West Coast University, Ontario

PHARM 180

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?
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?

4. a nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?

5. 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?
6. 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?

7. 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)
8. 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?

9. 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?
10. a nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?
11. a nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?

12. 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?
13. 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?
14. 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?

15. 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?
16. 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?

17. 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?

18. 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

19. 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?
20. 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?
21. 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?

22. a nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?

23. 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?

24. 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?
25. 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?
26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. a nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take?

Place an activated tuning fork in the middle of the clients forehead

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. a nurse is delegating client’s care to an assistive personnel. Which of the following tasks should the nurse delegate to the AP?

ADLs (bathing, grooming, toileting, ambulate etc) specimen collection, I&O, vital sign (stable)

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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?

I know this

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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