ATI RN Fundamentals Online Practice 2019 A (updated) correctly answered

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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? a. remove the outer cannul... a cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide b. use tracheostomy covers when outdoors -tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a. the client is receiving formula at room temperature b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the client's caregiver washes out the feeding bag with warm water once every 24 hr d. the client's caregiver flushes the tubing with water before and after administering medications c. the client's caregiver washes out the feeding bag with warm water once every 24 hr -feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. "You would have so much more time to spend with your family." b. "You should consider getting a part-time job or doing volunteer work." c. "Let's talk about how the change in your job status will affect you." d. "Why wouldn't you want to retire and relax?" c. "Let's talk about how the change in your job status will affect you." -this response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement 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? a. "Is your pain constant or intermittent?" b. "What would you rate your pain on a scale of 0 to 10." c. "Does the pain radiate?" d. "Is your pain sharp or dull?" d. "Is your pain sharp or dull?" -asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. discuss the risk factors of 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 d. 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 explain that this is an expected reaction to a cancer diagnosis 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? a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails a. pad the client's wrist before applying the restraints -the use of restraints without padding can abrade the client's skin, resulting in client injury A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client uses nonacetone nail polish remover c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment b. the client uses nonacetone nail polish remover -the client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher. c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment b. the client identifies the location of a fire extinguisher. - The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them 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? a. insert the suction catheter while the client is swallowing b. apply intermittent suction when withdrawing the catheter c. place the catheter in a location that is clean and dry for later use d. hold the suction catheter with her clean, nondominant hand b. apply intermittent suction when withdrawing the catheter -the nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. administer the medication with the needle at a 45 degree angle b. administer the medication into the client's nondominant arm c. pull the client's skin laterally or downward prior to administration d. massage the injection site after administration a. administer the medication with the needle at a 45 degree angle -the nurse should insert the needle at a 45-90 degree angle for a subQ injection -the nurse should administer enoxaparin into the abdomen at least 2 inches from the umbilicus -the nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? a. advocacy ensures clients' safety, health, and rights b. advocacy ensures that nurses are able to explain their own actions c. advocacy ensures that nurses follow through on their promises to clients d. advocacy ensures fairness in client care delivery and use of resources a. advocacy ensures clients' safety, health and rights -advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down and back toward her head d. tilt the clients head backward for 5 min a. press gently on the tragus of the client's ear -pressing gently on the tragus of the ear will help the medication get into the inner ear A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. use a bed exit alarm system b. raise four side rails while the client is in bed c. apply one soft wrist restraint d. dim the lights in the client's room a. use a bed exit alarm system -the nurse should identify that the client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. make sure the client's room has at least six air exchanges per hour b. make sure the client wears a mask when outside her room if there is construction in the area c. place the client in a private room with negative-pressure airflow d. wear an N95 respirator when giving the client direct care b. make sure the client wears a mask when outside her room if there is construction in the area -an allogenic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment -a protective environment requires at least 12 air exchanges per hour -the nurse should place the client in a private room that provides positive-pressure airflow -the nurse should wear a N95 respirator mask when caring for clients who require airborne precautions, not a protective environment. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a. "I can place an extension cord across my living room to plug in my TV." b. "I will hire someone to trim that tree that hangs low over the stairs of my front porch" c. "I will place my alarm clock on my bedroom dresser across the room." d. "I will replace the old throw rug in my kitchen with a new one." b. "I will hire someone to trim that tree that hangs low over the stairs of my front porch." -clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a. combine client care tasks when caring for multiple clients b. wait until the end of the shift to document care c. use the planning step of the nursing process to prioritize client care delivery d. allow for interruptions in tasks to discuss client care issues with colleagues c. use the planning step of the nursing process to prioritize client care delivery -setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management A nurse is planning to insert a peripheral IV catheter for an older adult. Which of the following actions should the nurse plan to take? a. insert the catheter at a 45 degree angle b. place the client's arm in a dependent position c. shave excess hair from the insertion site d. initiate IV therapy in the veins of the hand b. place the client's arm in a dependent position -the nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. -generally, the nurse should insert the catheter at a 10-30 degree angle; for an older adult 10-15 degrees is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue -the nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. -the nurse should avoid using the fragile veins of an older adult's hands because the loss of subQ tissue can allow those veins to roll away from the needle. Also, having an IV in the client's hand can interfere with the client's performance of ADLs and can diminish the older adult's sense of independence and mobility. 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? (Select all that apply.) a. assist the client with a partial bed bath b. measure the client's BP after the nurse administers an antihypertensive medication c. test the client's swallowing ability by providing thickened liquids d. use a communication board to ask what the client wants for lunch e. irrigate the client's indwelling urinary catheter a. assist the client with a partial bed bath, b. measure the client's BP after the nurse administers an antihypertensive medication, d. use a communication board to ask what the client wants for lunch A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. a lesion with uniform pigmentation b. a new appearance of petechiae c. a mole with an asymmetrical appearance d. the presence of a papule c. a mole with an asymmetrical appearance -an uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part. -variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. -petechiae are capillaries that have bust under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. -papules are solid elevations that are palpable in the skin and are less than 1 cm in size. They are not an expected indication of a skin malignancy. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. numbness of the extremities b. bradycardia c. positive Chvostek's sign d. abdominal cramping d. abdominal cramping -this client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea. -numbness of the extremities is a manifestation of hyperkalemia -tachycardia is a manifestation of hyponatremia along with hypovolemia -a positive Chvostek's sign is a manifestation of hypomagnesemia and hypocalcemia A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a. critical pathway b. situation, background, assessment, and recommendation (SBAR) c. transfer report d. medication administration record (MAR) b. situation, background, assessment, and recommendation (SBAR) -SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report -the nurse should use a transfer report when the client is moving from one health care area or facility to another 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? a. during the admission process b. as soon as the client's condition is stable c. during the initial team conference d. after consulting with the client's family a. during the admission process -discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility -the nurse should only consult with the client's family if the client gives the nurse permission to share that information A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? a. "We would consult the person appointed by your health care proxy to make decisions." b. "We would give you oxygen through a tube in your nose." c. "You would be unable to change your previous wishes about your care." d. "We would insert a breathing tube while we evaluate your condition." b. "We would give you oxygen through a tube in your nose." -oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula -intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will -clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives 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 d. have the client take sips of water to promote insertion of the NG tube into the esophagus -taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea -the client should be sitting in high-fowlers position with the end of the bed elevated to 90 degrees to reduce the risk of aspiration -the nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client -the nurse should not apply suction to until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client 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. -place a name tag on the body -ask the client's family members if they would like to view the body -obtain the pronouncement of death from the provider -wash the client's body -remove tubes and indwelling lines -obtain the pronouncement of death from the provider -remove tubes and indwelling lines -wash the client's body -ask the client's family if they would like to view the body -place a name tag on the body A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. insert the needle at a 15 degree angle b. aspirate for blood return prior to administration c. administer the medication into the abdomen d. massage the site following the injection c. administer the medication into the abdomen -the nurse should instruct the client to administer the medication into the abdomen at least 5 cm from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subQ tissue -the nurse should instruct the client to insert the needle at a 45-90 degree angle to administer the medication into the subQ tissue -the nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising -the nurse should instruct the client not to massage the site because this can cause tissue damage and bruising [Show More]

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