ATI FUNDAMENTALS PROCTOR
1. A nurse is teaching an assistive personnel about a upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching?
2. a nurse is assessing a client who is immobile and notices a red area over the client’s coccyx. Which of the following actions should the nurse take?
Change the clients position every 4 hours
Apply petroleum base ointment in the red area
Assess the red area for blanching
Use friction when cleansing the client’s skin
3. a nurse is preparing to insert an iv catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating an IV therapy?
The radial vein on the left wrist
The cephalic vein in the left distal forearm
The basilic vein in the right antecubital fossa
The cephalic vein on the back of the right hand
4. a nurse is preparing to administer a medication into a client by the intradermal route after applying gloves and cleaning the site with an antiseptic swab. In what order should the nurse take the steps to administer the medication? (move steps into box 1- 4 priority)
1.Use a nondominated hand to stretch the skin
2. Insert the needle at an angle
3. inject the medication
4. Withdrawal the needle
5. Activate the needle safety device
5. a nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?
Intake of dietary fiber
Have a fecal occult blood test every 2 years
Reduce intake of red meats
Have a colonoscopy every 3 years
6. a nurse is planning care to prevent skin breakdown for a client who is immobile and is urinary incontinent. Which of the following actions should the nurse include in the plan of care?
Reposition the client every 4 hours
Arrange for an alternating pressure mattress
Apply cornstarch to the skin
Request a prescription for an indwelling urinary catheter
7. a nurse is preparing to apply a condom catheter for a client who is uncircumcised which of the following actions should the nurse plan to take?
Place adhesive tape directly on the penis
Allow 2.5 to 5 m between the end of the catheter and the tip of the penis
Keep foreskin in a retractable position after application of the catheter
Change the condom catheter every 3 days
8. a nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should the include in the teaching? (select all that apply)
Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation
remove from the artificial eye by retracting the upper eyelid
Apply pressure just below artificial eye to break the suction
Clear the artificial eye with hydrogen peroxide before storing
Retract the upper and lower lids to reinsert the artificial eye
9. a nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPPA?
Faxing medical information about the client to a provider’s office
Teaching a client discharge instruction with his partner present
Giving a telephone report to a surgical nurse and sending the client to the surgical suite
Discussing the clients transfer to a long-term care facility with a nurse from another unit
10. a nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first?
Determine areas of resonance across the abdomen using a systematic approach
Expose the clients abdomen to look for changes in appearance
Perform abdominal palpation by pressing gently with the finger pads
Use the diaphragm of the stethoscope to listen for bowel sounds
11. a nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?
Determine the client’s reading ability
Review the use of an artificial larynx
With the client schedule a support session
For the client explain the techniques of esophageal speech
12. a home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)
I will use the bars when getting in and out of the bath tub
I need to check my medications for expiration dates
I need to have a fire escape plan with my family
I will apply tape over frayed areas of electrical cords
I need to set my hot water heater to 140 degrees Fahrenheit
13. a nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?
The client has a symmetrical smile
The client’s tongue is in a midline position
The client turns his head against resistance
The clients pupils constrict and responds to light
14. a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
Offer pain medication
Palpate the abdomen
Auscultate bowel sounds
Administer an antiemetic
15. a nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statements by the clients partner indicates maladaptive coping?
Don’t understand why he can’t get better and return to work
I cook for him at home and work hard to prepare a nutritious meals
I am going to ask my daughter to come and stay for a week
I don’t know if I will be able to meet his physical needs
16. a nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?
Dry gauge
Transparent
Calcium alginate
Hydrogel
17. a nurse is caring for a client who has brain cancer and is transferring to hospice care. The client’s son tells the nurse “I don’t know what to tell my dad if he asks how he is going to die”. Which of the following is an appropriate response from the nurse?
I think you should discuss this with the hospice nurse
18. a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?
I can apply lotion to soften the calluses as long as I don’t put lotion between my toes
I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly
I should soak my feet in warm water daily to soften corns and calluses
I should use an over the counter liquid medication to remove corns
19. a nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Tie the restraints to the side rale
Secure restraints with a square knot
Remove one restraint at a time
Remove the restraints every 3 hours
20. a nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply
Use an N95 respirator while providing client care
Wear a gown and gloves when providing client care
Assign the client to a private room with positive are flow
Wash hands with soap and water after contact with the client
Ensure the client does not receive fresh fruits
21. a nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?
Schedule the client as the first surgical procedure of the day
Cleanse the stoppers with primidone iodine for withdrawing medication
Remove the stop stocks from iv tubing
Ensure the gloves in the surgical suite are powdered gloves
22. a nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?
Offer written instructions in the clients language
Request that an assistive personnel interpret instructions for the client
Use proper medical terms giving instructions to client
Direct verbal discharge instructions to the interpreter
23. a nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?
The clients belief that his needs will be met through education
The nurse explaining the need for education to the client
The client seeking family approval by agreeing to a teaching plan
The nurses empathy about the client having to self-inject
24. a nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?
