ATI RN Fundamentals Practice Tests A & B, Exams of Nursing

Download ATI RN Fundamentals Practice Tests A & B and more Exams Nursing in PDF only on Docsity! ATI RN Fundamentals Practice Tests A & B A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I am having mild pain" "The pain is like a dull ache in my stomach" "I notice that the pain gets worse after I eat" "The pain makes me feel nauseous" - "The pain is like a dull ache in my stomach" A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm Extinguish the fire Evacuate the client Confine the fire - Evacuate the client A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distention Urine specific gravity 1.010 Rapid Heart rate Blood pressure 144/82 mmHg - Rapid heart rate A nurse has accepted a verbal prescription for "thee tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? .3 mg 0.3 mg 0.30 mg 3/10 mg - 0.3 mg A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 ml to infuse at 800 units/hour. At what rate should the nurse set the infusion pump? - 8 ml/hour A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5 C (105 F) Cleanse the wound from the center outward Use a 20 ml syringe to irrigate the wound - Cleanse the wound from the center outward A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? Purulent exudate Warmth Skin blanching Bleeding - Skin blanching 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? "When descending the stairs, I will first shift my weight to my right leg" "I should place my crutches 12 inches in front and to the side of each foot" "As I sit down, I will hold one crutch in each hand" "I will make sure the shoulder rests are snug against my armpits" - "When descending the stairs, I will first shift my weight to my right leg" A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Rinse the feeding back with water between feedings Tell the client to keep the head of the bed elevated at least 30 degrees Make sure the enteral formula is at room temperature Wipe the top of the formula can with alcohol - Tell the client to keep the head of the bed elevated at least 30 degrees A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse verify with the provider? Medication name Route of administration Medication dose Frequency of administration - Medication dose A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume" "I shouldn't have trouble keeping the hearing aid in place during exercise" "I expect to hear a whistling sound when I first insert the hearing aid" "I will be sure to remove my hearing aid before taking a shower" - "I will be sure to remove my hearing aid before taking a shower" A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? "Incident report completed" "Client climbed over the side rails" "Client found lying on the floor" "Client was trying to get out of bed" - A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse A nurse asks a nurse from another unit to assist with documentation for a client A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care A nurse discusses a client's status with the physical therapist who is caring for the client - A nurse asks a nurse from another unit to assist with documentation for a client A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficle infection. Which of the following information should the nurse include in the teaching? Assign the client to a room with a negative airflow system Use alcohol based hand sanitizer when leaving the client's room Clean contaminated surfaces in the client's room with a phenol solution Have family members wear a gown and gloves when visiting - Have family members wear a gown and gloves when visiting 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? Gently shake the container of medication prior to administration Transfer the medication to a medicine cup Place the client in a semi fowler's position prior to medication administration Verify the dosage by measuring the liquid before administering it - Gently shake the container of medication prior to administration A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high fowler's position Increase the client's intake of carbohydrates Massage reddened areas with unscented lotion Have the client use a trapeze bar when changing position - Have the client use a trapeze bar when changing position A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate? Ambulating a client who is postoperative Inserting an indwelling urinary catheter for a client Demonstrating the use of an incentive spirometer to a client Confirming that a client's pain has decreased after receiving an analgesic - Ambulating a client who is postoperative A nurse is an acute care facility preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include? Client flow sheet Acuity ratings Current medications Incident reports - Current medications A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" "I blame medical science for not curing me" "Where is my daughter at a time like this?" "Will I ever begin to fell in charge of my life again?" - "What could I have done to deserve this illness?" A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's intake and output record as 120 ml of fluid? 2 cups of soup 1 quart of water 8 oz of ice chips 6 oz of tea - 1 quart of water A nurse is planning teaching for a group of adolescents who each recently had a surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? Role play Group discussions Question-answer meetings Practice sessions - Practice sessions A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mmHg. Which of the following is the measurement in mmHg to which the nurse should inflate the cuff when obtaining blood pressure? 92 mmHg 102 mmHg 122 mmHg 140mmHg - 122 mmHg A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? Assign a staff member to feel the client Provide small handheld utensils for the client Thicken liquids on the client's tray Arrange food in a consistent pattern on the client's plate - Arrange food in a consistent pattern on the client's plate 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? "We can talk about advance directives, and I can also give you some brochures about them" "You should set up a time to talk with your provider about that" "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" "Why do you want to discuss this without your partner here to plan this with you?" - "We can talk about advance directives, and I can also give you some brochures about them" 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? Insert an implanted port Close a laceration with sutures Place an endotracheal tube Initiate an enteral feeding through a gastrostomy tube - Initiate an enteral feeding through a gastrostomy tube A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? Hypotension Weak, thready pulse Slow capillary refill Distended neck veins - Distended neck veins 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? Ensure sterilization of nondisposable items with ethylene oxide Wrap monitoring cords with stockinette and tape them in place Cleanse latex ports on IV tubing with chlorhexidine before injecting medication Wear hypoallergenic latex gloves that contain powder - Wrap monitoring cords with stockinette and tape them in place A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A client who has a history of physical abuse A client who has a permanent pacemaker A client who has ulcerative colitis A client who has asthma - A client who has asthma A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? Gown N95 respirator Shoe covers Surgical cap - N95 respirator A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units on NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle An x ray shows the end of the tube above the pylorus Bowel sounds are present on auscultation The client reports relief of nausea - An x ray shows the end of the tube above the pylorus A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball Apply a vibrating tuning fork to the client's forehead Have the client stand with their arms at their sides and their feet together Perform direct percussion over the area of the kidneys - Have the client stand with their arms at their sides and their feet together 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? Walking briskly Riding a bike Performing isometric exercises Engaging in high impact aerobics - Walking briskly A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply Place the client in a room with negative pressure airflow Wear gloves when assisting the client with oral care Limit each visitor to 2 hour increments Wear a surgical mask when providing client care Use antimicrobial sanitizer for hand hygiene - Place the client in a room with negative pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? Place a pillow under the client's knees Position a trochanter roll under each of the client's hips Advise the client to wear rubber soled slippers Apply an ankle foot orthotic device to the client's feet - Apply an ankle foot orthotic device to the client's feet A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? Dissolve each mediation in 5 ml of sterile water Draw up medications together in the syringe Push the syringe plunger gently when feeling resistance Flush the tube with 15 ml of sterile water - Flush the tube with 15 ml of sterile water A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? "Drink a cup of hot cocoa before bedtime" "Maintain a consistent time to wake up each day" "Exercise 1 hour before going to bed" "Watch a television program in bed before going to sleep" - "Maintain a consistent time to wake up each day" A nurse is caring for a client who requires a 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine" "I have a specimen in the bathroom for about 30 min ago" "I flushed what I urinated at 7 am, and have saved all urine since" "I drank a lot, so I will fill up the bottle and complete the test quickly" - "I flushed what I urinated at 7 am, and have saved all urine since" 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? Rock the client up to a standing position Pivot on the foot that is the farthest from the chair Assess the client for orthostatic hypotension Apply a gait belt to the client - Assess the client for orthostatic hypotension 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? Remove the outer cannula cautiously for routine cleaning Use tracheostomy covers when outdoors Use sterile techniques when performing tracheostomy care at home Cleanse irritated skin with full-strength hydrogen peroxide - Use tracheostomy covers when outdoors A home health nurse is performing a follow up visit for a client who as 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? The client is receiving formula at room temperature The feedings infuse at a slow, continuous drip over 8 hour each night The client's caregiver washes out the feedings bag with warm water once every 24 hours The client's caregiver flushes the tubing with water before and after administering medications - The client's caregiver washes out the feedings bag with warm water once every 24 hours 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 am not sure I want to retire." Which of the following responses should the nurse make? "You would have so much more time to spend with your family" "You should consider getting a part time job or doing volunteer work" "Let's talk about how the change in your job status will affect you" "Why wouldn't you want to retire and relax?" - "You should consider getting a part time job or doing volunteer work" 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? "Is your pain constant or intermittent" "What would you rate your pain on a scale of 0 to 10?" "Does the pain radiate?" "Is your pain sharp or dull?" - "Is your pain sharp or dull?" 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? Discuss the risk factors for colon cancer Focus teaching on what the client will need to do in the future to manage his illness Provide the client with written information about the phases of loss and grief Reassure the client that this is an expected response to grief - Reassure the client that this is an expected response to grief A nurse is on a medical surgical unit caringterm-66 for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? Pad the client's wrist before applying the restraints Evaluate the client's circulation every 8 hours after application Remove the restraints every 4 hours to evaluate the client's status Secure the restraint to the bed side rails - Pad the client's wrist before applying the restraints 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? The client uses a wool blanket on their bed The client identifies the location of a fire extinguisher The client stores an extra oxygen tank on its side under the bed The client has a weekly inspection checklist for oxygen equipment - The client identifies the location of a fire extinguisher 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? Insert the suction catheter while the client is swallowing Apply intermittent suction when withdrawing the catheter Place catheter in a location that is clean and dry for later use Hold the suction catheter with her clean, nondominant hand - Apply intermittent suction when withdrawing the catheter A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45 angle Administer the medication in the client's nondominant arm Pull the client's skin laterally or downward prior to administration Massage the injection site after administration - Administer the medication with the needle at a 45 angle During the admission process 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? "We would consult the person appointed by your health care proxy to make decisions" "We would give you oxygen trough a tube in your nose" "You would be unable to change your previous wishes about your care" "We would insert a breathing tube while we evaluate your condition" - "We would give you oxygen trough a tube in your nose" A nurse is caring for a client who requires a NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? Position the client with the head of the bed elevated to 30 prior to insertion of the NG tube Remove the NG tube if the client begins to gag or choke Apply suction