(Test Bank) Ati Rn Fundamentals Proctored Test Bank Versions Latest 2021 Over 2000 Q A

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ATI RN Fundamentals 1. a nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responsesshould the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "beginning at age 60, you should have a colonoscopy." C. "you should have a decal occult blood test every year." D. "the recommendation is to have a sigmoidoscopy every 10 years." "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for screening is a fecal occult blood test annually. 2. a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the followingintervention should the nurse take first? A. suction the client's airway B. administer a bronchodilator C. increase the humidity in the client's room D. assist the client to an upright position assist the client to an upright position When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright im proves gas exchange and prevents pressure on thediaphragm from abdominal organs. 3. 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 B. transfer the medication to a medicine cup C. place the client in a semi -fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication ismixed. 4. a nurse is planning care to improve self-feeding for a client who has visionloss. which of the following interventions should the nurse include in the plan of care? A. tell the client which food she should eat first B. provide small -handle utensils for the client C. thicken liquids on the client's tray D. use a clock pattern to describe food on the client's plate Use a clock pattern to describe food on the client's plate. Use a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location of the food on the plate by using a clock patternallows the client to have greater independence during meals. 5. a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a program of regular physical activity. which of the following types of activity should the nurse recommend? A. walking briskly B. riding a bicycle C. performing isometric exercises D. engaging in high -impact aerobics walking briskly Weight -bearing exercises are essential for maintaining bone mass, which helps toprevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. 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 mornin g." 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." "I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing thebest time for him to learn. 7. a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identifyas an indication that the client understands how to manage this therapy at home? A. "I'll make sure that, when my friend comes by, she smokes at least 6 feetaway from my oxygen tank." B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen." C. "I'll check the wires and cables on my TV to make sure they are in goodworking order." D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." "I'll check the wires and cables on my TV to make sure they are in good workingorder." Oxygen is a highly flammable gas. The client should make sure any electricalequipment in the room where she is using supplemental oxygen is functioningproperly so it does not create any electrical sparks. 8. a nurse is caring for a client who is reporting difficulty falling asleep. whichof the following measures should the nurse recommend? A. drink a cup of hot cocoa before bedtime B. exercise 1 hr before going to bed C. use progressive relaxation techniques at bedtime D. reflect on the day's activities before going to bed Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscletension. 9. a nurse is assisting a client who is postoperative with the use of an incentivespirometer. into which of the following positions should the nurse place theclient? A. side-lying B. supine C. semi -fowlers D. trendelenburg Semi -Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows formaximum expansion of the lungs. 10. a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requiresfurther intervention? A. erythema on pressure points B. lower -extremity pulse strength on 2+ C. fluid intake of 3,000 mL per day D. a bowel movement every other day Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additionalmeasures to protect the skin from further breakdown. 11. a nurse is caring for a client who requires a 24-hour urine collection. which of the following statement by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushes what I urinated at 7 am and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the txt quickly." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and saveall subsequent voidings. 12. a nurse is caring for a client who has herpes zoster and asks the runs aboutthe use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture Acupuncture The nurse should inform the client that the use of acupuncture is contraindicatedfor a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection. 13. a nurse is preparing to transfer a cli ent who has right -sided weakness fromthe bed to a chair. in what order should the nurse take the following actionsto assist the client? 1. ask the client is he can bear weight 2. use the stand -pivot technique to move the client to the chair 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 1. ask the client is he can bear weight 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 2. use the stand -pivot technique to move the client to the chair 14. a nurse is preparing to administer an injection of an opioid medication to aclient. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take? A. ask another nurse to observe the medication wastage B. notify the pharmacy when eating the medication C. lock the remaining medication in the controlled substance cabinet D. dispose of the vial with the remaining medication in a sharps container Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlledsubstance. 15. a nurse is preparing a herparing infusion for a client who was hospitalizedwith deep - vein thrombosis. the orders read: 25,000 units of heparin in 250mL of 0.9% sodium chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole number) 8mL/hr 16. a nurse is caring for a client who has a prescription for 5 units of regularinsulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure. 1. inject 5 units of air into the bottle of regular insulin 2. withdraw the corre ct dose of NPH insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 4. withdraw the correct dose of regular insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 1. inject 5 units of air into the bottle of regular insulin 4. withdraw the correct dose of regular insulin from the bottle 2. withdraw the correct dose of NPH insulin from the bottle 17. a nurse is caring for a client who is postoperative and refused to use anincentive spirometer following major abdominal surgery. which of the following is the nurse's priority action? A. request that a respiratory therapist discuss the technique for incentive spirometer B. determine the reasons why the client is refusing to use the onetime spirometer C. document the client's refusal to participate in health restorative activities D. administer a pain medication to the client Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assessthe client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment. 18. a nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." which of the following components ofthe prescription should the runs question? A. the medication B. the route C. the dose D. the frequency The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. 19. 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 preventskin breakdown? A. place the client in high -flowers position B. increase the client's intake of carbohydrates C. massage the reddened areas with unscented lotion D. have the client use a trapeze bar when changing positions Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the clientavoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure - ulcer development. 20. a nurse has accepted a verbal prescription for three 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 on the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg 0.3 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. 21. a nurse is caring for a client receiving fluid through a peripheral IV catheter.which of the following filings at the IV site should the nurse identify as infiltration? A. purulent exudate B. warmth C. skin blanching D. bleeding Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration. 22. a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse planto take? A. dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe C. push the syringe plunger gently when feeling resistance D. flush the tube with 15 mL of sterile water Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feedingtube with 30 to 60 mL of sterile water following the administration of the last medication. 23. a nurse is planning an education session for an older adult client who hasjust 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 B. expect the client to have difficulty understanding the information C. avoid references to the lento's past experiences D. keeping the learning session private and one-on-one Allow extra time for the client to respond to questions. Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to askquestions and absorb the information. 24. a nurse is evaluating a client's use of a cane. which of the following actionsshould the nurse identify as an indication of correct use? A. the top of the cane is parallel to the client's waist B. when walking, the client move the cane 46 cm (18 in) forward C. the client holds the cane on the stronger side of her body D. the client moves her stronger limb forward with the cane The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increasesupport and maintain alignment. 25. a nurse is caring for a client who has had his diet prescription changed to amechanical soft diet. which of the following food items should the nurse remove from the client's breakfast tray? A. smoothie B. sliced banana C. pancakes D. sunny side up (fired) eggs sunny side up (fired) eggs Evidence -based practice indicates the nurse should remove fried eggs from theclient's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item. 26. a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? A. "they allow the court to overrule an adult client's refusal of medical treatment." B. "they indicate the form of treatment a client is willing to accept in theevent of a serious illness." C. "the permit a client to withhold medical information from heath care personnel." D. "they allow heath care personnel in the emergency department tostabilize a client's condition." "They indicate the form of treatment a client is willing to accept in the event of aserious illness." Advance directives include a living will, which permits the client to directtreatment in the event of a terminal illness. 27. 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 indicationthat the client has developed thrombophlebitis? A. bladder distention B. decreased blood pressure C. calf swelling D. diminished bowel sounds Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations ofthrombophlebitis, a common complication of immobility. 28. a nurse is caring for a client who report pain. when documenting the qualityof the client' s pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "the pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "the pain makes me feel nauseous. " "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in herown words. 29. a nurse is administering an otic medication to an older adult client. which ofthe following actions should the nurse take to ensure that the medication reaches the inner ear? A. press gently on the tarsus of the client's ear B. pack a small piece of cotton deep into the cent's ear canal C. move the client's auricle down and back toward her head D. tilt the client's head backward for 5 min Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into theinner ear. 30. a nurse in a long -term care facility is planning to perform hygiene care for anew resident. which of the following assessment questions is the nurse's priority before beginning this procedure? A. "when do you usually bathe, in the morning or evening?" B. "do you prefer a bath or a shower?" C. "at what temperature do you prefer your bath water?" D. "are you able to help with you hygiene care?" "Are you able to help with your hygiene care?" The greatest risk to the client' s safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, thenurse's priority is to assess the client's ability to assist with her hygiene care. 31. a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following informationshould the nurse include in the teaching? A. assign the client to a room with a negative air-flow system B. use alcohol -based hand sanitizer when leaving he client's room C. clean contaminated surfaces in the client's room with a phone solution D. have family members wear gown and gloves when visiting Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregiversmust also wear gowns and gloves. 32. a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity B. pupil clarity D. visual fields E. visual acuity 33. a nurse is caring for a client who is expressing anger over his diagnosis ofcolorectal cancer. which of the following actions should the nurse take? A. discuss the risk factors for colon cancer B. focus teaching on what the client will need to do in the future to managehis illness C. provide the client with written information about the phases of loss andgrief D. reassure the client that this is an expected response to grief 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 ensure him that this is an expected reactionto a cancer diagnosis. 