ATI fundamentals 2016 B – Flashcards
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A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
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decrease in heart rate
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A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?
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1. A 16 yo client who is married 2. a 27 yo who has schizophrenia 3. an adoptive parent who brings in his 8 yo son 4. a 17 yo mother who brings in her toddler.
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A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
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Apply intermittent suction when withdrawing the catheter.
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A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client ass to his diet?
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Avocados
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A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
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assess the client for orthostatic hypotension
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A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
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place a client who has tuberculosis in a room with negative-pressure airflow.
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A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?
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talk directly to the client, instead of the interpreter, when speaking
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A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
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bladder scan shows 525mL of urine
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a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
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wash her hands before and after contact with the client
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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?
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Compare prescriptions with medications the client received during hospitalization.
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A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
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Thread the IV catheter so that the hub rests at the insertion site.
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A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
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Cheddar cheese
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A nurse is providing discharge teaching to 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?
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1. Check the cord routinely for frays or tearing 2. consider purchasing a generator for power backup 3. observe for signs of hypoxia
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A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
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Check the IV tubing for obstruction
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A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
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evaluate electrolytes
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A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?
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Insert the IV catheter without using a tourniquet
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A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?
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Second intercostal space at the left sternal boarder
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A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?
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elevate the head of the client's bed
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A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
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"We can talk about advance directives, and I can also give you some brochures about them."
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A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
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"Is your pain sharp or dull?"
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A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
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breath sounds
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A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?
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albumin level of 3g/dL
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a nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?
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bruises on the arms in various stages of healing
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A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
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Notify the nursing manager
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A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter
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Swelling and coolness are observed at the IV site
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A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
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evacuate the client
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A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?
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"We need to document the exact medication you were taking because you might be allergic to it."
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A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
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a client who has asthma
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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?
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Pad the client's wrist before applying the restraints.
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A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
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Make sure two fingers can fit under the sleeves.
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A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr?
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107mL/hr
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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?
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Make sure the client wears a mask when outside her room if there is construction in the area?
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A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
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administer the medication with the needle at a 45 degree angle
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A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
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examine personal values about the issue
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A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
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8 oz ice chips
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A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
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practice sessions
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A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
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use tracheostomy covers when outdoors
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A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?
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"We will apply oxygen through a tube in your nose"
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A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
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regulate oxygen via nasal cannula at a flow rate no more than 6l/min
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A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
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1. Assist the client with a partial bed bath 2. Measure the client's BP after the nurse administers an antihypertensive medication 3. use a communication board to ask what the client wants for lunch
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A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?
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The nurse opens the sterile field on a wet surface
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A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
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an uneven shape
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A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
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"I am available to talk if you should change your mind."
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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?
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wrap blankets around all four side rails
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A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?
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abdominal cramping
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A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
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A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
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A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.
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normal breath sounds
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A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
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The family member washed out the feeding bag with warm water once every 24 hours.
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A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?
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An x-ray shows the end of the tube above the pylorus
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A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
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Clean sutures along the incision site.
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A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
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1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body
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A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
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tap just bellow the kneecap
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A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?
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administer pain medication 45 min before changing the client's dressing
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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?
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"when descending stair, I will first shift my weight to my right leg."
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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
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"It might help me to listen to music while im lying in bed."
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A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
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droplet
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
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during the admission process
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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?
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"People in middle adulthood often find satisfaction in nurturing and guiding young people."
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A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document?
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"client was found lying on floor."
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A nurse is caring for a patient with behind the ear hearing aid.
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remove before shower