to the NG tube prior to insertion Have the client take sips of water to promote insertion of the NG tube into the esophagus - Have the client take sips of water to promote insertion of the NG tube into the esophagus A nurse is auscultating the anterior chest of a client who was newly admitted to a medical surgical unit. What is it called when it sounds like blowing as air moves through the larger airways on inspiration and expiration? Friction rub Normal breath sounds Crackles Rhonchi - Normal breath sounds 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. Wash the client's body Obtain the pronouncement of death from the provider Ask the client's family members if they would like to view the body Remove tubes and indwelling lines Place a name tag on the body - 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 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? Insert the needle at 15 angle Aspirate for blood return prior to administration Administer the medication into the abdomen Massage the site following the injection - Administer the medication into the abdomen A nurse is caring for a client who asks about the purpose of advance directive. Which of the following statements should the nurse make? "They allow the court to overrule an adult client's refusal of medical treatment" "They indicate the form of treatment a client is willing to accept in the event of a serious illness" "They permit a client to withhold medical information from health care personnel" "They allow health care personnel in the emergency department to stabilize a client's condition" - "They indicate the form of treatment a client is willing to accept in the event of a serious illness" A new is assessing an older adult 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) Lacrimal apparatus Pupil clarity Appearance of bulbar conjuctivae Visual fields Visual acuity - Pupil clarity Visual fields Visual acuity A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as a indication that the client has developed thrombophlebitis? Bladder distention Decreased blood pressure Calf swelling Diminished bowel sounds - Calf swelling A nurse is administering 1 L 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? Increase in hematocrit Increase in respiratory rate Decrease in heart rate Decrease in capillary refill time - Decrease in heart rate A nurse is reviewing evidenced based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter Regulate oxygen via nasal cannula at a flow rate of no more then 6 L/min Make sure the reservoir bag of a partial rebreathing mask remains deflated Use petroleum jelly to lubricate the clients nares, face, and lips - Regulate oxygen via nasal cannula at a flow rate of no more then 6 L/min A nurse is responding a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries Move hazardous objects away from the client Notify the provider Ask the client to describe how she felt prior to the fall - Check the client for injuries A nurse is caring for a client who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? Examine personal values about the nurse Tell the patents that this is a necessary procedure Inform the parents that the staff does not require their consent Contact a spiritual support person to explain the importance of the procedure - Examine personal values about the nurse A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? Turn the client every 2 hours Administer an antiemetic every 6 hours Hold oral care Increase the room's temperature - Turn the client every 2 hours A nurse is assessing a client's readiness to learn about insulin self administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning" "It is difficult to read the instructions because my glasses are at home" "I'm wondering why I need to learn this" "You will have to talk to my wife about this" - "I can concentrate best in the morning" A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 ml/hour. When the nurse performs the initial assessment, he notes that the client has received only 80 ml over the last 2 hours. Which of the following actions should the nurse take first? Reposition the client Document the client's IV intake in the medical record Request a new IV fluid prescription Check the IV tubing for obstruction - Check the IV tubing for obstruction A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 ml of the medication from a 2 ml vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage Notify the pharmacy when wasting the medications Lock the remaining mediation in the controlled substance cabinet Dispose the vial with the remaining medication in a sharps container - Ask another nurse to observe the medication wastage A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? Carry a client's soiled linens out of the room in a mesh linen bad Place a client who has tuberculosis in a room with negative pressure airflow Role ambiguity Sick role Role overload Role conflict - Role overload A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The op of the can is parallel to the client's waist When walking the client moves the cane 46 cm (18 in) forward The client holds the cane on the on the stronger side of her body The client moves her stronger limb forward with the cane - The client holds the cane on the on the stronger side of her body A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hour. The nurse should set the infusion pump to deliver how many ml/hour? - 107 ml/hour 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? "Use the complete name of the medication 'magnesium sulfate'" "Delete the space between the numerical dose and the unit of measure" "Write the letter 'U' when noting the dosage of insulin" "Use the abbreviation SC when indicating an injection" - "Use the complete name of the medication 'magnesium sulfate'" A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? Biofeedback Aloe Feverfew Acupuncture - Acupuncture A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? Have the client wear a mask when receiving visitors Limit the client's time with visitors to no more than 30 min per day Assign the client to a room with negative pressure air flow exchange Wear a gown when caring for the client - Wear a gown when caring for the client A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? Request that a respiratory therapist discuss the technique for incentive spirometry with the client Determine the reasons why the client is refusing to use the incentive spirometer Document the client's refusal to participate in health restorative activities Administer a pain mediation to the client - Determine the reasons why the client is refusing to use the incentive spirometer A client who is postoperative is verbalizing as a 2 on a pain scale of 0 to 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? "I think I should take my pain medication more often, since its not controlling my pain" "Breathing faster will help me keep my mind off of the pain" "It might help me listen to music while lying in bed" "I don't want to walk today because I have some pain" - "It might help me listen to music while lying in bed"