ATI RN Fundamentals Practice Tests A & B 2024/2025

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?

Seal unused medications from the facility in a plastic bag

Evaluate the client's ability to self administer medications

Report an identified discrepancy to The Joint Commission

Compare prescriptions with medications the client received while at the facility

Compare prescriptions with medications the client received while at the facility

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

Describe the procedure to the client

Witness the client's signature on the consent form

Inform the client of alternatives to the procedure

Tell the client which team members will assist with the procedure

Witness the client's signature on the consent form

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A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should have an eye examination every 2 years"

"You should receive a tetanus booster every 5 years"

"You should receive a shingles vaccine when you are 70 years old"

"You should receive a pneumococcal vaccine when you are 65 years old"

"You should receive a pneumococcal vaccine when you are 65 years old"

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Ask the client to consider a direct donation

Withhold the blood transfusion

Request a consultation with the ethics committee

Ask the client's family to intervene

Withhold the blood transfusion

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?

droplet

airborne

contact

protective environment

droplet

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds

Measure urine output

Monitor blood pressure readings

Monitor electrolyte levels

Measure urine output

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?

"Most people are happy when their children grow up and leave home"

"You should be proud that your children are becoming independent"

"Maybe you should consider why you are feeling useless"

"People in middle adulthood often find satisfaction in nurturing and guiding young people"

"People in middle adulthood often find satisfaction in nurturing and guiding young people"

A nurse is providing discharge teaching for 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? (select all that apply)

Check the cord routinely for frays or tearing

Keep the unit at least 1-2 m (4 feet) away from a gas stove

Consider purchasing a generator for power backup

Observe for signs of hypoxia

Select synthetic clothing and bedding

Check the cord routinely for frays or tearing

Keep the unit at least 1-2 m (4 feet) away from a gas stove

Observe for signs of hypoxia

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Use a resuscitation bag with 80% oxygen prior to the procedure

Select a suction catheter that is half the size of the lumen

Place the end of the suction catheter in water soluble lubricant

Adjust the wall suction apparatus to a pressure of 170 mmHg

Select a suction catheter that is half the size of the lumen

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep

Inform the client that because she is on PCA, vital signs will be taken every 8 hours

Teach the client to avoid pushing the button until the pain is above 7 on a scale of 0 to 10

Increase the basal rate and shorten the lock out interval time if the client's pain level is too high

Instruct the family to refrain from pushing the button for the client while she is asleep

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?

Wrap blankets around all 4 sides of the bed

Apply restraints during seizure activity

Place the client in a supine position during seizure activity

Have a tongue depressor at the client's bedside

Wrap blankets around all 4 sides of the bed

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manage intervene due to a violation of HIPPAA guidelines?

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

Inject 10 units of air into the bottle of NPH insulin

Withdraw the correct dose of NPH insulin from the bottle

1. Inject 10 units of air into the bottle of NPH insulin

2. Inject 5 units of air into the bottle of regular insulin

3. Withdraw the correct dose of regular insulin from the bottle

4. Withdraw the correct dose of NPH insulin from the bottle

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points

Lower extremity pulse strength of 2+

Fluid intake of 3,000 ml per day

One bowel movement every other day

Erythema on pressure points

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field

The new licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring

The sterile field is positioned at the level of the newly licensed nurse's waist

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

"I'll get a blood sample from you and send it for a screening test"

"Beginning at age 60, you should have a colonoscopy"

"You should have a fecal occult blood test every year"

"The recommendation is to have a sigmoidoscopy every 10 years"

"You should have a fecal occult blood test every year"

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system"

"I can take feverfew to reduce my level of anxiety"

"I can take ginger to improve my memory"

"I can take ginkgo biloba to relieve nausea"

"I can take echinacea to improve my immune system"

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Urine has an unusual odor

Urine specific gravity is 1.035

Bladder scan shows 535 ml of urine

Urine is positive for ketones

Bladder scan shows 535 ml of urine

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Admitting diagnosis

Breath sounds

Body temperature

Diagnostic test results

Breath sounds

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

The caregiver is the client's financial power of attorney

The client is in a wheelchair with the wheels locked

The client reports receiving a full bath twice each week

The caregiver insists on remaining in the room

The caregiver insists on remaining in the room

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears a "bruit". This sound indicates which of the following?

Narrowed arterial lumen

Distended jugular veins

Impaired ventricular contraction

Asynchronous closure of the aortic and pulmonic valves

Narrowed arterial lumen

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 or veracity?

A client who is unaware of her cancer diagnosis asks the nurse if she has cancer and the nurse responds affirmatively

A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes

A client who has a DNR order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family

A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer

A client who is unaware of her cancer diagnosis asks the nurse if she has cancer and the nurse responds affirmatively

A community health nurse is checking blood pressures for a group of clients at community health screening. Which of the following clients is at an increased risk for hypertension?

