Prepare for the ATI Fundamentals proctored exam with these practice questions and answers. This guide covers the nursing process, patient safety, infection control, documentation, and basic nursing care.
Q: A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nursing include in the teaching? (Select all that apply)A. Home healthcareB. Rehabilitation facilitiesC. Diagnostic centersD. Skilled nursing facilitiesE. Oncology centers
Answer: a. home health careb. rehabilitation facilities c. skilled nursing facilities
Q: A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply)A. Preferred provider organizationB. MedicareC. Long term care insuranceD. Exclusive provider organizationE. Medicaid
Answer: b. medicarec. medicaid
Q: A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?collaborating with providers to perform obesity screenings during routine office visits
Answer: collaborating with providers to perform obesity screenings during routine office visits
Q: A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health strategy?A. Collaborating with providers to perform obesity screenings during routine office visitB. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesityC. Providing specialized Intraoperative training regarding surgical treatments for obesityD. Educating acute care nurses on post operative complications related to obesity
Answer: A. Collaborating with providers to perform obesity screenings during routine office visits
Q: A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards?A. Monitoring evidence-based practice for clients who have a special diagnosisB. Ensuring that healthcare providers comply with regulationsC. Setting quality standards for accreditation of healthcare facilitiesD. Determining if medications are safe for administraion to clients
Answer: B. Ensuring that healthcare providers comply with regulations
Q: A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? SATAA. Intensive care unitB. Oncology treatment centerC. Burn centerD. Cardiac rehabilitationE. Home health care
Answer: A. Intensive care unitB. Oncology treatment centerC. Burn center
Q: When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which id the following actions should the nurse take when preparing the sterile field?A. Keep the sterile field at least 6 feet away from client’s bedside.B. Instruct the client to refrain from coughing and sneezing during the dressing change.C. Place a mask on the client to limit the spread of micro-organism into the surgical wound.D. Keep a box of facial tissues nearby for the client to use during the dressing change.
Answer: C. Place a mask on the client to limit the spread of micro-organism into the surgical wound.
Q: A nurse has removed a sterile pack form its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?A. The flap closet to the bodyB. The right side flapC. The left side flapD. The flap farthest from the body
Answer: D. The flap farthest from the body
Q: A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique. (Select all that apply.)A. A bottle containing a sterile solutionB. The edge of the sterile drape at the base of the fieldC. The inner wrapping of an item on the sterile fieldD. An irrigation syringe on the sterile fieldE. One gloved hand with the other gloved hand
Answer: C. The inner wrapping of an item on the sterile fieldD. An irrigation syringe on the sterile fieldE. One gloved hand with the other gloved hand
Q: A nurse is reviewing hand hygiene technique with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply.)A. Apply 3 to 5 mL of liquid soap to dry handsB. Wash the hands with soap and water for at least 15 seconds.C. Rinse the hands with hot water.D. Use a clean paper towel to turn off hand faucets.E. Allow the hands to air dry after washing.
Answer: B. Wash the hands with soap and water for at least 15 seconds.D. Use a clean paper towel to turn off hand faucets.
Q: A nurse has prepared a sterile field for assisting a provider with a chest tube injection. Which of the following events should the nurse recognize as contaminating the sterile field. (Select all that apply.)A. The provider drops a sterile instrument onto the near side of the sterile field.B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.C. The procedure is delayed 1 hour because the provider receives an emergency call.D. The nurse turns to speak to someone who enters through the door behind the nurse.E. The client’s hand brushes against the outer edge of the sterile field.
Answer: B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.C. The procedure is delayed 1 hour because the provider receives an emergency call.D. The nurse turns to speak to someone who enters through the door behind the nurse.
