ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel

ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel

ATI FUNDAMENTALS PROCTOR-A nurse is teaching an assistive personnel

ANSWER.docx (38.1 KB)

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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