ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel
ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel
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
ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel
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)
ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel
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?
ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel
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
ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel
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
Assault
Battery
30. a nurse is
preparing to insert an IV catheter for an older adult client who has fragile
skin. Which of the following actions should the nurse take?
Stabilize
the vein by applying traction above the insertion site
Engorge
the vein by placing the arm in the dependent position
Use
friction at the insertion site to increase venous distention
Leave
the tourniquet on for 30 to 60 seconds after initial insertion
31. a nurse is
planning care for a client who has a new prescription for parental nutrition in
20% dextrose and fat emulsion. Which of the following is the appropriate action
to indicate in the plan of care?
Prepare
the client for a central venous line
Change
the PN infusion bag every 48 hours
Administer
the PN and fat emulsion separately
Obtain
a random blood glucose daily
32. a nurse is
caring for a client who is schedule for surgery while witnessing the client
signature. While the client is saying I trust my doctor, but I don’t understand
what he meant when he said he’ll reset my intestines. Which of the following actions should the
nurse take?
Provide
brochures about the procedure
Notify
the provider
Complete
an incident report
Describe
the surgery to the client
33. a nurse is caring for a client who is agitated and
threating to harm others. The nurse places the client in restraints but does
not notify the provider or obtain a prescription for the restraints. The situation respects which of the following
torts?
False
imprisonment
Invasion
of privacy
Assault
Negligence
34. a nurse is
conducting a Webber test on a client. Which of the following is an appropriate
action for the nurse to take?
35. a nurse Is caring
for a client who is 6 hours postoperative abdominal surgery and who is having
difficulty voiding. Which of the following actions should the nurse take?
Encourage
fluid intake up to 1000 ml daily
Insert
an indwelling urinary catheter and connect to gravity drainage
Allow
the client to hear running water while attempting to void
Bring
the client a bedpan while lying supine
36. a nurse is
preparing to use the Z track method to administer iron dextran to a client who
has an iron deficiency anemia. The client asks why this method of injection is
necessary. Which of the following
responses should the nurse make?
Decrease
the risk of injecting medication thru the blood vessels
It
accelerates medication excretion
It
delays medication absorption
It
minimizes tissue irritation
37. a nurse on a
medical unit is caring for a group of client’s for which of the following tasks
should the nurse wear a face shield?
Suctioning
a clients tracheostomy tube
Changing
the brief of an older adult client who has clostridium difficile infection
Emptying
an indwelling catheter bag
Insertion
an IV catheter for a client that has peritonitis
38. an adult client
tells a nurse about recent lack of sleep due to changing to a night shift job.
Which of the following interventions should the nurse suggest?
Use the
television to mask external noises
Listen
to soft music before lying down
Exercise
just prior to bedtime
Keep
the sleeping environment warm
39. a nurse is
teaching a group of newly licensed nurses about the Braden scale. Which of the
following responses by a newly licensed nurse indicates understanding in the
teaching?
Each
element has a range 1 to 5 points
The
higher the score the higher the pressure ulcer risk
The
clients age is part of the measurement
The
scale measures six elements
40. a nurse is planning care for client who is scheduled for
an intravenous pyelogram. Which of the following actions is appropriate for the
nurse to include?
Ensure the
client is free of medal objects
Administer
240 ml (8oz) oral contrast before the procedure
Monitor
the client for pain in the suprapubic region
Assist
the client with a bowel cleansing
41. a nurse in a long
term care facility is planning care for 4 client’s. which of the following
client’s is at greatest risk of developing a pressure ulcer?
A
client who is incontinent of urine 1 to 2 times a day
A
client who is receiving enteral tube feedings
Client
who requires assistance to transfer from the bed to a chair
Client
who is unresponsive to pain stimuli
42. a nurse is
preparing to perform a sterile dressing change for a client. Which of the
following actions should the nurse plan to take?