Maintain a lean body mass
Walk for 30 mins 3 to 5 times a week
Perform water aerobics 3 times each week
Increase intake of vitamin B12
25. a nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?
Heat the formula to 105 degrees Fahrenheit
Flush the tubing with 10 ml of water every 2 hours
Change the tubing every 72 hours
Aspirate residual volume every 4 hours
26. a nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following images indicates the proper method of cleaning a wound site?
27. a nurse is caring for a client who reports a pain level of 5 on a scale of 0- 10. The client informs the nurse that pain medications is not an option for managing pain. Which of the following is an appropriate response by the nurse?
Would you like me to give you a back message
Im sure it will work if you just give it a chance
Why do you think pain medication is not going to help you
You may take any herbal remedies you bring from home
28. a nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?
The client picks up the walker with each step
The client stoops slightly forward when moving the walker
The client stands with her elbows slightly flexed while holding the walker
The client moves the walker ahead 10inches with each step
29. a nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears an assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?
Libel
Defamation of character
Assault
Battery
30. a nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?
Stabilize the vein by applying traction above the insertion site
Engorge the vein by placing the arm in the dependent position
Use friction at the insertion site to increase venous distention
Leave the tourniquet on for 30 to 60 seconds after initial insertion
31. a nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
Prepare the client for a central venous line
Change the PN infusion bag every 48 hours
Administer the PN and fat emulsion separately
Obtain a random blood glucose daily
32. a nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don’t understand what he meant when he said he’ll reset my intestines. Which of the following actions should the nurse take?
Provide brochures about the procedure
Notify the provider
Complete an incident report
Describe the surgery to the client
33. a nurse is caring for a client who is agitated and threating to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts?
False imprisonment
Invasion of privacy
Assault
Negligence
34. a nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take?
35. a nurse Is caring for a client who is 6 hours postoperative abdominal surgery and who is having difficulty voiding. Which of the following actions should the nurse take?
Encourage fluid intake up to 1000 ml daily
Insert an indwelling urinary catheter and connect to gravity drainage
Allow the client to hear running water while attempting to void
Bring the client a bedpan while lying supine
36. a nurse is preparing to use the Z track method to administer iron dextran to a client who has an iron deficiency anemia. The client asks why this method of injection is necessary. Which of the following responses should the nurse make?
Decrease the risk of injecting medication thru the blood vessels
It accelerates medication excretion
It delays medication absorption
It minimizes tissue irritation
37. a nurse on a medical unit is caring for a group of client’s for which of the following tasks should the nurse wear a face shield?
Suctioning a clients tracheostomy tube
Changing the brief of an older adult client who has clostridium difficile infection
Emptying an indwelling catheter bag
Insertion an IV catheter for a client that has peritonitis
38. an adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?
Use the television to mask external noises
Listen to soft music before lying down
Exercise just prior to bedtime
Keep the sleeping environment warm
39. a nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?
Each element has a range 1 to 5 points
The higher the score the higher the pressure ulcer risk
The clients age is part of the measurement
The scale measures six elements
40. a nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
Ensure the client is free of medal objects
Administer 240 ml (8oz) oral contrast before the procedure
Monitor the client for pain in the suprapubic region
Assist the client with a bowel cleansing
41. a nurse in a long term care facility is planning care for 4 client’s. which of the following client’s is at greatest risk of developing a pressure ulcer?
A client who is incontinent of urine 1 to 2 times a day
A client who is receiving enteral tube feedings
Client who requires assistance to transfer from the bed to a chair
Client who is unresponsive to pain stimuli
42. a nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?
Place the cap of the sterile solution inside the sterile field
Don sterile gloves prior to opening sterile dressing supplies
Setup the sterile field above the waist level
Consider 2 inches of the sterile fields boarder to be contaminated
43. a nurse is caring for a client who has a new diagnosis for fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead the medication prescribed by the provider. Which of the following is an appropriate response by the nurse?
I can arrange a referral to a Practioner for traditional Chinese medicine
You should ask your provider if she recommends traditional Chinese medicine
The FDA regulates traditional Chinese medicine
You should try the prescribed medication before choosing an alternative
44. a nurse is teaching newly licensed nurse about the care of a client who has a MRSA infection. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
I will remove my gown before my gloves after client care
I will place the client in a private room
I will tell the client’s visitors to wear a mask when they are within 3 feet away of the client
I will wear an N95 respiratory mask when caring for the client
45. a nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
Eat a light carbohydrate snack before bedtime
Exercise 1 hour before bedtime
Drink a cup of hot cocoa before bedtime
Take a 30 min nap daily
46. a staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?
Use full length side rales on the clients bed
Check on the client frequently while he is in the restroom
Encourage physical activity throughout the day to expand energy
Remove clocks from the clients room
47. a nurse is providing teaching to a client about reducing first effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
I will have my partner help me change positions every 4 hours
I will hold my breath rising from a sitting positing
I will perform my ankle and knee exercises every hour
I will remove my antiembolic stockings while I am in bed
48. to ensure a clients safety a manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. Which of the following roles is the nurse manager functioning?
