ATI PN FUNDAMENTALS PROCTORED EXAM

ATI PN FUNDAMENTALS PROCTORED EXAM (11 LATEST DoDwDonwolownalnodlaoedaedbdeyd:byabD:cyaT:odEweSxnmalTomiBacgAdeNndKiuPbsyR:|0bwjai|simnjhneoiasepklwmeawbanitusgaka5|iar8i@413@ Distribution of this document is illegal use?atiiibook iiwasiinotiithoroughiisoiiiiihad iito iigoiion iidifferent iisitesiiforiichartsii-iinotiiconfidentiiwith iithis,iplease iidoubleiicheck. iiperiod the iinurseiideterminesiithatiitheiiclientsiiBPiiisii158/96 iimmhg. iiwhichiiofiitheiifollowing iiactionsiishoulditheiinurseiitake?  Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. Nolonger than 10-15 seconds to avoid hypoxemia 10. a. “SS” for sliding scale b. “BRP” for bathroom privileges c. “OJ” for orange juice- do not d. “SQ” for subcutaneous- do not 11. MISSING 12. a. Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. Itisays 40% b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATICHYPOTENSION c. Recheck the clients BP and her other arm for comparison. d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes 13. A nurse is caring for a client who has left lower atelectasis. in which of the followingipositions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562 e. Supine and low-Fowler's position f. g. Side lying with the right side of the chest elevated h. Prone with pillows under the extremities Aiinurse iiisiicollecting iiAiibloodiipressureiireading iifromiia iiclient iiwhoiiisiisitting iiiniia iichair Aiinurse iiisiidocumentingiiclient iicare. iiWhich iiofiitheiifollowingiiabbreviationsiishouldiitheiinurse RightiilateraliiiniiTrendelenburg iiposition S -i-TiThheeMiiMaarkreketptplalacceetoiitoBiuiByuayniiadnSdeiilSl eyolluiiyroSutruiidSytuMdyaterial DoDwDonwolownalnodlaoedaedbdeydb: yabD:cyaT:odEweSxnmalTomiBacgdAgeNndKiuPbsyR:|0bwjai|simnjhneoiaespklwmeawbanitsugaka5|iar8i@413@ Distribution of this document is illegal 14. A nurse is receiving the prescription for a client who is experiencing dysphagia following astroke. Which of the following prescriptions should the nurse clarify? a. Dietitian consult b. Speech therapy referral c. Oral suction at the bedside d. Clear iiliquids-iiliquidsiimustiibe iiTHICK. Clear liquids can cause aspiration  Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular. 15. iitheinurseiishouldiifollowiiafteriipreparationiiandiilubricatingiitheiienema iiset.(ati funds video enema) 1. Administer the enema solution.(2) 2. Remove the enema tube from the clients rectum.(4) 3. Wrap the end of the enema tube with a disposable tissue.(5) 4. Insert the enema tube into the client's rectum.(1) 5. Clamp the enema tube.(3) nurse is inserting an NG tube for a client who requires gastric decompression. Which ofthefollowing actions should the nurse take to verify proper placement of the tube? a. Place the end of the NG tube in water to observe for bubbling. b. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. AIRNOT WATER OR BY ASPIRATING GASTRIC FOR PH. c. Assess the client's gag reflex. d. 17. A nurse is teaching a group of newly licensed nurses about the Braden Scale. Which of thefollowing responses by the newly licensed nurse indicates an understanding of the teaching? a. “The client‟s age is part of the measurement.” - rationale is same as b. b.  Rationale: The six elements are 1. Sensory Perception, 2. Moisture, 4. activity, 5. mobility ,6. nutrition , 7. friction and shear. “The iiscale iimeasuresiisixiielements.” Measure iitheiipHiiofiithe iigastric iiaspirate. Aiinurse iiisiiadministering iia iilargeiivolume iienema iito iia iiclient. iiIdentifyiitheiisequence iiofiisteps DoDwDonwolownalnodlaoeadedbdeydb: yabD:cyaTo: dEweSxnmalTomiBacgAdeNndKiuPbsyR:|0bwjai|simnjhneoiasepklwmeawbanitusgaka5|iar8i@413@ Distribution of this document is illegal iishouldti heiinurseiirecord? c. “The higher the score, the higher the pressure ulcer risk.”- the higher the score the betterchance the patient has of NOT getting an ulcer . score of 12 or less is high risk. Anything above 18 is healthy. d. “Each element has a range from 1 to 5 points.”- each elements is scored from 1-4 actually . 18. A nurse is caring from a client who has a tracheostomy. Which of the following actionsishould the nurse take? a. b. Secure the tracheostomy ties with one finger to fit snugly underneath. → 2 snug fingersiwidths under neck strap c. Soak the outer cannula in warm tap water. STERILE NS d. Use a cotton tip applicator to clean the inside in the inner cannula. to clean OUTERicannula surfaces, cllity-approved solutionean the inside with the faci  Rationale: according to POTTER, funda pg. 866 using NS-saturated cotton-tipped sterile swabs and 4x4 gauze, clean exposed outer cannula surfaces and soma under faceplate, extending 5-10cm (2-4in) in all directions from stoma. 