Question ATI FUNDAMENTALS PROCTOR

ATI FUNDAMENTALS PROCTOR

1. A nurse is teaching an assistive personnel about a upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching?

2. a nurse is assessing a client who is immobile and notices a red area over the client’s coccyx. Which of the following actions should the nurse take?

Change the clients position every 4 hours

Apply petroleum base ointment in the red area

Assess the red area for blanching

Use friction when cleansing the client’s skin

3. a nurse is preparing to insert an iv catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating an IV therapy?

The radial vein on the left wrist

The cephalic vein in the left distal forearm

The basilic vein in the right antecubital fossa

The cephalic vein on the back of the right hand

4.  a nurse is preparing to administer a medication into a client by the intradermal route after applying gloves and cleaning the site with an antiseptic swab. In what order should the nurse take the steps to administer the medication?  (move steps into box 1- 4 priority)

1.Use a nondominated hand to stretch the skin

2. Insert the needle at an angle

3. inject the medication

4. Withdrawal the needle

5. Activate the needle safety device

5. a nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?

Intake of dietary fiber

Have a fecal occult blood test every 2 years

Reduce intake of red meats

Have a colonoscopy every 3 years

6. a nurse is planning care to prevent skin breakdown for a client who is immobile and is urinary incontinent. Which of the following actions should the nurse include in the plan of care?

Reposition the client every 4 hours

Arrange for an alternating pressure mattress

Apply cornstarch to the skin

Request a prescription for an indwelling urinary catheter

7.  a nurse is preparing to apply a condom catheter for a client who is uncircumcised which of the following actions should the nurse plan to take?

Place adhesive tape directly on the penis

Allow 2.5 to 5 m between the end of the catheter and the tip of the penis

Keep foreskin in a retractable position after application of the catheter

Change the condom catheter every 3 days

8. a nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should the include in the teaching? (select all that apply)

Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation

remove from the artificial eye by retracting the upper eyelid

Apply pressure just below artificial eye to break the suction

Clear the artificial eye with hydrogen peroxide before storing

Retract the upper and lower lids to reinsert the artificial eye

9. a nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPPA?

Faxing medical information about the client to a provider’s office

Teaching a client discharge instruction with his partner present

Giving a telephone report to a surgical nurse and sending the client to the surgical suite

Discussing the clients transfer to a long-term care facility with a nurse from another unit

10.  a nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain.Which of the following actions should the nurse take first?

Determine areas of resonance across the abdomen using a systematic approach

Expose the clients abdomen to look for changes in appearance

Perform abdominal palpation by pressing gently with the finger pads

Use the diaphragm of the stethoscope to listen for bowel sounds

11. a nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?

Determine the client’s reading ability

Review the use of an artificial larynx

With the client schedule a support session

For the client explain the techniques of esophageal speech

12. a home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)

I will use the bars when getting in and out of the bath tub

I need to check my medications for expiration dates

I need to have a fire escape plan with my family

I will apply tape over frayed areas of electrical cords

I need to set my hot water heater to 140 degrees Fahrenheit

13.  a nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?

The client has a symmetrical smile

The client’s tongue is in a midline position

The client turns his head against resistance

The clients pupils constrict and responds to light

14. a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?

Offer pain medication

Palpate the abdomen

Auscultate bowel sounds

Administer an antiemetic

15.  a nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statements by the clients partner indicates maladaptive coping?

Don’t understand why he can’t get better and return to work

I cook for him at home and work hard to prepare a nutritious meals

I am going to ask my daughter to come and stay for a week

I don’t know if I will be able to meet his physical needs

16.  a nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?

Dry gauge

Transparent

Calcium alginate

Hydrogel

17.  a nurse is caring for a client who has brain cancer and is transferring to hospice care. The client’s son tells the nurse “I don’t know what to tell my dad if he asks how he is going to die”.  Which of the following is an appropriate response from the nurse?

I think you should discuss this with the hospice nurse

18. a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes.  Which of the following statements by the client indicates understanding of the teaching?

I can apply lotion to soften the calluses as long as I don’t put lotion between my toes

I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly

I should soak my feet in warm water daily to soften corns and calluses

I should use an over the counter liquid medication to remove corns

19. a nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?

Tie the restraints to the side rale

Secure restraints with a square knot

Remove one restraint at a time

Remove the restraints every 3 hours

20.  a nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply

Use an N95 respirator while providing client care

Wear a gown and gloves when providing client care

Assign the client to a private room with positive are flow

Wash hands with soap and water after contact with the client

Ensure the client does not receive fresh fruits

21.  a nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?

Schedule the client as the first surgical procedure of the day

Cleanse the stoppers with primidone iodine for withdrawing medication

Remove the stop stocks from iv tubing

Ensure the gloves in the surgical suite are powdered gloves

22. a nurse is providing discharge teaching to a client who does not speak the same language as the nurse.  Which of the following actions should the nurse take?

Offer written instructions in the clients language

Request that an assistive personnel interpret instructions for the client

Use proper medical terms giving instructions to client

Direct verbal discharge instructions to the interpreter

23. a nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?

The clients belief that his needs will be met through education

The nurse explaining the need for education to the client

The client seeking family approval by agreeing to a teaching plan

The nurses empathy about the client having to self-inject

24. a nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?

Maintain a lean body mass

Walk for 30 mins 3 to 5 times a week

Perform water aerobics 3 times each week

Increase intake of vitamin B12

25. a nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?

Heat the formula to 105 degrees Fahrenheit

Flush the tubing with 10 ml of water every 2 hours

Change the tubing every 72 hours

Aspirate residual volume every 4 hours

26. a nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following images indicates the proper method of cleaning a wound site?

 

27.  a nurse is caring for a client who reports a pain level of 5 on a scale of 0- 10. The client informs the nurse that pain medications is not an option for managing pain. Which of the following is an appropriate response by the nurse?

Would you like me to give you a back message

Im sure it will work if you just give it a chance

Why do you think pain medication is not going to help you

You may take any herbal remedies you bring from home

28.  a nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

The client picks up the walker with each step

The client stoops slightly forward when moving the walker

The client stands with her elbows slightly flexed while holding the walker

The client moves the walker ahead 10inches with each step

29.  a nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears an assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?

Libel

Defamation of character

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