34. a nurse is planning to insert a peripheral IV catheter for an older adultclient. which of the following actions should the nurse plan to take? A. insert the other at a 45º angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiative IV therapy in the veins of the hand place the client's arm in a dependent position The nurse should place the client's arm in a dependent position because the veinswill dilate due to gravity. 35. a nurse is lifting a bedside cabinet to move it closer to a client who is sittingin a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? A. bend at the waist B. keep his feet close together C. use his back muscles for lifting D. stand close to the banner when lifting it Stand close to the cabinet when lifting it. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. 36. a nurse is providing care to four clients. which of the following situationsrequires the nurse to complete an incident report? A. a nurse tied a client's restraints straps to the moveable part of the bedframe B. an assuétude personnel placed a surgical mask on a client who has TBbefore transporting her to radiology C. a nurse administer a medication to a client 30 min before the dose is due D. a client who has an IV infusion pump receives an additional 250 mL of IVfluid A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management todetermine actions to take to prevent further similar incidents. 37. a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should thenurse manger plan to include in the teaching? A. "use the complete name of the medication magnesium sulfate." B. "delete the space between the numerical dose and the unit of measure." C. "write the letter U when noting the dosage of insulin." D. "use the abbreviation SC when indicating an injection." "Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providerswrite the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO 4 as MSO 4, which means morphine sulfate 38. 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 ofthe following precautions should the nurse take? A. ensure sterilization of non disposable items with ethylene oxide B. wrap monitoring cords with stockinette and tape them in place C. cleanse latex pots on IV tubing with chlorohexidine before injection medication D. wear hypoallergenic latex gloves that contain powder Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent anycontact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. 39. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take wheninserting the NG tube? A. position the client with the head of the bed elevated to 30º prior toinsertion of the NG tube B. remove the NG tube if the client begins to gag of choke C. apply suction to the NG tube prior to insertion D. have the client take sips of water to promote insertion of the NG tube intothe esophagus Have the client take sips of water to promote insertion of the NG tube into theesophagus. Taking sips of water as the NG tube passes through the oropharynx will close theepiglottis over the trachea and prevent the tube's passage into the trachea. 40. a nurse is admitting a client who has an abdominal wound with a largeamount of purulent drainage. which of the following types of transitionprecautions hold the nurse initiate? A. protective environment B. airborne precautions C. droplet precautions D. contact precaut ions Contact precautions Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown andgloves during direct contact with this client. 41. a nurse is caring for a client who has a prescription for wound irrigation.which of the following actions should the nurse take? A. wear sterile gloves when removing the old dressing B. warm the irrigation solution of 40.5ºc (105ºF) C. cleanse the wound from the center outward D. use a 20 mL syringe to irrigate the wound Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to preventintroduction of micro - organisms from the outer skin surface. 42. a nurse is caring for a client who requires bed rest and has a prescription foranti embolic stocking. which of the following actions should the nurse take? A. apply the stockings so the creases are on the front of the leg B. apply the stockings while the client's legs are in a dependent position C. remove the stockings at least once per shift D. remove the stockings while the client is sitting in a reclining chair Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client'scirculation and skin integrity. 43. 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 actionsshould the nurse take first? A. rinse the feeding bag with water between feedings B. tell the client to keep the head of the bed elevated at least 30º C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteralformula; therefore, the priority intervention is to keep the head of the bedelevated at least 30° to prevent reflux of the formula backward into the esophagus. 44. a nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene 45. a nurse is responding to a call light and finds a client lying on the bathroomfloor. which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. notify the provider D. ask the client to describe how she felt prior to the fall Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries. 46. a nurse is talking with the partner of an older adult male client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role -performing stress? A. role ambiguity B. sick role C. role overload D. role conflict Role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can perform. 47. a nurse is administering IV fluid to an older adult client. the nurse shouldperform which priority assessment to monitor for adverse effects? A. auscultate lung sounds B. masure urine output C. monitor blood pressure readings D. monitor serum electrolyte levels 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 volumeexcess include moist crackles heard in lung fields, dyspnea, and shortness of breath. 48. a nurse is performing a peripheral vascular assessment for a client. whenplacing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent bloodflow. this sound indicates which of the following? A. narrowed arterial lumen B. distended jugular veins C. impaired ventricular contraction D. asynchronous closure of the aortic and pulmonic valve Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occludedor narrowed arteries. 49. a nurse is completing an admission assessment for a client who reports