ATI RN Fundamentals Exam 6
Total Questions : 57
Showing 25 questions, Sign in for moreA nurse is calculating the 8-hr fluid intake for a client who is receiving IV fluids and a clear liquid diet. The client had 880 mL of dextrose 5% in water IV bolus, a 6 oz cup of tea, 4 oz of apple juice, 8 oz of water, 3 oz of flavored gelatin, and 6 oz of broth.
What should the nurse document as the client's 8-hr fluid intake? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.)
Explanation
To calculate the 8-hr fluid intake, convert all the measurements to milliliters (mL).
1 oz = 30 mL, so 6 oz of tea = 180 mL, 4 oz of apple juice = 120 mL, 8 oz of water = 240 mL, 3 oz of flavored gelatin = 90 mL, and 6 oz of broth = 180 mL.
Add up all the fluid intake from IV fluids and clear liquids: 880 + 180 + 120 + 240 + 90 + 180 = 1690 mL.
Round the answer to the nearest whole number: 1690 mL.
The nurse should document 1690 mL as the client's 8-hr fluid intake.
The parent of a toddler is concerned that his child has suddenly become disinterested in certain foods. Which of the following statements is the appropriate response by the nurse?
Explanation
A. Encouraging feeding anything the child will eat might lead to poor nutrition. It's important to ensure a balanced diet.
B. Acknowledging the concern is valid, but the nurse should provide guidance rather than just expressing concern.
C. This response acknowledges the concern but reassures the parent that, if the child appears healthy, no immediate intervention is necessary, promoting a balanced approach.
D. Increasing calories and water without a specific reason or assessment may not address the underlying issue and is not the initial recommended intervention.
A nurse is caring for a client who has diabetes mellitus. Which of the following statements by the client indicates a need for further teaching about diabetic foot care?
Explanation
A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.
D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.
A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following is an appropriate action for the nurse to take?
Explanation
A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are
usually suitable, and the choice depends on factors such as accessibility and patient preference.
C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.
A nurse is preparing to administer carbamazepine to a client who has an NG tube. The provider orders 800 mg each day in two divided doses. Carbamazepine oral suspension is available in 20 mg/mL doses. How many mL should the nurse administer with each dose?
(Round the answer to the nearest whole number. Use a leading zero when applicable. Do not use a trailing zero.)
Explanation
To calculate the amount of carbamazepine oral suspension needed for each dose, divide the total daily dose by the concentration of the suspension and then by the number of doses per day.
- 800 mg / 20 mg/mL / 2 = 20 mL
The nurse should administer 20 mL of carbamazepine oral suspension with each dose.
A nurse is teaching a client who can bear weight on only one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct this client to use?
Explanation
A. Two-point gait involves simultaneous partial weight-bearing on both legs. For a client who can bear weight on only one leg, this gait is not suitable.
B. Four-point gait involves alternating weight-bearing on each leg. It provides a stable and slow gait pattern, making it appropriate for a client who can bear weight on only one leg.
C. Swing-through gait is more advanced and involves swinging both crutches and the affected leg forward together. This is typically used for clients with more strength and coordination.
D. Three-point gait involves non-weight-bearing on one leg and requires the use of crutches or an assistive device on one side only. It is not suitable for a client who can bear weight on one leg.
A nurse is caring for a client who has been diagnosed with breast cancer. After months of treatment, the client refuses to undergo further radiation therapy. Which of the following actions by the nurse is appropriate?
Explanation
A. Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare.
B. Referring the client to a counselor can be appropriate, but the primary response should be to support the client's decision.
C. Encouraging the client not to give up may not be appropriate if the client has made a well- considered decision to refuse further treatment.
D. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.
A nurse is caring for a client who has diabetes mellitus. Which of the following statements by the client indicates a need for further teaching about diabetic foot care?
Explanation
A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.
D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.
A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?
Explanation
A. Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B. Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C. Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D. Using a footstool while sitting in a chair promotes proper positioning and comfort.
A nurse is caring for a client who has a new prescription for a medication that she thinks may be harmful to the client. After seeking clarification from the provider, the nurse still feels that it is unsafe. Which of the following actions should the nurse take?
Explanation
A. If the nurse still has concerns after seeking clarification, the appropriate action is to contact another provider for a second opinion to ensure the safety and well-being of the client.
B. Withholding the treatment without further consultation may not be the best course of action.
Seeking additional input is important.
C. Carrying out the prescription despite concerns about its safety may pose risks to the client.
D. Notifying the ethics committee should be considered if there are ongoing ethical concerns or if the issue cannot be resolved through collaboration with other providers.