Place
the cap of the sterile solution inside the sterile field
Don
sterile gloves prior to opening sterile dressing supplies
Setup
the sterile field above the waist level
Consider
2 inches of the sterile fields boarder to be contaminated
43. a nurse is caring
for a client who has a new diagnosis for fibromyalgia. The client tells the
nurse that she wants to use traditional Chinese medicine for treatment instead
the medication prescribed by the provider. Which of the following is an appropriate
response by the nurse?
I can
arrange a referral to a Practioner for traditional Chinese medicine
You
should ask your provider if she recommends traditional Chinese medicine
The FDA
regulates traditional Chinese medicine
You
should try the prescribed medication before choosing an alternative
44. a nurse is
teaching newly licensed nurse about the care of a client who has a MRSA
infection. Which of the following statements by the newly licensed nurse
indicates understanding of the teaching?
I will
remove my gown before my gloves after client care
I will
place the client in a private room
I will
tell the client’s visitors to wear a mask when they are within 3 feet away of
the client
I will
wear an N95 respiratory mask when caring for the client
45. a nurse is caring
for a client who reports that she has insomnia. Which of the following
interventions is appropriate for the nurse to recommend?
Eat a
light carbohydrate snack before bedtime
Exercise
1 hour before bedtime
Drink a
cup of hot cocoa before bedtime
Take a
30 min nap daily
46. a staff nurse is
teaching a newly hired nurse about alternatives to the use of restraints on
clients who are confused. Which of the following instructions should the staff
nurse include?
Use
full length side rales on the clients bed
Check
on the client frequently while he is in the restroom
Encourage
physical activity throughout the day to expand energy
Remove
clocks from the clients room
47. a nurse is
providing teaching to a client about reducing first effects of immobility.
Which of the following statements by the client indicates an understanding of
the teaching?
I will
have my partner help me change positions every 4 hours
I will
hold my breath rising from a sitting positing
I will
perform my ankle and knee exercises every hour
I will
remove my antiembolic stockings while I am in bed
48. to ensure a
clients safety a manager is planning to observe a newly licensed nurse perform
a straight catheterization on a client. Which of the following roles is the
nurse manager functioning?
Client
care provider
Client
educator
Client
advocate
Client
case manager
49. a nurse is
planning to obtain a blood sample from a client for capillary blood glucose
post test. Which of the following should the nurse take to obtain the sample?
The pad
of the finger tip
The
lateral aspect of the finger
The
pinna of the ear
The
side of the wrist
50. a nurse enters a
clients room an discovers a smoldering fire in the drapes. After moving clients
to a safe location which of the following actions should the nurse take next?
Use an
extinguisher to put out the fire
Close
the doors to the client’s room
Pull
the fire alarm
Turn
off any electrical equipment in the room
51. a nurse is
planning to discharge a client who has diabetes and a new prescription for
insulin which of the following actions should the nurse plan to complete first?
Provide
the client with a contact number for a diabetes education specialist
Make a
copy of the medication record of the reconciliation for the client
Determine
whether the client can afford the insulin administration supplies
Obtain
printed information about self-administration
52. a nurse is
assessing a client who’s therapy has included bedrest for several weeks. Which
of the following findings the nurse would identify as priority?
Loss of
appetite
Musculoskeletal
weakness
Left
lower extremity tenderness
Increased
heart rate during physical activities
53. a nurse is caring
or a client who has a influenza and has isolation precautions in place. Which
of the following actions should the nurse take to prevent the spread of
infection?
Don
protective eye wear before entering the room
Administer
metronidazole
Wear a
mask when working within 3 ft of the client
Place
the client in a negative air pressure flow room
54. a nurse is
delegating client’s care to an assistive personnel. Which of the following
tasks should the nurse delegate to the AP?
55. a nurse is teaching about home safety with a client .
which of the following instructions should the nurse include?
