Ati nsg 131 fundamentals exam
Total Questions : 44
Showing 25 questions, Sign in for moreA nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select All that Apply)
Explanation
A. The provider's name is not an acceptable identifier for verifying the client; it does not confirm the identity of the patient receiving the medication.
B. A facility-assigned identification number is an acceptable identifier as it uniquely identifies the client within the healthcare system.
C. The facility room number is not reliable for identifying clients, as multiple clients can be in the same room or there could be room changes.
D. The partner's full name is not an appropriate identifier for the client; it does not confirm the identity of the patient.
E. The client's full name is an acceptable identifier as it is a primary method to verify the identity of the client before medication administration.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select All that Apply.)
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
Explanation
A. Mixing medications can alter their effectiveness and increase the risk of tube blockage. Each medication should be administered separately.
B. Flushing the NG tube with 30 mL of water after administering medications is important to ensure that the medications are cleared from the tube and absorbed properly by the patient. This also helps to prevent tube occlusion.
C. Diluting medications may not be necessary for all liquid medications, and it depends on the specific medication's guidelines. Each medication should be administered as directed.
D. The head of the bed should be elevated during and after medication administration to prevent aspiration. Keeping it flat is not recommended.
A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
Explanation
A. Urinary retention typically presents with difficulty urinating, rather than changes in urine color or odor.
B. Dark amber, cloudy urine with an unpleasant odor is indicative of a urinary tract infection (UTI). The cloudiness suggests the presence of bacteria or pus, while the dark color and odor are common signs of infection.
C. Urinary incontinence is characterized by the involuntary loss of urine, not changes in the characteristics of urine.
D. Urinary frequency refers to the need to urinate more often, which does not directly relate to the appearance or odor of the urine.
A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
Explanation
A. Thicken gravies with cornstarch is acceptable as it does not add significant sodium and can be a healthier alternative to flour or other thickening agents.
B. Fresh fruits are indeed a healthy snack option and are encouraged in a heart-healthy diet due to their low sodium and high fiber content.
C. Eating 2 cans of soup a day is concerning because many canned soups are high in sodium, which can exacerbate hypertension. This statement indicates a need for further teaching about sodium intake.
D. Replacing table salt with dried herbs is a positive change that promotes flavor without adding sodium, aligning with heart-healthy dietary recommendations.
A nurse is caring for a client who needs to increase his protein intake. The client tells the nurse some of the food he enjoys. Which of the following foods should the nurse recommend as the best source of protein among these suggestions?
Explanation
A. Peanuts contain protein but also have a higher fat content, making them less optimal compared to lean meats.
B. Chicken is an excellent source of high-quality protein, providing essential amino acids with lower fat content, making it the best recommendation among the options listed.
C. Yams are primarily a carbohydrate source and do not significantly contribute to protein intake.
D. Eggs are a good source of protein, but chicken typically provides more protein per serving, making it the superior choice for increasing protein intake.
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?
Explanation
A. The nurse can provide information about the procedure and assist the client in understanding the consent form, but they are not responsible for obtaining informed consent.
B. The surgical suite nurse assists in the surgical environment but does not have the authority to obtain consent.
C. The anesthesiologist discusses the anesthesia involved but does not obtain consent for the surgery itself.
D. The surgeon is responsible for obtaining informed consent, as they must explain the procedure, risks, and benefits to the client before the client can make an informed decision.
A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?
Explanation
A. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.
. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?
Explanation
A. Discarding the tablet and obtaining another dose is the safest option, as it ensures the medication's integrity and prevents any potential contamination.
B. Using the tablet's packaging to pick it up is not appropriate as it could introduce contaminants from the surface of the counter to the tablet.
C. Washing the tablet with alcohol is not advisable because it could alter the medication's properties or effectiveness.
D. Placing the tablet directly into a medication cup without addressing its contamination would also be inappropriate and could jeopardize client safety.
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
Explanation
A. While a high-protein diet can support healing, it does not directly prevent the transmission of infection.
B. Performing hand hygiene before, during, and after direct contact with the client is crucial to prevent the transmission of pathogens and is a fundamental practice in infection control.
