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Nursing Process and Client Care: ATI Fundamentals Practice Questions and Answers, Exams of Nursing

DeVry University - WisconsinNursing

Practice questions and answers related to the nursing process and client care. Topics covered include assessing clients, managing time effectively, administering medications, and ensuring safety. Students can use these questions and answers to prepare for exams or as study notes.

Typology: Exams

2023/2024

Available from 04/11/2024

Jayju
Jayju 🇺🇸

416 documents

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ATI fundamentals practice A Questions
and answers
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. CORRECT
ANSWERS✅ 3
The client should hold the cane on the stronger side of her body to increase
support and maintain alignment.
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. CORRECT ANSWERS✅ 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
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and answers

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. CORRECT ANSWERS✅ 3 The client should hold the cane on the stronger side of her body to increase support and maintain alignment. 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?
  5. Reposition the client.
  6. Document the client's IV intake in the medical record.
  7. Request a new IV fluid prescription.
  8. Check the IV tubing for obstruction. CORRECT ANSWERS✅ 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

and answers

able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. 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. CORRECT ANSWERS✅ 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. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
  5. BUN 15 mg/dL.
  6. Creatinine 0.8 mg/dL.
  7. Sodium 143 mEq/L.
  8. Potassium 5.4 mEq/L CORRECT ANSWERS✅ 4.

and answers

  1. Measure the client's BP after the nurse administers an antihypertensive medication.
  2. Test the client's swallowing ability by providing thickened liquids.
  3. Use a communication board to ask what the client wants for lunch.
  4. Irrigate the client's indwelling urinary catheter. CORRECT ANSWERS✅ 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. 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?
  5. Discuss the risk factors for colon cancer.
  6. Focus teaching on what the client will need to do in the future to manage his illness.
  7. Provide the client with written information about the phases of loss and grief.
  8. Reassure the client that this is an expected response to grief. CORRECT ANSWERS✅ 4

and answers

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. 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 CORRECT ANSWERS✅ 4 Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. 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?
  5. Press gently on the tragus of the client's ear.
  6. Pack a small piece of cotton deep into the client's ear canal.
  7. Move the client's auricle down and back toward her head.
  8. Tilt the client's head backward for 5 min. CORRECT ANSWERS✅ 1

and answers

  1. Wear an N95 respirator when giving the client direct care. CORRECT ANSWERS✅ 2 An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
  2. Combine client care tasks when caring for multiple clients.
  3. Wait until the end of the shift to document client care.
  4. Use the planning step of the nursing process to prioritize client care delivery.
  5. Allow for interruptions in tasks to discuss client care issues with colleagues. CORRECT ANSWERS✅ 3 Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. A nurse 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?

and answers

  1. Assist the client into a prone position.
  2. Place a sleeve over the top of each leg with the opening at the knee.
  3. Make sure two fingers can fit under the sleeves.
  4. Set the ankle pressure at 65 mm Hg. CORRECT ANSWERS✅ 3 The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. 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?
  5. Insert the suction catheter while the client is swallowing.
  6. Apply intermittent suction when withdrawing the catheter.
  7. Place the catheter in a location that is clean and dry for later use.
  8. Hold the suction catheter with her clean, nondominant hand. CORRECT ANSWERS✅ 2 The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

and answers

spread the skin at the injection site to administer the medication into the subcutaneous tissue. A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps

  1. Place a name tag on the body
  2. Obtain the pronouncement of death from the provider
  3. Remove the tubes and indwelling lines
  4. Wash the clients body
  5. Ask the clients family member if they would like to view the body CORRECT ANSWERS✅ 2,3,4,5, 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?
  6. Remove the outer cannula cautiously for routine cleaning.
  7. Use tracheostomy covers when outdoors.
  8. Use sterile technique when performing tracheostomy care at home.
  9. Cleanse irritated skin with full-strength hydrogen peroxide. CORRECT ANSWERS✅ 2

and answers

Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. 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. Which of the actions should the nurse take?

  1. Turn the client every 2 hr.
  2. Administer an antiemetic every 6 hr.
  3. Hold oral care.
  4. Increase the room's temperature. CORRECT ANSWERS✅ 1 The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations. A nurse is caring for a child 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?
  5. Examine personal values about the issue.
  6. Tell the parents that this is a necessary procedure.
  7. Inform the parents that the staff does not require their consent.

and answers

  1. After consulting with the client's family CORRECT ANSWERS✅ 1 Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. 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 an indication that the client has developed thrombophlebitis?
  2. Bladder distention
  3. Decreased blood pressure
  4. Calf swelling
  5. Diminished bowel sounds CORRECT ANSWERS✅ 3 Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
  6. Use a bed exit alarm system.
  7. Raise four side rails while the client is in bed.
  8. Apply one soft wrist restraint.

and answers

  1. Dim the lights in the client's room. CORRECT ANSWERS✅ 1 The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. A nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the clients safety needs?
  2. Lacrimal apparatus
  3. Pupil clarity
  4. Appearance of bulbar conjunctivae
  5. Visual fields
  6. Visual acuity CORRECT ANSWERS✅ 2,4, . Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an

and answers

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should in form the client that this condition is a contraindication for which of the following therapies?

  1. Biofeedback
  2. Aloe
  3. Feverfew
  4. Acupuncture CORRECT ANSWERS✅ 4 The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection. 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?
  5. Protective environment
  6. Airborne precautions
  7. Droplet precautions
  8. Contact precautions CORRECT ANSWERS✅ 4

and answers

Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. 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 arrive at the emergency department and I had difficulty breathing? Which of the following responses should the nurse make?

  1. "We would consult the person appointed by your health care proxy to make decisions."
  2. "We would give you oxygen through a tube in your nose."
  3. "You would be unable to change your previous wishes about your care."
  4. "We would insert a breathing tube while we evaluate your condition." CORRECT ANSWERS✅ 2 Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. 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 skin malignancy?
  5. A lesion with uniform pigmentation

and answers

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?

  1. The client uses a wool blanket on their bed.
  2. The client uses nonacetone nail polish remover.
  3. The client stores an extra oxygen tank on its side under their bed.
  4. The client has a weekly inspection checklist for oxygen equipment. CORRECT ANSWERS✅ 2 The client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen. A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize which of the following statements by the client's partner indicates effective coping?
  5. "I am not worried because I still have hope that he will be okay."
  6. "I am relying on support from our family during this time."
  7. "We can plan our family reunion once he recovers and comes home."
  8. "We don't see any reason to start discussing funeral arrangements right now." CORRECT ANSWERS✅ 2

and answers

This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis. 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. Im not sure I want to retire." Which of the following responses should the nurse make?

  1. "You would have so much more time to spend with your family."
  2. "You should consider getting a part-time job or doing volunteer work."
  3. "Let's talk about how the change in your job status will affect you." 4."Why wouldn't you want to retire and relax?" CORRECT ANSWERS✅ 3 This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
  4. Carry a client's soiled linens out of the room in a mesh linen bag.
  5. Place a client who has tuberculosis in a room with negative-pressure airflow.
  6. Provide disposable plates and utensils for a client who is HIV-positive.
  7. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag. CORRECT ANSWERS✅ 2