ATI RN Fundamentals Online Practice 2023 B

A nurse is caring for a client who has COPD.

Select the 3 findings that require follow-up.

Breath sounds

Blood pressure

Oxygen saturation

Temperature

Heart rate

Correct Answer:

Breath Sounds

Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse.

Oxygen Saturation

The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse.

Temperature

The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse.

Incorrect Answer:

Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not require follow-up by the nurse.

Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to 100/min and does not require follow-up by the nurse.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.

Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply.

Assist the client to a left side-lying position with the right knee flexed.

Prepare the client for a chest x-ray.

Administer a cleansing enema.

Auscultate the client's bowel sounds.

Perform a manual digital examination of the client's rectum.

Administer oxycodone extended-release tablets.

Prepare the client for NG tube placement.

Correct Answer:

Assist the client to a left side-lying position with the right knee flexed

The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure.

Administer a cleansing enema

The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray.

Auscultate the client's bowel sounds

The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract.

Perform a manual digital examination of the client's rectum

The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract.

Incorrect Answer:

Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary.

Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client for placement of an NG tube because there is no indication or prescription to do so. Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract and peristalsis is absent.

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 medication.

Lock the remaining medication in the controlled substances cabinet.

Dispose of the vial with the remaining medication in a sharps container.

Correct Answer:

Ask another nurse to observe the medication wastage.

A second nurse must witness the disposal of any portion of a dose of a controlled substance.

Incorrect Answer:

Notify the pharmacy when wasting the medication.

Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance.

Lock the remaining medication in the controlled substances cabinet.

The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act.

Dispose of the vial with the remaining medication in a sharps container.

The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.

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 bicycle

Performing isometric exercises

Engaging in high-impact aerobics

Correct Answer:

Walking briskly

Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

Incorrect Answer:

Riding a bicycle

Cycling has no weight-bearing advantages; therefore, it does not help prevent osteoporosis.

Performing isometric exercises

Isometric exercises have no weight-bearing advantages; therefore, they do not help prevent osteoporosis.

Engaging in high-impact aerobics

High-impact aerobics can injure bones that have lost density; therefore, the nurse should not recommend these exercises for a client who is at risk for developing osteoporosis.

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 potential indications 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.

Correct Answer:

The caregiver insists on remaining in the room.

A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

Incorrect Answer:

The caregiver is the client's financial power of attorney.

Having a caregiver who is the client's financial power of attorney allows the caregiver to perform necessary financial transactions on the client's behalf. This it is not an indication of elder abuse.

The client is in a wheelchair with the wheels locked.

If the client uses a wheelchair, it is important to lock the wheels when the client is stationary to keep the client safe. Locking the wheels of a wheelchair is not an indication of elder abuse.

The client reports receiving a full bath twice each week.

Neglect is a form of abuse or mistreatment that is characterized by omission of necessary care. Although hygiene is an important part of care for all clients, a full bath is not necessary every day for older adults due to the adverse effects it can have on fragile skin. Therefore, a full bath twice each week is sufficient for effective care and is not an indication of neglect or elder abuse.

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Apply transparent dressing over the IV insertion site and securement device.

Shave excess hair from around the IV insertion site.

Cleanse the site with hydrogen peroxide before IV catheter insertion.

Palpate the site carefully just before inserting the IV catheter.

Correct Answer:

Apply transparent dressing over the IV insertion site and securement device.

Transparent dressing prevents infection by protecting the IV site.

Incorrect Answer:

Shave excess hair from around the IV insertion site.

Shaving can increase the risk for microabrasions and infection.

Cleanse the site with hydrogen peroxide before IV catheter insertion.

The nurse should use chlorhexidine or povidone-iodine, per facility protocol, as the cleansing agent for IV catheter insertion.

Palpate the site carefully just before inserting the IV catheter.

Unless nurses use sterile technique, they should not palpate the site after cleansing, because this can introduce micro-organisms and lead to infection.

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first?

Encourage the client to include a support person in the teaching.

Schedule a series of teaching sessions.

Provide written directions for the client to use.

Determine the client's learning style.

Correct Answer:

Determine the client's learning style.

Using the nursing process, the first action the nurse should take is to assess the client's learning style.

Incorrect Answer:

Encourage the client to include a support person in the teaching.

