ATI fundamentals proctored exam 2022
- A nurse is reaching a client and his family how to care for the client’s tracheostomy at home. Which of the following should the nurse include in the teaching?
Answer:- Use tracheostomy covers when outdoors
- A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
Answer:- The client’s care giver washed out the feeding bag once every 24 hours with warm water
- A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses should the nurse make?
Answer:-Let’s talk about how the change in your hob status will affect you.
- A nurse is assessing a client who reports increased pain following pt. Which of the following questions should t15he nurse ask hen assessing the quality of the client’s pain?
Answer:-Sharp & dull
- A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Answer:-Reassure the client that this is an expected response to grief.
- A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Answer:-Pad the client’s wrist before applying the restraints
- A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
Answer:- The client uses no acetone nail polish remover.
- Nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning?
Answer:- Apply intermittent suction when withdrawing the catheter.
- Nurse is preparing for change of shift. Which document or tools should the nurse use to communicate?
Answer:- SBAR
- Nurse is planning care for a client who had a stroke. What should be assigned to the assistive personal? (SATA)
- -Assist the client with a partial bed bath.
- -Measure the client’s BP after the nurse administers antihypertensive meds.
- -Use a communication board to ask what the client wants for lunch.
- A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal after excessive as I get older."
- A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect?
Absent bowel sounds with distention
- A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?
Temperature
- A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day and night.
- A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
Pericardial friction rub
- A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
"There are times I should use soap and water rather than alcohol based hand rub to clean my hands."
- A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15
- A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
- A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
Temporal
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