Fundamentals Exam 2 -- ATI Questions With complete expert solutions already graded A+

a nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (select all that apply)

a. place a belt restraint on the client when they are sitting on the bedside commode

b. keep the bed in its lowest position with all side rails up

c. make sure that the client's call light is within reach

d. provide the client with nonskid footwear

e. complete a fall-risk assessment

c. make sure that the client's call light is within reach

d. provide the client with nonskid footwear

e. complete a fall-risk assessment

a nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse required further instruction

a. I will place the client on their side

b. I will go to the nurses station for assistance

c. I will not the time the seizure begins

d. I will prepare to insert an airway

b. I will go to the nurses station for assistance

a nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority?

a. extinguish the fire

b. activate the fire alarm

c. move clients who are nearby

d. close all open doors on the unit

c. move clients who are nearby

a nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority?

a. complete a fall-risk assessment

b. educate the client and family about fall risks

c. eliminate safety hazards from the client's environment

d. make sure the client uses assistive aids in their possession

a. complete a fall-risk assessment

a nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?

a. open the windows in the clients room to allow smoke to escape

b. obtain a class C fire extinguisher to extinguish the fire

c. remove all electrical equipment from the client's room

d. place wet towels along the base of the door to the client's room

d. place wet towels along the base of the door to the client's room

a nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (select all that apply)

a. family members who smoke must be at least 10 ft from the client when oxygen is in use

b. nail polish should not be used near client who is receiving oxygen

c. a "no smoking" sign should be placed on the front door

d. cotton bedding and clothing should be replaced with items made from wool

e. a fire extinguisher should be readily available in the home

b. nail polish should not be used near client who is receiving oxygen

c. a "no smoking" sign should be placed on the front door

e. a fire extinguisher should be readily available in the home

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?

a. hypotension

b. bradycardia

c. clammy skin

d. bradypnea

a. hypotension

a nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?

a. I will set my water heater at 130 F

b. once my baby can sit up, they should be safe in the bathtub

c. I will place my baby on their stomach to sleep

d. once my infant starts to push up, I will remove the mobile from over the crib

d. once my infant starts to push up, I will remove the mobile from over the crib

a home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

a. carbon monoxide has a distinct odor

b. water heaters should be inspected every 5 years

c. the lungs are damaged from carbon monoxide inhalation

d. carbon monoxide binds with hemoglobin in the body

d. carbon monoxide binds with hemoglobin in the body

a home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (select all that apply)

a. most food poisoning is caused by a virus

b. immunocompromised individuals are at increasing risk for complications from food poisoning

c. clients who are high risk should eat or drink only pasteurized dairy products

d. healthy individuals usually recover from the illness in a few weeks

e. handling raw and fresh foods separately can prevent food poisoning

b. immunocompromised individuals are at increasing risk for complications from food poisoning

c. clients who are high risk should eat or drink only pasteurized dairy products

e. handling raw and fresh foods separately can prevent food poisoning

a nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk of the client?

a. decreased subcutaneous fat

b. muscle atrophy

c. pressure injury

d. fecal impaction

c. pressure injury

a nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (select all that apply)

a. instruct the client not to perform the Valsalva maneuver

b. apply elastic stockings

c. review laboratory values for total protein level

d. place pillows under the client's knees and lower extremities

e. assist the client to change positions often

b. apply elastic stockings

e. assist the client to change positions often

a nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

a. encourage the client to perform antiembolic exercises every 2 hr.

b. instruct the client to cough and deep breathe every 4 hr.

c. restrict the client fluid intake

d. reposition the client every 4 hr.

a. encourage the client to perform antiembolic exercises every 2 hr.

a nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding?

a. this device will keep me from getting sores on my skin

b. this device will keep the blood pumping through my leg

c. with this device on, my leg muscles won't get weak

d. this device is going to keep my joints in good shape

b. this device will keep the blood pumping through my leg

a nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (select all that apply)

a. hold the can on the right side

b. keep two points of support on the floor

c. place the cane 38 cm (15 in) in front of the feet before advancing

d. after advancing the cane, move the weaker leg forward

e. advance the stronger led so that it aligns evenly with the cane

a. hold the can on the right side

b. keep two points of support on the floor

d. after advancing the cane, move the weaker leg forward

a nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?

a. eating more protein is optimal prior to testing

b. one stool specimen is sufficient for testing

c. a red color change indicated a positive test

d. the specimen cannot be contaminated with urine

d. the specimen cannot be contaminated with urine

a nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend?

a. macaroni and cheese

b. one medium apple with skin

c. one cup of plain yogurt

d. roast chicken and white rice

b. one medium apple with skin

a nurse is assessing a client who has had diarrhea for 4 days. Which of the following fidnings should the nurse expect? (select all that apply)

a. bradycardia

b. hypotension

c. elevated temperature

d. poor skin turgor

e. peripheral edema

b. hypotension

c. elevated temperature

d. poor skin turgor

while the nurse is administering a cleansing enema the client reports abdominal cramping. Which of the following actions should the nurse take?

a. have the client hold their breath briefly and bear down

b. clamp the enema tubing

c. remind the client that cramping is common at this time

d. raise the level of the enema fluid container

b. clamp the enema tubing

a nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (select all that apply)

a. warm the enema solution prior to installation

b. position the client on the left side with the right leg flexed forward

c. lubricate the rectal tube or nozzle

d. slowly insert the rectal tube about 5 cm (2 in).

e. hang the enema container 61 cm (24 in) above the client's anus

a. warm the enema solution prior to installation

b. position the client on the left side with the right leg flexed forward

c. lubricate the rectal tube or nozzle

a nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (select all that apply)

a. restlessness

b. tachypnea

c. bradycardia

d. confusion

e. hypertension

a. restlessness

b. tachypnea

d. confusion

e. hypertension

a provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (select all that apply)

a. apply petroleum jelly around and inside the nares

b. remove the nasal cannula during mealtimes

c. check the position of the cannula frequently

d. report any nausea or difficulty breathing

e. post "no smoking" signs in prominent locations

c. check the position of the cannula frequently

d. report any nausea or difficulty breathing

e. post "no smoking" signs in prominent locations

a nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

a. increase the oxygen flow

b. assist the client to Fowler's position

c. promote removal of pulmonary secretions

d. obtain a specimen for arterial blood gases

b. assist the client to Fowler's position

a nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (select all that apply)

a. apply suction while withdrawing the catheter

b. perform suctioning on a routine basis every 2 to 3 hours

c. maintain medical asepsis during suctioning

d. use a new catheter for each suctioning attempt

e. apply suction for 10 to 15 seconds

a. apply suction while withdrawing the catheter

d. use a new catheter for each suctioning attempt

e. apply suction for 10 to 15 seconds

a nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (select all that apply)

a. apply the oxygen source loosely if the SpO2 decreases during the procedure

b. use surgical asepsis to remove and clean the inner cannula

c. clean the outer cannula surface in a circular motion from the stoma site outward

d. replace the tracheostomy ties with new ties

e. cut a slit in gauze squares to place beneath the tube holder

a. apply the oxygen source loosely if the SpO2 decreases during the procedure

b. use surgical asepsis to remove and clean the inner cannula

c. clean the outer cannula surface in a circular motion from the stoma site outward