Q: A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. WHich of the following illistrate the rationale for reporting? (select all that apply.)A. Planning and evaluating control and prevention strategies.B. Determining public health prioritiesC.Ensuring proper medical treatmentD. Identifying endemic diseasesE. Monitoring for common-source outbreaks
Answer: A. Planning and evaluating control and prevention strategies.B. Determining public health prioritiesC. Ensuring proper medical treatmentE. Monitoring for common-source outbreaks
Q: A nurse is caring for a client who reprtds of severe sore throat, pain when swallowing, and swollen lymph nodes. The cleint is experiencing which of the following stages of infection.A. ProdromalB. IncubationC. ConvalescenceD. Illness
Answer: D. Illness
Q: A nurse educator is revieing with a newly hired nurse the diferencies in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systmeic infection? (Slect all that apply.)A. feverB. malaiseC. edemaD. pain or tendernessE. increase in pulse and repiratory rate
Answer: A. feverB. malaiseE. increase in pulse and respiratory rate
Q: A nurse is contributingto the plan of care for a client who is being admitted to the facility wit a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)A. Place the client in a room that has negative air pressure of at least six exchanges per hour.B. Wear a mask when providing care within 3 ft of the clientC. PLace a surgical mask on the client if transportation to another department is unavoidableD. Use sterile gloves when handling soiled linens.E. Wear a gown when performing care that might result in contamination from secretions.
Answer: B, C, E
Q: A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (select all that apply)A. Address the client with the appropriate title and their last name.B. Use a mix of open- and closed-ended questions.C. Reduce environmental noise.D. Have the client complete a printed history form.E.Perform the general survey before the examination.
Answer: B. Use a mix of open- and closed-ended questions.C. Reduce environmental noise.E.Perform the general survey before the examination.
Q: A nurse in a provider’s office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (select all that apply)A. PostureB. Skin lesionsC. SpeechD. AllergiesE. Immunization status
Answer: A, B, C
Q: A nurse is collecting data for a client’s comprehensive physical examination. After inspecting the client’s abdomen, which of the following skills of the physical examination process should the nurse perform next?A. OlfactionB. AuscultationC. PalpationD. Percussion
Answer: B. Auscultation
Q: A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client’s age? (Select all that apply)A. Expect the session to be shorter than for a younger client.B. Plan to allow plenty of time for position changes.C. Make sure the client has any essential sensory aids in place.D. Tell the client to take their time answering bathroom before beginning the examination.
Answer: B. Plan to allow plenty of time for position changes.C. Make sure the client has any essential sensory aids in place.D. Tell the client to take their time answering bathroom before beginning the examination.
Q: A nurse in a provider’s office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature?A. Palmar SurfaceB. FingertipsC. Dorsal SurfaceD. Base of the fingers
Answer: C. Dorsal Surface
Q: A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F ), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.)A. Obtain culture specimens before initiating antimicrobials.B. Restrict the client’s oral fluid intake.C. Encourage the client to rest and limit activity.D. Allow the client to shiver to dispel excess heat.E. Assist the client with oral hygiene frequently.
Answer: A. Obtain culture specimens before initiating antimicrobials.C. Encourage the client to rest and limit activity.E. Assist the client with oral hygiene frequently.
Q: A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priory for measuring vital signs for this client?A. “Do not measure the client’s temperature rectally.”B. “Count the client’s radial pulse for 30 seconds and multiply it by 2.”C. “Do not let the client know you are counting their respirations.”D. “Let the client rest for 5 minutes before you measure their blood pressure.”
Answer: A. “Do not measure the client’s temperature rectally.”(can cause bleeding)
Q: A nurse is instructing a group of assistive personnel in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)A. Place the client in semi-Fowler’s positionB. Have the client rest an arm across the abdomen.C. Observe one full respiratory cycle before counting the rate.D. Count the rate for 30 sec if it is irregular.E. Count and report an sighs the client demonstrates.
Answer: A. Place the client in semi-Fowler’s positionB. Have the client rest an arm across the abdomen.C. Observe one full respiratory cycle before counting the rate.
Q: A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?A. Request a prescription for an anti hypertensive medicationB. Ask client if they are having pain.C. Request a prescription for an anti anxiety medication.D. Return in 30 min to recheck the client’s blood pressure.
Answer: B. Ask client if they are having pain.
Q: A nurse is performing an admission assessment on a client. The nurse determines the client’s radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit?
