ATI Fundamentals with reasoning – Flashcards

A nurse is caring for a client who requires 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. I had a bowel movement but was unable to save the urine B. I have a specimen in the bathroom from about 30 minutes ago C. I flushed what I urinated at 7am. I have saved all urine since D. I drink a lot, so I will fill up the bottle and complete the test quickly

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 B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

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 B. A nurse asks a nurse from another unit to assist with her documentation 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 D. A nurse discusses the client's status with the physical therapist that is caring for the client at the client's bedside

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic 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 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

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 B. Measure urine output C. Monitor blood pressure readings D. Monitor serum electrolyte levels

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 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

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 B. Apply a vibrating tuning fork to the client's forehead C. Have the client stand with her arms at her side and her feet together D. Perform direct percussion over the area of the kidneys

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 B. Expect the client to have difficulty understanding the information C. Avoid references to the client's past experiences D. Keep the learning session private and one-on-one

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 B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics

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 B. Lower-extremity pulse strength of 2+ C. Fluid intake of 3,000 mL per day D. A bowel movement every other day

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-Fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administering it

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 B. Move hazardous objects away from the client C. Notify the provider D. Ask the client to describe how she felt before the fall

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 B. Focus teaching on what the client will need to do in the future to manage his illness C. Provide the client with written information about the phases of loss and grief D. Reassure the client that this is an expected response to grief

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 B. Beginning at age 60, you should have a colonoscopy C. You should have a fecal occult blood test every year D. The recommendation is to have a sigmoidoscopy every 10 years

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 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

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 B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2-hour increments D. Wear a surgical mass when providing client care E. Use antimicrobial sanitizer for hand hygiene

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 B. Use alcohol-based hand sanitizer when leaving the client's room C. Clean contaminated surfaces in the client's room with a phenol solution D. Have family members wear a gown and gloves when visiting

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 B. Wrap monitoring cords with stockinette and tape them in place C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication D. Wear hypoallergenic latex gloves that contain powder

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 cu of hot cocoa before bedtime B. Exercise 1 hour before going to bed C. Use progressive relaxation techniques at bedtime D. Reflect on the day's activities before going to bed

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 B. Inject 10 units of air into the bottle of NPH insulin C. Withdraw the correct dose of NPH insulin from the bottle D. Inject 5 units of air into the bottle of regular insulin

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A. Insert an implanted port B. Close a laceration with sutures C. Place an endotracheal tube D. Initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube B. Remove the NG tube if the client begins to gag or 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 into the esophagus

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity