ATI Fundamentals Proctored Exam Patient Care and Safety Part 3

A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
A.choose the most proximal site on the extremity selected
B. apply a cool compress for several minutes before insertion of the IV catheter
C. place the tourniquet below the proposed insertion site
D. place the extremity in a dependent position

A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching?
A.Your partner must be present when you sign the advance directives
B. You will receive written information about advance directives prior to signing
C. You are required to sign advance directives prior to surgery
D. Your provider must sign the advance directives before surgery

A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
a. Remove one restraint at a time

A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
A. Dilute each crushed medication with sterile water
B. Mix the medication together in a single syringe
C. Flush the NG tube with 5mL of sterile water prior to administration D. Combine the medication with the formula in the feeding bag

A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?
a. Toilet the client every 4hr while the client is awake
b. Apply a moisture barrier in a thick layer to vulnerable skin areas
c. Cleanse the skin with antibacterial soap and hot water after each incontinence episode
d. Reduce the clients daily fluid intake

A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?
A. Complete an incident report
B. Obtain the client's vital signs
C. Document the fluid infusion in the client's chart
D. Report the incident in to the unit manager

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA)
- I need to check my medications for expiration dates
- I will use the grab bars when getting in and out of the bathtub
- I need to have a fire escape plan with my family

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, I trust my doctor, but I don't understand what is meant by resecting my intestine. Which of the following actions should the nurse take?
a. notify the provider

A nurse is discussing the stages of general adaptation syndrome with a newly
licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?
A. Dilated pupils
B. Physical exhaustion
C. Bradycardia
D. Depression

A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
A. Unplug the pump
B. obtain a replacement pump
C. Notify the biomedical department to fix the pump
D. Label the pump with a defective equipment sticker

A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective?
A. The client's skin on the lower back is intact without redness
B. The client's laughing at a television show
C. The client states that he is able to concentrate while eating D. The clients's vital signs are within the expected reference range

A nurse is preparing a sterile field to assist with suturing a clients laceration. Which of the following actions should the nurse plan to take?
A. Pour the sterile solution with the bottle 20cm(8in) above the sterile bowl
B. Hold the bottle of sterile solution so that the label is facing the palm of the hand
C. Place the lid of the sterile solution bottle face down on the sterile drape
D. Apply sterile gloves before opening the bottle of sterile solution

A nurse is caring for a client who is scheduled to have his alanine amino transferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
A. This test will determine if your heart is performing properly
B. This test will indicate if you are at risk for developing blood clots
C. This test is used to check how your kidneys are working
D. This test will provide information about the function of your liver

a nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?
A. Ensure that the provider signs the prescription
B. Write down the complete prescription
C. Read back the prescription to the dr
d. Document the prescription as a telephone prescription in the medical record

A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes?
A. Petechiae on the client's right anterior thigh
B. Flat rash on the client's ankle
C. non-palpable macule on the client's left shoulder
D. Non Blanching darkened area over the client's trochanter

A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?
A. After insert the hearing aid, i will turn it up as high as it will go
B. I should leave the battery in the hearing aid when i take it out to sleep
C. I will need to get a new hearing aide every year
D. I should gradually increase the time that i wear the hearing aid

A nurse is preparing to collect a specimen from a client. Which of the following actions should the nurse take?
a. Collect the sputum specimen in the morning

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?
A. Thirst
B. Confusion
C. Coolskin
D. Shakiness

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?
a. Decreased sense of balance

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?
A. Report any discrepancy in the court total of the controlled substance after administration
B. Place the assisted portion of the controlled substance in the sharps container
C. Verify the count total of the controlled substance after removing the amount needed
D. Ask a second nurse to report her signature when wasting any unused portion of the controlled substance

A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, i'm
worried about the bag. Which of the following is an appropriate response by the nurse?
A. You are worried about having to wear a colostomy bag?
B. Have you ever known someone who has a colostomy
C. Let's wait until after the surgery to discuss your concerns about your colostomy
D. The surgeon will only place the colostomy if it is necessary

A nurse is preparing to administer medication to a client. Which of the following should the nurse use as a client identifier?
A. Age
B. Room number
C. Photograph
D. Bed number

A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the injection?
A. Discard the needle in a puncture proof container
B. Place the needle on the bedside table
C. Remove the needle from the syringe
D. Recap the needle before disposal