C. Positive-pressure airflow is used for clients who are immunocompromised to prevent them from contracting infections, not for clients with existing infections.
D. Changing bed linens daily can contribute to infection control but is not as effective as hand hygiene in preventing transmission.
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
Explanation
A. Applying the pulse oximeter to a finger may not be ideal due to edema, which can affect the accuracy of the reading.
B. Using a skin fold is not a typical location for pulse oximetry and may not provide accurate readings.
C. Applying the probe to a toe may be less effective if the toenails are thickened, potentially affecting blood flow to that area and the accuracy of the reading.
D. The earlobe is a suitable alternative for measuring oxygen saturation, particularly in cases where peripheral sites (like fingers or toes) are compromised.
A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?
Explanation
A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.
B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.
C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.
D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
Explanation
A. While completing an incident report is important for documentation and quality improvement, it is not the immediate priority in the event of a medication error.
B. Notifying the nurse manager is a necessary step for reporting the error, but it should occur after ensuring the client's safety.
C. Calling the client's provider is essential to discuss the medication error and possible interventions, but the client's health and safety must be assessed first.
D. Assessing the client is the priority action to ensure the client’s safety and to identify any adverse effects resulting from the wrong medication. The nurse needs to determine the client's vital signs, level of consciousness, and any immediate symptoms related to the medication administered.
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?
Explanation
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.
A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
Explanation
A. Cleaning and drying the area before applying the patch is essential to ensure proper adhesion and effectiveness of the medication. This statement indicates the client understands proper application procedures.
B. Using lotion on irritated skin before applying a new patch can interfere with the patch's ability to adhere and may affect medication absorption. Therefore, this statement indicates a lack of understanding.
C. Removing the old patch and applying a new one in the same location is generally not recommended because it can lead to skin irritation and decreased absorption. This indicates a misunderstanding of proper patch rotation.
D. While pressing the patch securely is important, it is not as critical as ensuring the skin is clean and dry before application. Thus, this statement alone does not indicate full understanding of the teaching.
A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
Explanation
A. Shaving the hair off the skin where the electrodes will be placed is correct, as it helps ensure proper contact and effectiveness of the TENS therapy.
B. Expressing hope to reduce the need for pain pills indicates the client understands the potential benefit of TENS in managing pain.
C. Wishing to avoid attaching electrodes indicates a common apprehension about the treatment but does not necessarily signify a misunderstanding of the TENS process.
D. The statement about having to be in the hospital suggests a misunderstanding since TENS is often used as an outpatient therapy and does not typically require hospitalization. This indicates the client needs further education about the treatment setting and process.
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Which of the following rooms should the nurse assign to the client?
Explanation
A. A private, negative-pressure room is essential for clients suspected of having tuberculosis (TB) to prevent airborne transmission. This setup helps contain airborne pathogens and protects other clients and staff.
B. A private, positive-pressure room is inappropriate for this situation because it is designed for immunocompromised patients, not those with potential infectious diseases.
C. A semi-private, negative-pressure room would not provide adequate isolation for a client with suspected TB, increasing the risk of transmission to another patient.
D. A semi-private, positive-pressure room is also inappropriate, as it poses a risk of spreading infectious agents to others in the facility.
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?
Explanation
A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.
B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.
C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.
D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?
Explanation
A. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.
B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.
C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.
D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.
A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first?
Explanation
A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.
B. Documenting that the medication was administered should occur after the medication has been given, not before.
C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.
D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Explanation
A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.
B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.
C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.
D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.
A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.
A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?
Explanation
A. Requesting a prescription for an oral formulation of the medication is the appropriate action, as sublingual medications are designed to dissolve under the tongue and bypass the gastrointestinal tract, which is not feasible with an NG tube in place.
B. Administering the medication under the client's tongue is incorrect because the NG tube prevents effective absorption through the sublingual route.
C. Dissolving the medication in water and giving it through the NG tube defeats the purpose of sublingual administration and may not provide the desired therapeutic effect.
D. Administering the crushed medication through the NG tube is inappropriate for sublingual medications, as this can alter the medication's pharmacokinetics and effectiveness.
Sign Up or Login to view all the 44 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