Answer: 16
Q: A nurse in a provider’s office is preparing to test a client’s cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply).A. “Close your eyes.”B. “Tell me what you can taste.”C. “Clench your teeth.”D. “Raise your eyebrows.”E. “Tell me when you feel a touch.”
Answer: C and E
Q: A nurse is assessing a client’s thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)A. Palpating the thyroid in the lower half of the neckB. Visualizing the thyroid on inspection of the neckC. Hearing a bruit when auscultating the thyroidD. Feeling the thyroid ascend as the client swallowsE. Finding symmetric extension off the trachea on both sides of the mid-line.
Answer: A. Palpating the thyroid in the lower half of the neckD. Feeling the thyroid ascend as the client swallowsE. Finding symmetric extension off the trachea on both sides of the mid-line.
Q: A nurse is assessing an adult client’s internal ear canals with an otoscope as part of a head and neck examination. Which of the following action should the nurse take? (Select all that apply)A. Pull the auricle down and backB.insert speculum slightly down and forwardC. Insert the speculum slightly down 2 to 2.5cm (0.8 to 1 in).D. Make sure the speculum does not touch the ear canalE. Use the light to visualize the tympanic membrane in a cone shape
Answer: B, D, E
Q: A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? ( Select all the apply.)A. Reddened gumsB. Lowered vocal pitchC. Tooth lossD. Glare intoleranceE. Thickened eardrums
Answer: C. Tooth lossD. Glare intoleranceE. Thickened eardrums
Q: A nurse in a provider’s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.)A. Smaller nipplesB. Less adipose tissueC. Nipple dischargeD. More pendulousE. Nipple Inversion
Answer: ADE
Q: A nurse in a provider’s office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all the apply.)A. RhonchiB. CracklesC. ResonanceD. Tactile fremitusE. Bronchovesicular sounds
Answer: C, E
Q: During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?A. FatB. FluidC. FlatusD. Hernias
Answer: C (with flatus, the protrusion is mainly midline, and there is no change in flanks)
Q: During a cardiovascular examination, a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.)A. Ventricular gallopB. Closure of the mitral valveC. Closure of the pulmonic valveD. Closure of the tricuspid valveE. Murmur
Answer: B, DA. Incorrect: To auscultate a ventricular gallop (an S3 sound), the nurse places the bell of the stethoscope at ech of the auscultatory sites.B. Correct: To auscultate the closure of the mitral valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space.C. Incorrect: To auscultate the closure of the pulmonic valve, the nurse places the diaphragm of the stethoscope over the aortic area, which is just to the right of the sternum at the second intercostal space.D. Correct: To auscultate the closure of the tricuspid valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space.E. Incorrect: To auscultate a murmur, the nurse places the bell of the stethoscope at various auscultatory sites.
Q: A nurse in a provider’s office is preparing to auscultate and percuss a client’s abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)A. TympanyB. High-pitched clicksC. BorborygmiD. Friction rubsE. Bruits
Answer: A, BA. Correct: Tympany is the expected drumlike percussion sound over the abdomen. It indicates air in the stomach.B. Correct: Typical bowel sounds are high-pitched clicks and gurgles occurring about 35 times/min.C. Incorrect: Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some foods.D. Incorrect: Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings.E. Incorrect: Bruits indicate narrowed blood vessels and are unexpected findings.