19. a. “Incision without redness or drainage.” b. “Drink adequate amounts of fluid with meals.” WHATS THE AMOUNT c. “Oral temperature slightly elevated at 0800.” WHATS THE TEMP d. “Administered pain medication.” Any action & change to the client‟s condition should be recorded 20. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints onclients who are confused. Which of the following instructions should the nurse include? a. “Use full-length side rails on the client‟s bed.” b. “Check on the client frequently while he is in the restroom.” c. “Encourage iiphysicaliiactivityiithroughoutiithe iidayiitoiiexpandiienergy.” Aiinurseiiisiidocumentingiiiniia iiclient‟siimedicaliirecordii. iiWhichiiofiitheiifollowingiientries Cleaniithe iiskiniiaroundiithe iistoma iiwithiinormaliisaline. DoDwDonwolownalnodlaoedaedbdeydb: yabD:cyaTo: dEweSxnmalTomiBacgdAeNndKiuPbsyR:|0bwjai|simnjhneoiaespklwmeawbanitsugaka5|ira8i4@13@ Distribution of this document is illegal d. “Remove clocks from the client‟s room.” 21. A nurse in an emergency department is assessing a client who reports RIGHT lower quadrantpain, nausea and vomiting for the past 48 hr. Which of the following actions should the nurse take first? a. b. Administer an antiemetic. c. Offer a pain med. d. Palpate the abdomen. Possible appendicitis “nausea/vomiting” with RLQ pain. (IAPP) INSPECTION. AUSCULTATE. PERCUSS. PALPATE- FOR BOWEL 22. A nurse is assessing a client‟s extraocular eye movements. Which of the following should thenurse take? a.  Rationale: Cardinal fields of gaze test for cranial nerves 3, 4, and 6 which are for eye movement b. Hold a finger 46 cm (18 in) in front of the client‟s eyes. c. Ask the clients to cover her right eye during assessment of her left eye. d. Position the client‟s 6.1 m (20 feet) away from the Snellen chart. (This is for cranialnerve 2) 23. A nurse is providing a teaching to a client who had a new medication prescription. Which ofthe following manifestations of a mild allergic reaction should the nurse include? a. Urticaria b. Ptosis c. Nausea d. Hematuria Instructiithe iiclientsiitoiifollowiiaiifingeriithroughiitheiisix iicardinaliifieldsiiofiigaze. Auscultate iiboweliisounds. DoDwDonwolownalnodlaoedaedbdeyd:byabD:cyaTo: dEweSxnmalTomiBacAdgeNndKiuPbsyR:|0bwjai|simnjhneoiaespklwmeawbanitusgaka5|ira8i4@13@ Distribution of this document is illegal 24. A provider prescribes cold application for a client who reports ankle joint stiffness. Which ofthe following assessments findings should the nurse identify as a contraindication to the application of cold? a. Capiirefillii4iiseconds-ITS CONTRAINDICATED TO USE APPLICATION OF COLD b. 7.5 cm (3 in) diameter bruise on the ankle IT HELPS ON BRUISE c. Warts on the affected ankle d. 2+ pitting edema -HELPS REDUCE INFLAMMATION (EDEMA) 25. A nurse is caring for a client who has TB. Which of the following precautions should the nurse plan to implement when working with the client? Chapter 11 fundamentals 9.0 infectioncontrol page 52 a. Airborne  Rationale:measle, varicella, pulmonary or laryngeal tuberculosis b. Droplet-streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia andsepsis, pneumonic plague). c. Protective d. Contact 26. A nurse is performing a dressing change on a client and observes granulation tissue. Whichiof the following findings should the nurse document? Chapter 55 Pressure ulcers, wounds and wound management? fundamentals pdf page 330 a. Stringy, white tissue- same as slough. Means that it is sepatated from the body. b. c. Soft, yellow tissue= means presence of slough and drainage. d. Thick, black tissue- black is necrotic = eschar is present and needs removal 27. A nurse is screening several clients at a neighborhood health fair. Which of the followingai ssessments findings is the priority for referral for further care? Translucent, iirediitissue-iirediimeansiihealthyiiandiiitsiihealing DoDwDonwolownalnodlaoeadedbdeydb: yabD:cyaTo: dEweSxnmalTomiBacgdAeNndKiuPbsyR:|0bwjai|simnjhneoiaespklwmeawbanitusgaka5|iar8i@413@ Distribution of this document is illegal ii(PN)in ii20% iidextrose iiand iifat iiemulsions. iiWhich iiof iithe iifollowing iiisiian iiappropriate iiaction iito iiincludeiiinitheiiplaniiofiicare? iiadultimaleiiclients. iiWhich iiofiitheiifollowingiiguidelinesiishouldiitheiinurse iiinclude? a.  Rationale: low/hypoglycemia may lead to shock  level is abnormally low, [74-106 mmol/L] b. Blood pressure 148/92 mm Hg STAGE 1 HYPERTENSION c. Body mass index 28 kg/m2 OVERWEIGHT d. Heart rate 105/mi