A client who is 52 years old

A client who smokes 1 pack of cigarettes a day

A client who walks for 30 min every day

A client who drinks 1 glass of wine 3 times per week

A client who smokes 1 pack of cigarettes a day

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

The tube aspirate has a pH of 7

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

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures client's safety, health, and rights

Advocacy ensures that nurses are able to explain their own actions

Advocacy ensures that nurses follow through on their promises to client's

Advocacy ensures fairness in client care delivery and use of resources

Advocacy ensures client's safety, health, and rights

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear

Pack a small piece of cotton deep into the client's ear canal

Move the client's auricle down and back toward her head

Tilt the client's head backward for 5 minutes

Press gently on the tragus of the client's ear

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to the client?

Use a bed exit alarm system

Raise four side rails while the client is in bed

Apply one soft wrist restraint

Dim the lights in the client's room

Use a bed exit alarm system

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?

Make sure the client's room has at least 6 air exchanges per hour

Make sure the client wears a mask when outside her room if there is construction in the area

Place the client in a private room with negative pressure air flow

Wear an N95 respirator when giving the client direct care

Make sure the client wears a mask when outside her room if there is construction in the area

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?

"I can place an extension cord across my living room to plug in my television"

"I will hire someone to trim the area that hangs low over the stairs of my front porch"

"I will place my alarm clock on my bedroom dresser across the room"

"I will replace the old throw rug in my kitchen for a new one"

"I will hire someone to trim the area that hangs low over the stairs of my front porch"

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Combine client care tasks when caring for multiple clients

Wait until the end of the shift to document client care

Use the planning step of the nursing process to prioritize client care delivery

Allow for interruptions in tasks to discuss client care issues with colleagues

Use the planning step of the nursing process to prioritize client care delivery

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Insert the catheter at a 45 angle

Place the client's arm in a dependent position

Shave excess hair from the insertion site

Initiate IV therapy in the veins of the hand

Place the client's arm in a dependent position

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)? (select all that apply

Assist the client with a partial bed bath

Measure the client's BP after the nurse administers an antihypertensive medication

Test the client's swallowing ability by providing thickened liquids

Use a communication board to ask what the client wants for lunch

Irrigate the client's indwelling urinary catheter

Assist the client with a partial bed bath

Measure the client's BP after the nurse administers an antihypertensive medication

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 lesion with uniform pigmentation

New appearance of petechiae

A mole with an asymmetrical appearance

The presence of a papule

A mole with an asymmetrical appearance

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?

Numbness of the extremities

Bradycardia

Positive chvostek's sign

Abdominal cramping

Abdominal cramping

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?

Critical pathway

Situation, background, assessment, and recommendation (SBAR)

Transfer report

Medication administration record (MAR)

Situation, background, assessment, and recommendation (SBAR)

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?

During the admission process

As soon as the client's condition is stable

During the initial team conference

After consulting with the client's family

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

Provide disposable plates and utensils for a client who is HIV positive

Dispose of a client's blood saturated dressing in a trash bag inside a second trash bag

Place a client who has tuberculosis in a room with negative pressure airflow

A nurse is caring for a client who has a terminal illness and is at the end of the line. The nurse should recognize that which of the following statement by the client's partner indicates effective coping?

"I am not worried because I still have hope that he will be okay"

"I am relying on support from our family during this time"

"We can plan our family reunion once he recovers and comes home"

"We don't see any reason to start discussing funeral arrangements right now"

"I am relying on support from our family during this time"

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take?

Assist the client into a prone position

Place a sleeve over the top of each leg with the opening at the knees

Make sure 2 fingers can fit under the sleeves

Set the ankle pressure at 65 mmHg

Make sure 2 fingers can fit under the sleeves

A nurse is using an open irrigation techniques to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Place the client in a side lying position

Instill 15 ml of irrigation fluid onto the catheter with each flush

Subtract the amount of irrigate used from the client's urine output

Perform the irrigation using a 20 ml syringe

Subtract the amount of irrigate used from the client's urine output

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Contact

Droplet

Airborne

Protective

Droplet

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 minutes and to report back in 1 hour. Which of the following actions should the nurse take?

Document the provider's statement in the medical record

Complete an incident report

Consult the facility's risk manager

Notify the nursing manager

Notify the nursing manager

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

BUN 15 mg/dL

Creatine 0.8 mg/dL

Sodium 143 mEq/L

Potassium 5.4 mEq/L

Potassium 5.4 mEq/L

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?

Encourage the client to relax and take deep breaths during the dressing change

Educate the client about the importance of the dressing change to prevent infection

Assist the client to a comfortable position for the dressing change

Administer pain mediation 45 min before changing the client's dressing

Administer pain mediation 45 min before changing the client's dressing

A nurse is admitting a new client. Which of the following actions should the nurse take while performing mediation reconciliation?

Verify the client's name on their identification bracelet with the mediation administration record

Call the pharmacy to determine whether the client's medications are available

Compare the client's home medications with the provider's prescriptions

Place the client's home medication bottles in a secure location

Compare the client's home medications with the provider's prescriptions

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Protective environment

Airborne precautions

Droplet precautions

Contact precautions

Contact precautions

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self injury, which of the following actions should the nurse take when lifting this object?

Bend at the waist

Keep his feet close together

Use his back muscles for lifting

Stand close to the cabinet when lifting it

Stand close to the cabinet when lifting it

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Alginate

Gauze

Transparent

Hydrocolloid

Hydrocolloid

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsiblities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types role performance stress?

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