurse who is caring for a client returns a call to the client's durable power of attorney for healthcare designee to discuss the client's care – The person the durable power of attorney for health care designates has a legal right to information about the client’s care. d. A nurse discusses the client's status with the physical therapist that is caring for the client at the client's bedside – any healthcare professional directly caring for a client has access to the medical information. 4. A nurse is caring for a client who requires bed rest and has a prescription for anti- embolic stockings. Which of the following actions should the nurse take? a. Apply the stockings so the creases are on the front side of the leg – nurse should assure that there are no creases or wrinkles in the stocked to prevent kind irritation and promote venous return b. Apply the stockings while the client's legs are in a dependent position – nurse should apply stockings in the morning before the client gets our o bed because the legs are less edematous at that time c. Remove the stockings at least once per shift – nurse should remove stocking to check for CMS. d. Remove the stockings while the client is sitting in a reclining chair – Client should wear the stockings while sitting in the chair to promote venous return. 5. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds – ABC approach. Auscultate lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifested in moist crackles heard in lung fields, dyspnea, and SOB b. Measure urine output – The nurse should measure urine output to monitor the renal function of an older client, however it is not the priority assessment c. Monitor blood pressure readings - The nurse should monitor BP readings to evaluate the hemodynamic stability of an older client, however it is not the priority assessment d. Monitor serum electrolyte levels - The nurse should monitor serum electrolyte levels (esp Na) to guide the planning of interventions to correct any imbalances in an older client, however it is not the priority assessment 6. A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. I can concentrate best in the morning – best indicates readiness to learn bc he is verbalizing the best time frame for him to learn b. It is difficult to read the instructions because my glasses are at home c. I'm wondering why I need to learn this d. You will have to talk to my wife about this 7. A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? a. Touch the face with a cotton ball – tests CN 5 - trigeminal b. Apply a vibrating tuning fork to the client's forehead – Weber test - sound lateralization for hearing c. Have the client stand with her arms at her side and her feet together – Romberg’s test helps identify alterations in balance. The nurse should observe for swaying and loss of balance d. Perform direct percussion over the area of the kidneys – This evaluates for kidney inflammation 8. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? a. Allow extra time for the client to respond to questions – Older clients process information at a slower rate than younger clients. The nurse should plan for extra time to allow for questions and absorption of information b. Expect the client to have difficulty understanding the information – cognitive abilities vary between individuals. Rather than expecting misunderstanding, the nurse should assess their cognition and ability to learn, teach, and understand. c. Avoid references to the client's past experiences – The nurse should explore their past experience and use them to establish connections to new knowledge d. Keep the learning session private and one-on-one – It is helpful when working with older adult clients to invite another household member to the teaching session so that person can help reinforce new information later. The nurse should also honor the client’s preference for one-on-one or group settings. 9. 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? a. Walking briskly – weight bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adults in this preventative and therapeutic strategies b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics 10. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention. a. Erythema on pressure points – requires prompt relief of pressure and additional measures to protect the skin from further breakdown b. Lower extremity pulse strength of 2+ - expected finding c. Fluid intake of 3000 mL per day – clients should drink 2.5-3L a day d. A bowel movement every other day – bowel movements less frequent than 3x/week indicate constipation and need for intervention 11. 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? a. Gently shake the container of medication prior to administration – nurse should gently shake the liquid to ensure the medication is mixed b. Transfer the medication to a medicine cup – this could risk altering the pre- measured dose c. Place the client in a semi-Fowler's position prior to medication administration – High-Fowler’s to reduce the risk of aspiration d. Verify the dosage by measuring the liquid before administering it – this could risk altering the pre-measured dose 12. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. Check the client for injuries – The 1st action the nurse should take when using the nursing process is to assess for injuries b. Move hazardous objects away from the client – this prevents further injury but not priority c. Notify the provider – not priority d. Ask the client to describe how she felt before the fall – not priority 13. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. Discuss the risk factors for colon cancer – client might perceive as challenging or argumentative b. Focus teaching on what the client will need to do in the future to manage his illness – focus on teaching on the present c. Provide the client with written information about the phases of loss and grief – unless requested by client, this is not an optimal time for teaching/learning d. Reassure the client that this is an expected response to grief – during the anger stage, the nurse should support the client and ensure him that this psychosocial adaptation response is expected to cancer diagnosis. 14. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? a. I'll get a blood sample from you and send it for a screening test – blood tests do not detect colorectal cancer. One option for screening is a double contrast barium enema every 5 years b. Beginning at age 60, you should have a colonoscopy – colorectal cancer screening for clients at average risk begins at age 50. Once option for screening is a colonoscopy every 10 years c. You should have a fecal occult blood test every year d. The recommendation is to have a sigmoidoscopy every 10 years – One option for screening is a flexible sigmoidoscopy every 5 years 15. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? a. Use the complete name of the medication magnesium sulfate – nurses and providers to write medication name when documenting to avoid misinterpretation (Institute for Safe Medication Practices) b. Delete the space between the numerical dose and the unit of measure – include a space to avoid confusion c. Write the letter U when noting the dosage of insulin – “unit(s)” as the correct term for use in documentation d. Use the abbreviation SC when indicating an injection – “subcut” or “subcutaneously” as the correct terms for documentation 16. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply) a. Place the client in a room with negative-pressure airflow – TB is airborne b. Wear gloves when assisting the client with oral care – standard precautions which the nurse must adhere to for all clients regardless of diagnosis. The nurse should wear gloves whenever her hands might come in contact with body fluids (including saliva) c. Limit each visitor to 2-hour increments – no limitations for visitors. The nurse should limit the client’s presence outside the room and have them wear a surgical mask outside the room d. Wear a surgical mass when providing client care – nurse should wear N95 respirator for airborne precautions e. Use antimicrobial sanitizer for hand hygiene – The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client with TB. The nurse should also wash her hands with soap and water when her hands have visible soiling. 17. A charge nurse is discussing the responsibility of nurses caring for clients who have C. Diff infection. Which of the following information should the nurse include in the teaching? a. Assign the client to a room with a negative-airflow system – only private room b. Use alcohol-based hand sanitizer when leaving the client's room – soap and water bc alcohol-based hand sanitizer does not kill C. Diff c. Clean contaminated surfaces in the client's room with a phenol solution – phenol solution cleans bacteria and fungi but does not kill C. Diff spores d. Have family members wear a gown and gloves when visiting – nurses are responsible for ensuring that family members & caregivers wear a gown and gloves to prevent transmission. 18. A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. Ensure sterilization of non-disposable items with ethylene oxide – Ethylene oxide can cause an allergic reaction. The nurse should rinse any items that have this type of sterilization before use. b. Wrap monitoring cords with stockinette and tape them in place – Many monitoring devises and cords contain latex. The nurse should prevent any contact of these cords and devises with skin by covering them with a nonlatex barrier (stockinette and tape) c. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication – The nurse should use a stopcock for injecting medications. Cleansing a latex item will not remove the latex protein d. Wear hypoallergenic latex gloves that contain powder – hypoallergenic latex gloves contain latex and can still provoke an allergic reaction response. Power is especially harmful because it contains the latex protein. The nurse should make sure all members of the client-care staff wear nonlatex gloves. 19. A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? a. Drink a cup of hot cocoa before bedtime – cocoa has caffeine b. Exercise 1 hour before going to bed – exercising within 2 hours of bedtime can interfere with sleep c. Use progressive relaxation techniques at bedtime – decreases stress and reduces muscle tension d. Reflect on the day's activities before going to bed – can cause stress and worry 20. 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. a. Withdraw the correct dose of regular insulin from the bottle (3) b. Inject 10 units of air into the bottle of NPH insulin (1) c. Withdraw the correct dose of NPH insulin from the bottle (4) – prevent contaminating the regular insulin with NPH insulin d. Inject 5 units of air into the bottle of regular insulin (2)