A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?
Explanation
A. Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B. Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.
C. Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D. Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.
A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following indicates fluid volume deficit?
Explanation
A. Decreased hematocrit may be seen in fluid volume excess, not deficit.
B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.
D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.
A nurse is planning care for an older adult client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care?
Explanation
A. Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C. Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.
A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?
Explanation
A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping
A nurse in a hospital setting is preparing to administer a partial dose of a prefilled opioid analgesic parenterally. Which of the following is an appropriate action by the nurse?
Explanation
A. Controlled substances typically require a licensed nurse or provider to witness the wasting, not assistive personnel.
B. Wasted medication should be disposed of according to facility policies but not necessarily in a sharps container unless it is a sharp object.
C. Recording the amount of medication wasted on the controlled substance inventory record is a crucial step to maintain accurate documentation.
D. Returning the unused portion of a controlled substance to the pharmacy is not an appropriate action and goes against medication safety protocols. Controlled substances should be wasted and documented properly.
A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?
Explanation
A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.
B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
A nurse is caring for a client who has a dysrhythmia. Which of the following techniques is appropriate for the nurse to use to assess for a pulse deficit?
Explanation
A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).
B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.
C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.
A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?
Explanation
A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.
C. Puncturing the side of the fingertip is not the recommended site for a capillary finger stick.
The recommended site is the center of the fleshy pad of the fingertip.
D. Elevating the finger above heart level can assist in increasing blood flow to the fingertip.
A nurse is planning to provide instruction to a group of older adult clients about measures to promote health and prevent disease. Which of the following information should the nurse include in the teaching? (Select all that apply.)
Explanation
A. Eye exams are generally recommended more frequently, especially for older adults, to monitor for age-related changes and conditions.
B. Women should have a clinical breast examination every year, in addition to mammograms as recommended by their healthcare provider.
C. Both men and women should have a colonoscopy periodically, depending on individual risk factors and age.
D. Regular hearing screenings are important for older adults, especially as age-related hearing loss may occur.
E. Testicular self-exams are recommended for men to detect any abnormalities early on.
A nurse is preparing a client for a central line dressing change. Which of the following actions should the nurse take as part of the procedure?
Explanation
A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.
C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.
A nurse is observing a client who has right-sided weakness ambulate using a cane. Which of the following actions by the client should alert the nurse that further teaching is necessary?
Explanation
A. Holding the cane on the affected side is a correct technique to provide support.
B. Keeping two points of support on the ground is a proper technique for stability.
C. Advancing the cane before moving the unaffected leg is incorrect and may lead to instability and increased risk of falls.
D. Supporting weight on both legs while moving the cane forward is a correct technique for stability during ambulation.
A 5-year-old client is refusing to let the nurse take his blood pressure. To promote cooperation, the nurse should:
Explanation
A. Telling the child that it will not hurt may not be effective, as children may still have anxiety or fear related to the unknown.
B. Forcing a child or having the parent hold tightly may increase anxiety and make the child more resistant to the procedure.
C. Allowing the child to operate the equipment can give the child a sense of control and involvement, increasing cooperation.
D. Deferring the procedure until the next visit may not be practical or necessary if alternative strategies can be employed to promote cooperation.
To plan culturally competent care, a nurse should consider that:
Explanation
A. While some clients may be receptive to a scientific perspective, cultural beliefs and practices can significantly influence health-related decisions and behaviors.
B. Assigning clients to specific cultural categories can lead to stereotyping and may not account for the individual variations within a cultural group.
C. Disease and illness can indeed be influenced by cultural factors, including beliefs about health and healing practices.
D. The meaning of behavior can vary widely across cultures, and understanding the cultural context is crucial for providing culturally competent care.
A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?
Explanation
A. Purulent drainage is characterized by the presence of pus, indicating infection. Blood-tinged drainage does not necessarily indicate infection.
B. Serous drainage is a clear, watery fluid. Blood-tinged drainage has a reddish tinge and is not clear and watery.
C. Sanguineous drainage is characterized by the presence of blood, which may be bright red or old and brownish. Blood-tinged drainage falls under the sanguineous category.
D. Hyperemia refers to increased blood flow to a particular area, not the type of drainage observed in a wound.
A nurse is performing an assessment of an older adult client in an assisted living facility.
Which of the following findings is the highest priority for the nurse to address when planning care?
Explanation
A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.
A. Ensuring safety and preventing falls is a priority.
B. Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C. Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D. Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.
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