Q: A nurse in a provider’s office is preparing to assess a client’s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)A. Capillary refill 2 secondsB. 1+ pitting edema in both feetC. Pale nail beds in both handsD. Thick skin on the soles of the feetE. Numerous light brown macules on the face
Answer: A. Capillary refill 2 secondsD. Thick skin on the soles of the feetE. Numerous light brown macules on the face
Q: A nurse’s assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply)A. Thin, parchment-like skinB. Loss of adipose tissueC. DehydrationD. Diminished skin elasticityE. Excessive dryness and wrinkling
Answer: B. Loss of adipose tissueC. DehydrationD. Diminished skin elasticity
Q: A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client’s peripheral vascular system? (Select all that apply)A. Range of motionB. Skin colorC. EdemaD. Skin lesionsE. Skin temperature
Answer: B. Skin colorC. EdemaE. Skin temperature
Q: A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles? (Select all that apply)A. AcneB. WartsC. PsoriasisD. Herpes simplexE. Varicella
Answer: D E
Q: A nurse in a provider’s office is preparing to assess a young adult male client’s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)A. A concave thoracic spin posteriorlyB. An exaggerated lumbar curvatureC. A concave lumbar spine posteriorlyD. An exaggerated thoracic curvatureE. Muscles slightly larger on his dominant side
Answer: C, E
Q: A nurse is evaluating a client’s neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items?A. A word she whispers 30 cm from his earB. A number she traces on the palm of his handC. The vibration of a tuning fork she places on his footD. A familiar object she places in his hand
Answer: D
Q: A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?A. Mopping her floorsB. Brushing the back of her hairC. Fastening her bra behind her backD. Reaching into a cabinet above her sink
Answer: C
Q: A nurse is performing a neurologic examination for a client. Which of the following tests should the nurse perform to test the client’s balance? (Select all that apply)A. Romberg testB. Heel-to-toe walkC. Snellen testD. Spinal accessory functionE. Rosenbaum test
Answer: A, B
Q: A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply)A. Slower light touch sensationB. Some vision and hearing declineC. Slower fine finger movementD. Some short-term memory declineE. Slower superficial pain sensation
Answer: A, B, C, D
Q: A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take?a. Offer information on a relaxation technique and ask the client if he is interested in trying it.b. Request a social worker to see the client to discuss meditation.c. Attempt to use biofeedback techniques with the clientd. Tell the client many people feel the same way before surgery and to think of something else
Answer: a. Offer information on a relaxation technique and ask the client if he is interested in trying it.
Q: A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients?a. Chamomileb. Ginsengc. Gingerd.Echinacea
Answer: A
Q: A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (Select all that apply.)a. Art therapyb. Acupressurec. Yogad. Therapeutic touche. Biofeedback
Answer: A, C, E
Q: A nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (Select all that apply.)a. Guided imageryb. Massage therapyc. Meditationd. Music therapye. Therapeutic touch
Answer: A, C, E
Q: A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention?a. Tell the client the goal of the therapy is to promote healing.b. Ask whether the client is comfortable with using prayer.c. Encourage the client participate actively for best results.d. Instruct the client to relax during the therapy.
Answer: B
Q: A nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. The client states his pain level is 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should the nurse administer?A. Meperidine (Demerol) 75 mg IMB. Fentanyl 50 mcg/hr transdermal patchC. Morphine 2 mg IVD. Oxycodone 10 mg PO
Answer: C. CORRECT: IV morphine is the best choice because the onset is rapid, and absorption of the medication into the blood is immediate, which provides an immediate response for a client who is reporting pain at a level of 10.A. INCORRECT: Although meperidine is used for pain control, the IM route of administration can allow for slow absorption delaying the onset of pain relief. The IM route also can cause additional pain from injection.B. INCORRECT: Although fentanyl is used for pain control, the transdermal route of administration can allow for slow absorption delaying the onset of pain relief.D. INCORRECT: Although oxycodone is used for pain control, the oral route of administration of this medication can allow for onset of pain relief in 10 to 15 min, which can be a long time for a client who is reporting pain at a level of 10.
Q: A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and narcotics. Which of the following statements by the client indicates an understanding of the teaching?A. “I can open the capsule with the beads in it and sprinkle them on my oatmeal.”B. “If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding.”C. “The pills with the coating on them can be crushed.”D. “I will eat two crackers with the pain pills.”
Answer: D. CORRECT: It is recommended to administer irritating medications with small amounts of food. This will assist with prevention of nausea and vomiting so that the medication can be retained and take effect.A. INCORRECT: Although this may assist a client with swallowing issues, enteric-coated or timerelease medications should be swallowed whole.B. INCORRECT: Although it is recommended to add a liquid medication to food if the client is having difficulty swallowing, it is not recommended to mix the medication with large amounts of food or beverage in case the client is unable to consume the entire quantity.C. INCORRECT: Enteric-coated or time-release medications should be swallowed whole and cannot be crushed.