The nurse should encourage the client to include a support person in the teaching to provide support. However, this is not the first action the nurse should take.

Schedule a series of teaching sessions.

The nurse should schedule a series of teaching sessions to reinforce learning. However, this is not the first action the nurse should take.

Provide written directions for the client to use.

The nurse should provide written directions for future reference. However, this is not the first action the nurse should take.

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 mm Hg.

Correct Answer:

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

The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

Incorrect Answer:

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

The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia.

Place the end of the suction catheter in water-soluble lubricant.

The nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation solution to decrease trauma to the mucosa.

Adjust the wall suction apparatus to a pressure of 170 mm Hg.

The nurse should adjust the suction pressure to approximately 120 mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma to the mucosa.

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

Correct Answer:

Medication dose

In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

Incorrect Answer:

Medication name

The prescription states that the medication name is digoxin; therefore, this component of the prescription does not require verification.

Route of administration

In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

Frequency of administration

The prescription states that the frequency of administration is every day; therefore, this component of the prescription does not require verification.

A nurse is caring for a client who is receiving a unit of packed RBC's.

Complete the following sentence by using the lis of options.

The client has manifestations of _____ as evidenced by the client's ______.

Correct Answer (1):

Allergic Reaction

The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider.

Correct Answer (2):

Itching

The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider.

Incorrect Answer (1):

Febrile reaction is incorrect. A febrile reaction has manifestations of fever, chills, headache, flushing of the face, and muscle pain.

Fluid overload is incorrect. Fluid overload has manifestations of cough, crackles heard in bases of the client's lungs, shortness of breath, and distended neck veins.

Incorrect Answer (2):

Temperature is incorrect. The client's temperature is within the expected reference range. An increase in temperature is a manifestation of febrile or hemolytic reaction to blood administration.

Oxygen saturation is incorrect. The client's oxygen saturation is within the expected reference range.

A nurse is caring for a client who had a spinal cord injury and has paraplegia.

The nurse is reviewing the client's medical record.

Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.

Client is repositioned every 2 hr.

Passive range-of-motion exercises to lower extremities performed once each day.

Feet warm. Pedal pulses 2+ bilaterally.

Plantar flexion contractures noted bilaterally.

Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

Correct Answer:

Client is repositioned every 2 hr

The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. Therefore, this finding does not require intervention at this time.

Passive range-of-motion exercises to lower extremities performed once each day

The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures.

Plantar flexion contractures noted bilaterally

The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures.

Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact

The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.

Incorrect Answer:

Feet warm. Pedal pulses 2+ bilaterally is incorrect. The nurse should identify that the client has adequate circulation to their feet. Therefore, this finding does not require intervention at this time.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.

The nurse is assessing the client. Which of the following actions should the nurse take?

Select all that apply.

Stop the IV infusion.

Elevate the client's left arm.

Apply heat to the client's left hand.

Place a pressure dressing over the IV site.

Start a new IV in the client's left hand.

Correct Answer:

Stop the IV infusion.

The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage.

Elevate the client's left arm.

The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage.

Apply heat to the client's left hand.

The nurse should apply heat to the client's left hand to reduce swelling and promote comfort.

Incorrect Answer:

Place a pressure dressing over the IV site.

The nurse should not apply pressure to the IV site, because this can cause tissue damage.

Start a new IV in the client's left hand.

The nurse should start a new IV in a different extremity to reduce the risk of tissue damage.

A nurse is admitting a client to a health care facility.

The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include?

Select all that apply.

Wear an N95 mask when caring for the client.

Place a container for soiled linens inside the client's room.

Place the client in a negative airflow room.

Remove mask after exiting the client's room.

Wear a sterile, water-resistant gown if within 3 feet of the client.

Correct Answer:

Wear an N95 mask when caring for the client.

The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client.

Place a container for soiled linens inside the client's room.

The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection.

Place the client in a negative airflow room.

The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system.

Remove mask after exiting the client's room.

The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection.

Incorrect Answer:

Wear a sterile, water-resistant gown if within 3 feet of the client.

The nurse should identify that the client has tuberculosis, which requires airborne precautions. Sterile gowns are not indicated when caring for a client who is in airborne precautions. Water-resistant gowns are only indicated if there is a likelihood of contact with the client's body fluids.