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?
A. Assist the client in setting goals to make the change
B. Develop a plan for the client to integrate the change into her lifestyle
C. Present information about the benefits of quitting smoking
D. Recommend small changes for the client to make to change her behavior overtime

A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?
A. I will keep my legs crossed while sitting
B. I will perform exercises once every 4 hours while i am awake
C. I should massage my legs when they hurt
D. I should limit the time that i spend sitting in a chair

A nurse is documenting client care. Which of the following abbreviations should the nurse use?
a. BRP for bathroom privileges

A nurse who is documenting information in a clients electronic medical record is asked to assist with an emergency. Which of the following actions should the nurse take?
A. Ask another nurse to monitor the computer
B. Turn the computer off
C. Move the computer to a secure place
D. Print out the current notes to finish later

A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?'
A. Diarrhea one time in a 24 hour period
B. A weight gain of 0.91kg(2Ib) in 2 days
C. A gastric residual of 300mL at the end of the shift
D. A blood glucose level of 110 mg/dL

A nurse is planning care for a female client who has an indwelling urinary catheter.Which of the following actions should the nurse include in the plan?
A. Tape the catheter to the lower abdomen
B. Attach the drainage bag to the side rails of the bed
C. Keep the drainage bag below the level of the bladder
D. Empty the drainage bag when it is three quarters full

A nurse is reviewing the medical record for a newly admitted client. Which of thefollowing laboratory values should the nurse report to the provider?
A. Sodium 140
B. Potassium 1.8
C. Magnesium 1.9
D. Calcium 6.5

A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220Ib. How many mg should the nurse administer? (Round to the nearest whole number.Use a leading zero if it applies. Do not use trailing zero).
DOSAGE CALCULATION

A nurse is caring for a client who tells the nurse, since I retired, I have a lot of time on my hands and nothing to do. I guess nobody needs me. Which of the following responses should the nurse make?
A. If i were you, i would volunteer my time
B. Do you have family members you can visit
C. You need to realize that you have valuable skills to offer others
D. Tell me about some hobbies you enjoy

A nurse is caring for a client who has an NG tube and has repeatedly pulled it out.
The nurse should identify that which of the following findings indicates a need for restraints?
A. The client's family is unable to stay with the client
B. The client becomes confused at night
C. The client gets out of bed to use the bathroom frequently
D. The client is assigned a room near the nurses station

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation?
A. No changes noted to the wound from previous nursing notes
B. Client pre-medicated with MSO4 sunq prior to dressing change
C. The wound seems clean and does not appear to be infected
D. New dressing applied as prescribed, no drainage on old dressing

a nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?
A. Place the clients arms at their sides
B. Flex the client's knees
C. Place the client at the side of the bed nearest the direction they will be turned
D. Roll the client as one unit in a smooth continuous motion.

A nurse is caring for a client who has TB. which of the following precautions should the nurse plan to implement when working with the client?
a. airborne

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside?
a. Oral suction equipment and oral airway.

A nurse is providing teaching to the family of a client who is at the end stage of life. Which of the following client manifestations should the nurse instruct the family to expect?
A. Increased periods of wakefulness
B. Altered breathing patterns
C. Increased salivation
D. Warm and dry extremities

A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take?
a. recommend an interpreter who is the same gender as the client.

A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?
a. Aspirate residual volume every 4 hr

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 IV therapy?
a. The cephalic vein in the left distal forearm

A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet?
a. Plain yogurt

A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?
a. Schedule the client as the first procedure

Type 2 diabetes mellitus patient with corns and calluses.
a. I can apply lotion to soften calluses as long as i don't put lotion between my toes

A nurse is caring for a male client who has a prescription for intermittent catheterization with a coude catheter. Which of the following images show the type of catheter the nurse should use?
a. The picture with the curled end of the catheter

A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first?
A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to a breast cancer support group
C. identify the impact of the mastectomy on the client's body image
D. encourage the client to assist with her dressing change

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Place them in order of performance. Use all steps)
- 1. Provide adequate lighting to inspect the abdomen
- 2. Listen to the abdomen arteries using the bell of a stethoscope
- 3. Percuss all four quadrants of the abdomen to measure sound quality
- 4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into
the abdomen
- 5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen

a nurse working on a medical surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel?
a. assisting with ambulation for a client who has a pulmonary infection.

A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first?
a. Inject air into the short acting insulin vial.

A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority?
a. Develop a list of goals