Q: A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching?A. “Flush the tube before and after each medication.”B. “Administer your medications with your enteral feeding.”C. “Administer tablets through the tube slowly.”D. “Mix all the crushed medications prior to dissolving in water.”
Answer: A. CORRECT: The client should flush the tubing before and after each medication with 15 to 30 mL of water to prevent clogging of the tube.B. INCORRECT: In order to maximize the therapeutic effect of a medication, it is recommended to never mix medications with enteral feeding. In addition, if the client does not receive the entire feeding he does not receive the entire medication. This can also delay the client receiving the medication.C. INCORRECT: The client should not administer tablets or undissolved medications through a jejunostomy tube because they may clog the tube.D. INCORRECT: The client should administer each medication separately.
Q: A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the first-pass effect?A. “Some medications block normal receptor activity regulated by endogenous compounds or receptor activity caused by other medications.”B. “Some medications may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver.”C. “Some medications leave the body more slowly and therefore have a greater risk for medication accumulation and toxicity.”D. “Some medications have a wide safety margin, so there is no need for routine serum medication level monitoring.”
Answer: B. CORRECT: Some medications are inactivated on their first pass through the liver and must be given by a nonenteral route to prevent this inactivation. These medications are usually given by routes such as sublingual or IV.A. INCORRECT: This statement describes an antagonist medication, not the first pass-effect.C. INCORRECT: This statement describes a long half life, not the first-pass effect.D. INCORRECT: This statement describes a high therapeutic index, not the first-pass effect.
Q: A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?A. “I will straighten my ear canal by pulling my ear down and back.”B. “I will gently apply pressure with my finger to the tragus of my ear after putting in the drops.”C. “I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.”D. “After the drops are in, I will place a cotton ball all the way into my ear canal.”
Answer: B. CORRECT: The client should gently apply pressure with the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal.A. INCORRECT: The adult client should straighten the ear canal by pulling the auricle upward and outward to open up the ear canal to allow the medication to reach the eardrum.C. INCORRECT: The client should never occlude the ear canal with the dropper when instilling ear drops because this can cause pressure that could injure the eardrum.D. INCORRECT: The client should not place a cotton ball past the outermost part of the ear canal because it could introduce bacteria to the inner or middle ear.
Q: A nurse prepares an injection of morphine (Duramorph) to administer to a client who reports pain. Prior to administering the medication, the nurse is called to another room to assist another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take?A. Offer to assist the client needing the bedpan.B. Administer the injection prepared by the other nurse.C. Prepare another syringe and administer the injection.D. Tell the client needing the bedpan she will have to wait for her nurse.
Answer: A. CORRECT: The second nurse should offer to assist the client needing the bedpan. This will allow the nurse who prepared the injection to administer it.B. INCORRECT: A nurse should only administer medications that he prepared.C. INCORRECT: Preparing another syringe will delay the administration of the pain medication.D. INCORRECT: Telling the client to wait is not an acceptable option for a client needing a bedpan.
Q: A nurse is reviewing a client’s prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 & 1100? (Select all that apply.)-A once-daily multivitamin-Eye drops prescribed every 3 hrs-An antibiotic prescribed every 8 hr-A blood pressure prescribed twice daily-A subcutaneous injection prescribed once weekly
Answer: A once a day multivitaminA subcutaneous injection prescribed once weekly
Q: A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statement should the nurse identify as an indication that the newly licensed nurse understands the process?-“A second nurse enters the prescription into the client’s medical record.”-“Another nurse should listen to the phone call”-“The provider can clarify the prescription when they sign the health record.”-“I should omit the ‘read back’ if this is a one-time prescription”
Answer: “Another nurse should listen to the phone call”
Q: A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.)-“I will observe for adverse effects.”-“I will monitor for therapeutic effects”-“I will prescribe the appropriate dose”-“I will change the dose if adverse effects occur.”-“I will refuse to give a medication if I believe it is unsafe”
Answer: -“I will observe for adverse effects”-“I will monitor for therapeutic effects”-I will refuse to give a medication if I believe it is unsafe”
Q: A nurse reviewing a client’s health record notes a new prescription for lisinprol 10 mg PO once every day. The nurse should identify this as which of the following types of prescription?-Single-Stat-Routine-Now
Answer: Routine
Q: A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure?A. “I will thread the needle all the way into the vein until the hub rests against the insertion site after I see flashback of blood.”B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with he bevel up.”C. “I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle.”D. “I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location.”