Client care provider
Client educator
Client advocate
Client case manager
49. a nurse is planning to obtain a blood sample from a client for capillary blood glucose post test. Which of the following should the nurse take to obtain the sample?
The pad of the finger tip
The lateral aspect of the finger
The pinna of the ear
The side of the wrist
50. a nurse enters a clients room an discovers a smoldering fire in the drapes. After moving clients to a safe location which of the following actions should the nurse take next?
Use an extinguisher to put out the fire
Close the doors to the client’s room
Pull the fire alarm
Turn off any electrical equipment in the room
51. a nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first?
Provide the client with a contact number for a diabetes education specialist
Make a copy of the medication record of the reconciliation for the client
Determine whether the client can afford the insulin administration supplies
Obtain printed information about self-administration
52. a nurse is assessing a client who’s therapy has included bedrest for several weeks. Which of the following findings the nurse would identify as priority?
Loss of appetite
Musculoskeletal weakness
Left lower extremity tenderness
Increased heart rate during physical activities
53. a nurse is caring or a client who has a influenza and has isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?
Don protective eye wear before entering the room
Administer metronidazole
Wear a mask when working within 3 ft of the client
Place the client in a negative air pressure flow room
54. a nurse is delegating client’s care to an assistive personnel. Which of the following tasks should the nurse delegate to the AP?
55. a nurse is teaching about home safety with a client . which of the following instructions should the nurse include?
Use electrical tape to secure extension cords next to base boards on the floor
Replace carpet floors with tiles
Unplug electronics by grasping the cord
To use a fire extinguisher, aim high at the top of the flames
56. a nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first?
Elimination needs
Comfort level
Peripheral pulses
Skin integrity
57. a nurse is caring for a client who has a new prescription of inserting a NG tube. Which of the following is the most reliable method for evaluating tube placement?
Obtain an x-ray of the abdomen
Observing the color of the aspiration
Measuring pH of the aspirate
Auscultating the epigastrium while instilling air into the tube
58. a nurse in long term care facility is assessing a client which of the following findings should the nurse recognize as an indication of a fecal impaction?
Hypoactive bowel sounds
No bowel movement for 48 hours
Persistent heart burn
Seepage of liquid stool
59. a nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take?
Cotton tip applicator to clean the inside of the cannula
Soak the outer cannula in warm soapy tap water
Cleanse the skin around the stoma with normal saline
Secure the tracheostomy ties to allow one finger to fit snuggly underneath
60. a charge nurse is monitoring the documentation of the medication by a newly licensed nurse the charge nurse should intervene if the newly licensed nurse uses which of the following abbreviations?
61. a nurse is caring for a client who has a drainage evacuator. Which of the following is a appropriate action by the nurse?
Check the volume of the drainage every 24 hr
Ensure the drainage suction is set on high pressure
Discontinue the drainage when it becomes full
Measure drainage by emptying into a graduated cylinder
62. nurse is preparing to transfer a client is partially weight bearing from the bed to a chair. Which of the following actions should the nurse take?
Position the chair next to the bed at a 90 degree angle
Stand with his feet together when lifting the client
Keep his knees straight when moving the client
Have the client bear weight on the stronger leg
63. nurse is preparing change of shift report after the night shift using ISBAR communication tool . which fof the following data should the nurse include when reporting background information?
Pain rating of 5 on a scale of 0-10
Code status do not resuscitate
Start first dose of penicillin
Blood pressure /92
64. a nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report?
Time of the client’s last bath
Number of family members who hve visited
Effectiveness of the last dose of pain medication
Frequency of previous vital signs
65. nurse is teaching a client how to perform breast self-examination. Which of the following instructions should the nurse include?
Perform BSE 1 week prior to the onset of menses
Palpate I horizontal motion from the outer breast toward the nipple
Squeeze the nipple to see if discharge
Wash and dry each breast prior to palpation
66. nurse is assessing a breath sounds of an adult client who has pneumonia. which of the following actions should the nurse take?
Place the bell of the stethoscope on the clients chest
Instruct the client to sit erect with head tilted back
Ask the client to breath in deeply thru his nose
Follow systemic pattern side to side by moving down the clients chest
67. nurse is assessing a client’s bowel sounds. Which of the following actions should the nurse take
Listen to bowel sounds after performing abdominal palpation
Place diaphragm of stethoscope over each quadrant
Ask client to cough upon auscultating
Auscultate for 2 mins to determine if bowel sounds are active
68. math
69. nurse is caring for a client who is prescribed a special diet the client is concerned that he does not have the resources to purchase the food he needs to adhere to. The nurse should notify which of the following members of the health care team?
70. nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the following statements by the client indicates understanding of the teaching?
I will keep my eyes closed for 5 mins after inserting drops
I will insert the drops in the center of the eye
I will press the inner corner of my eye after insert drops
I will raise my eye lid up while looking down and insert drops