Use
electrical tape to secure extension cords next to base boards on the floor
Replace
carpet floors with tiles
Unplug
electronics by grasping the cord
To use
a fire extinguisher, aim high at the top of the flames
56. a nurse is caring
for a client who has restraints to each extremity. Which of the following
assessment should the nurse perform first?
Elimination
needs
Comfort
level
Peripheral
pulses
Skin
integrity
57. a nurse is caring
for a client who has a new prescription of inserting a NG tube. Which of the
following is the most reliable method for evaluating tube placement?
Obtain
an x-ray of the abdomen
Observing
the color of the aspiration
Measuring
pH of the aspirate
Auscultating
the epigastrium while instilling air into the tube
58. a nurse in long
term care facility is assessing a client which of the following findings should
the nurse recognize as an indication of a fecal impaction?
Hypoactive
bowel sounds
No
bowel movement for 48 hours
Persistent
heart burn
Seepage
of liquid stool
59. a nurse is caring
for a client who has a tracheostomy which of the following actions should the
nurse take?
Cotton
tip applicator to clean the inside of the cannula
Soak
the outer cannula in warm soapy tap water
Cleanse
the skin around the stoma with normal saline
Secure
the tracheostomy ties to allow one finger to fit snuggly underneath
60. a charge nurse is
monitoring the documentation of the medication by a newly licensed nurse the
charge nurse should intervene if the newly licensed nurse uses which of the
following abbreviations?
61. a nurse is caring
for a client who has a drainage evacuator. Which of the following is a
appropriate action by the nurse?
Check
the volume of the drainage every 24 hr
Ensure
the drainage suction is set on high pressure
Discontinue
the drainage when it becomes full
Measure
drainage by emptying into a graduated cylinder
62. nurse is
preparing to transfer a client is partially weight bearing from the bed to a
chair. Which of the following actions should the nurse take?
Position
the chair next to the bed at a 90 degree angle
Stand
with his feet together when lifting the client
Keep
his knees straight when moving the client
Have
the client bear weight on the stronger leg
63. nurse is
preparing change of shift report after the night shift using ISBAR
communication tool . which fof the following data should the nurse include when
reporting background information?
Pain
rating of 5 on a scale of 0-10
Code
status do not resuscitate
Start
first dose of penicillin
Blood
pressure /92
64. a nurse in an
acute care facility is preparing to transfer a client to a long term care
facility. Which of the following information should the nurse include in the
hand off report?
Time of
the client’s last bath
Number
of family members who hve visited
Effectiveness
of the last dose of pain medication
Frequency
of previous vital signs
65. nurse is teaching
a client how to perform breast self-examination. Which of the following
instructions should the nurse include?
Perform
BSE 1 week prior to the onset of menses
Palpate I horizontal motion from the outer
breast toward the nipple
Squeeze
the nipple to see if discharge
Wash
and dry each breast prior to palpation
66. nurse is assessing a breath sounds of an adult client
who has pneumonia. which of the following actions should the nurse take?
Place
the bell of the stethoscope on the clients chest
Instruct
the client to sit erect with head tilted back
Ask the
client to breath in deeply thru his nose
Follow
systemic pattern side to side by moving down the clients chest
67. nurse is
assessing a client’s bowel sounds. Which of the following actions should the
nurse take
Listen
to bowel sounds after performing abdominal palpation
Place
diaphragm of stethoscope over each quadrant
Ask
client to cough upon auscultating
Auscultate
for 2 mins to determine if bowel sounds are active
68. math
69. nurse is caring
for a client who is prescribed a special diet the client is concerned that he
does not have the resources to purchase the food he needs to adhere to. The nurse should notify which of the
following members of the health care team?
70. nurse is
providing teaching to a client who is self-administer an ophthalmic solution.
Which of the following statements by the client indicates understanding of the
teaching?
I will
keep my eyes closed for 5 mins after inserting drops
I will
insert the drops in the center of the eye
I will
press the inner corner of my eye after insert drops
I will
raise my eye lid up while looking down and insert drops
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