ATI fundamentals practice
A
1. 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?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane.: 3
The client should hold the cane on the stronger side of her body to increase support
and maintain alignment.
2. A nurse receives a report about a client who has 0.9% sodium chloride
infusing IV at 125mL/hr. When the nurse performs the initial assessment, he
notes that the client has received only 80mL over the last 2 hr. Which of the
following actions should the nurse take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for obstruction.: 4
The first action the nurse should take using the nursing process is to assess the
client. If checking the IV tubing and verifying an obstruction, the nurse might be able
to facilitate the flow of fluid through the tubing. This could re-establish the infusion
rate the provider prescribed.
3. A nurse is caring for a client who requires an NG tube for stomach
decompression. Which of the following actions should the nurse take when
inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to
insertion of the NG tube.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion of the NG tube into
the esophagus.: 4
Taking sips of water as the NG tube passes through the oropharynx will close the
epiglottis over the trachea and prevent the tube from passing into the trachea.
4. A nurse is reviewing a client's fluid and electrolyte status. Which of the
following findings should the nurse report to the provider?
1. BUN 15 mg/dL
, ATI fundamentals practice
A
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L: 4
This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse
should report this finding to the provider. This client is at risk for dysrhythmias.
5. 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?
1."I can place an extension cord across my living room to plug in my
television."
2. "I will hire someone to trim the tree that hangs low over the stairs of my
front porch."
3. "I will place my alarm clock on my bedroom dresser across the room."
4. "I will replace the old throw rug in my kitchen with a new one.": 2
Clearing stairs of any object that could cause the client to trip or require them to
bend over while walking will decrease the risk for falls.
6. 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? SATA
1. Assist the client with a partial bed bath.
2. Measure the client's BP after the nurse administers an antihypertensive
medication.
3. Test the client's swallowing ability by providing thickened liquids.
4. Use a communication board to ask what the client wants for lunch.
5. Irrigate the client's indwelling urinary catheter.: 1, 2, 4
Assisting a client with a bed bath poses minimal risk to the client and is within the
AP's range of function.
Measuring a client's BP poses minimal risk to the client and is within the AP's range
of function.
Using a communication board poses minimal risk to the client and is within the AP's
range of function.
7. 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?
1. Discuss the risk factors for colon cancer.
, ATI fundamentals practice
A
2. Focus teaching on what the client will need to do in the future to manage
his illness.
3. Provide the client with written information about the phases of loss and
grief.
4. Reassure the client that this is an expected response to grief.: 4
During the anger stage of the client's psychosocial adaptation to illness, the nurse
should support the client and explain that this is an expected reaction to a cancer
diagnosis.
8. A nurse is preparing to apply a dressing for a client who has a stage 2
pressure injury. Which of the following types of dressings should the nurse
use?
1. Alginate
2. Gauze
3. Transparent
4. Hydrocolloid: 4
Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a
moist wound bed.
9. A nurse is administering an otic medication to an older adult client. Which
of the following actions should the nurse take to ensure the medication
reaches the inner ear?
1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min.: 1
Pressing gently on the tragus of the ear will help the medication get into the inner
ear.
10. A nurse is using an open irrigation technique to irrigate a client's
indwelling urinary catheter. Which of the following actions should the nurse
take?
1. Place the client in a side-lying position.
2. Instill 15 mL of irrigation fluid into the catheter with each flush.
3. Subtract the amount of irrigant used from the client's urine output.
4. Perform the irrigation using a 20-mL syringe.: 3
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