1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements indicates an understanding of the teaching? a. I had a bowel movement, but I was able to save the urine – should be free of feces b. I have a specimen in the bathroom from about 30 minutes ago- Client should place any urine in the container immediately and keep it on ice or in the fridge. c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24 hr urine collection, the client should discard the first voiding and save all subsequent voiding. d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified amount 2. A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention – urinary retention which causes bladder distension is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles b. Decreased blood pressure – client on bed rest can develop postural hypotension. Drop in BP when the client moves from a lying to a sitting position. Nurse should assess for pulse rate and dizziness. c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations of thrombophlebitis, a common complication of immobility d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis. Constipation is common complication of immobility. 3. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse – any healthcare professional directly caring for a client has access to the medical information. b. A nurse asks a nurse from another unit to assist with her documentation – only health care professionals directly caring for a client may access medical information. c. A nurse who is caring for a client returns a call to the client's durable power of attorney for healthcare designee to discuss the client's care – The person the durable power of attorney for health care designates has a legal right to information about the client’s care. d. A nurse discusses the client's status with the physical therapist that is caring for the client at the client's bedside – any healthcare professional directly caring for a client has access to the medical information. 4. A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? a. Apply the stockings so the creases are on the front side of the leg – nurse should assure that there are no creases or wrinkles in the stocked to prevent kind irritation and promote venous return ATI-FUNDAMENTALS-PROCTORED-EXAM-2020-RETAKE-GUIDE b. Apply the stockings while the client's legs are in a dependent position – nurse should apply stockings in the morning before the client gets our o bed because the legs are less edematous at that time c. Remove the stockings at least once per shif – nurse should remove stocking to check for CMS. d. Remove the stockings while the client is sitting in a reclining chair – Client should wear the stockings while sitting in the chair to promote venous return. 5. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds – ABC approach. Auscultate lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifested in moist crackles heard in lung fields, dyspnea, and SOB b. Measure urine output – The nurse should measure urine output to monitor the renal function of an older client, however it is not the priority assessment c. Monitor blood pressure readings - The nurse should monitor BP readings to evaluate the hemodynamic stability of an older client, however it is not the priority assessment d. Monitor serum electrolyte levels - The nurse should monitor serum electrolyte levels (esp Na) to guide the planning of interventions to correct any imbalances in an older client, however it is not the priority assessment 6. A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. I can concentrate best in the morning – best indicates readiness to learn bc he is verbalizing the best time frame for him to learn b. It is difficult to read the instructions because my glasses are at home c. I'm wondering why I need to learn this d. You will have to talk to my wife about this 7. A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? a. Touch the face with a cotton ball – tests CN 5 - trigeminal b. Apply a vibrating tuning fork to the client's forehead – Weber test - sound lateralization for hearing c. Have the client stand with her arms at her side and her feet together – Romberg’s test helps identify alterations in balance. The nurse should observe for swaying and loss of balance d. Perform direct percussion over the area of the kidneys – This evaluates for kidney inflammation 8. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? a. Allow extra time for the client to respond to questions – Older clients process information at a slower rate than younger clients. The nurse should plan for extra time to allow for questions and absorption of information b. Expect the client to have difficulty understanding the information – cognitive abilities vary between individuals. Rather than expecting misunderstanding, the nurse should assess their cognition and ability to learn, teach, and understand. c. Avoid references to the client's past experiences – The nurse should explore their past experience and use them to establish connections to new knowledge d. Keep the learning session private and one-on-one – It is helpful when working with older adult clients to invite another household member to the teaching session so that person can help reinforce new information later. The nurse should also honor the client’s preference for one-on-one or group settings. 9. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly – weight bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adults in this preventative and therapeutic strategies b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics 10. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention. a. Erythema on pressure points – requires prompt relief of pressure and additional measures to protect the skin from further breakdown b. Lower extremity pulse strength of 2+ - expected finding c. Fluid intake of 3000 mL per day – clients should drink 2.5-3L a day d. A bowel movement every other day – bowel movements less frequent than 3x/week indicate constipation and need for intervention 11. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration – nurse should gently shake the liquid to ensure the medication is mixed b. Transfer the medication to a medicine cup – this could risk altering the premeasured dose c. Place the client in a semi-Fowler's position prior to medication administration – High-Fowler’s to reduce the risk of aspiration d. Verify the dosage by measuring the liquid before administering it – this could risk altering the pre-measured dose 12. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. Check the client for injuries – The 1st action the nurse should take when using the nursing process is to assess for injuries b. Move hazardous objects away from the client – this prevents further injury but not priority c. Notify the provider – not priority d. Ask the client to describe how she felt before the fall – not priority

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  • Pages 14
  • Category Exam Elaboration
  • School / University other / unknown
  • Course Uncategorized
  • Course Level University level
  • Year 2023
  • Keywords ATI, NURSING
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