Answer: B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with he bevel up.”
Q: A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and “not feeling well.” The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?A. Obtain a specimen for cultureB. Apply a warm compress.C. Administer analgesicsD. Discontinue the infusion
Answer: D. Discontinue the infusion
Q: During new employee orientation, a nurse is explaining how to prevent IV infusions. Which of the following statements by an oriented indicates understanding of the preventive strategies?A. “I will leave the IV catheter in place after the client completes the course of IV antibiotics.”B. “As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt.”C. “If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab.”D. “I will replace any IV catheter when I suspect contamination during insertion.”
Answer: D. “I will replace any IV catheter when I suspect contamination during insertion.”
Q: A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)A. “The temperature around the IV site is cooler.”B. “The rate of infusion increases.”C. “The skin at the IV site is red.”D. “The IV dressing is damp.”E. “The tissue around the venipuncture site is swollen.”
Answer: A. “The temperature around the IV site is cooler.”D. “The IV dressing is damp.”E. “The tissue around the venipuncture site is swollen.”
Q: A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (select all that apply.)A. “I feel lightheaded.”B. “I feel as though my heart is racing.”C. “I feel a little short of breath.”D. “The nurse technician told me that my blood pressure was 150 over 90.”E. “I think my ankles are less swollen.”
Answer: B. “I feel as though my heart is racing.”C.”I feel a little short of breath.”D. “The nurse technician told me that my blood pressure was 150 over 90.”
Q: To promote adherence with medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (select all that apply)a. adjust dosages according to daily weightb. place pills in daily pill holdersc. ask for liquid forms if the client has difficulty swallowing pillsd. ask a relative to assist periodicallye. request child-resistant caps on medication containers
Answer: b. place pills in daily pill holdersc. ask for liquid forms if the client has difficulty swallowing pillsd. ask a relative to assist periodicallyOrganizing medications in daily pill holders promotes medication adherenceProviding a form of medication that is easier for the client to swallowpromotes medication adherenceIncluding the client’s support system promotes medication adherence
Q: A young adult client in a provider’s office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity?a. increasing the metabolism of the medications over timeb. increasing the protein-binding responsec. increasing medications’ transit time through the intestinesd. decreasing the excretion of medications
Answer: b. increasing the protein-binding responseInadequate nutrition, such as starvation, can affect the protein-binding response of medications. It increases their response and thus increases the risk for medication toxicity.
Q: A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (select all that apply).a. increased gastric acid productionb. lower blood pressurec. higher body water contentd. increased absorption of topical medicationse. increased gastric emptying time
Answer: b. lower blood pressurec. higher body water contentd. increased absorption of topical medicationsChildren have a lower blood pressureChildren have a higher body water contentChildren have increased absorption of topical medications
Q: A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk?a. Drink 8 oz milk with each dose of medication.b. Use medications that have an extended half-lifec. Take each dose right after breastfeedingd. Pump breast milk and freeze it prior to feeding the newborn
Answer: C. Take each dose right after breastfeedingTaking medication immediately after breastfeeding helps minimize medication concentration in the next feeding
Q: A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make?a. “You will need to get a rubella immunization if you haven’t had one prior to pregnancy”b. “You can safely take over-the-counter medications”c. “You should avoid any vitamin preparations containing iron.”d. “Your provider can prescribe medication for nausea if you need it”
Answer: d. “Your provider can prescribe medication for nausea if you need it”Providers can prescribe medications to treat nausea and other discomforts of pregnancy