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Kaplan Fundamentals of Nursing ATI Proctored Exam

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ATI Fundamentals Proctored Final

Kaplan Fundamentals Proctored Exam

1. A nurse is teaching an assistive personnel about using proper body mechanics to prevent injury. Which of the following actions by the AP indicates an understanding of the teaching?

A. The AP extends his pelvis outward when reaching for an object.

B. The AP keeps the object he is lifting close to his body

C. The AP bends at the waist when lifting an object.

D. The AP relaxes his abdominal muscles when reaching for an object.

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?

A. Change the client’s position every 4 hours

B. Use friction when cleansing the client’s skin

C. Apply a petroleum-based ointment to the red area

D. Assess the red area for blanching

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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 IV therapy?

A. The cephalic vein in the left distal forearm.

B. The radial vein on the left wrist.

C. The cephalic vein on the back of the right hand.

D. The basilic vein in the right antecubital fossa

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)

A.Use a nondominated hand to stretch the skin

B. Insert the needle at an angle

C. inject the medication

D. Withdrawal the needle

E. 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.

A. Have a colonoscopy every 3 years.

B. Have a fecal occult blood test every 2 years.

C. Limit intake of dietary fiber.

D. Reduce intake of red meats

6. A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

A. Apply cornstarch to the client’s skin.

B. Arrange for an alternating pressure mattress.

C. Reposition the client every 4 hours.

D. 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?

A. Allow 2.5 to 5 cm (1 to 2 in) between the end of the catheter and the tip of the penis.

B. Keep foreskin in a retracted position after application of the catheter.

C. Place adhesive tape directly on the penis.

D. 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 nurse include in the teaching ( Select all that apply).

A. Apply pressure just below the artificial eye to break the suction.

B. Store the artificial eye in a labeled container filled with 0.9% sodium chloride irrigation.

C. Clean the artificial eye with hydrogen peroxide before storing.

D. Remove the artificial eye by retracting the upper eyelid.

E. Retract the upper and lower lids to reinsert the artificial eye

9. A nurse is reviewing client confidentially with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPAA?

A. Teaching the client discharge instructions with his partner present.

B. Giving a telephone report to a surgical nurse when sending the client to the surgical suite.

C. Discussing the client’s transfer to a long term care facility with a nurse from another unit.

D. Faxing medical information to the client’s provider’s office.

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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?     

A. Determine areas of resonance across the abdomen using a systematic approach
B. Expose the clients abdomen to look for changes in appearance
C. Perform abdominal palpation by pressing gently with the finger pads
D. 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?

A. Determine the client’s reading ability
B. Review the use of an artificial larynx
C. With the client schedule a support session
D. 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

A. I will use the bars when getting in and out of the bath tub

B. I need to check my medications for expiration dates

C. I need to have a fire escape plan with my family

D. I will apply tape over frayed areas of electrical cords

E. 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?

A. The client turns his head against resistance.

B. The client’s tongue is in a midline position.

C. The client’s pupils constrict in response to light.

D. The client has a symmetrical smile.

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?

A. Offer pain medication

B. Palpate the abdomen

C. Auscultate bowel sounds

D. 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?

A. Don’t understand why he can’t get better and return to work

B. I cook for him at home and work hard to prepare a nutritious meals

C. I am going to ask my daughter to come and stay for a week

D. I don’t know if I will be able to meet his physical needs

16. A nurse is planning care for a patient withba stage 1 pressure ulcer on a heel. the nurse should anticipate application of which of the following dressings?
a) dry gauze
b) calcium alignate
c) transparent
d) hydrogel

17.  A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client’s son tell the nurse ‘ i don’t know what to tell he asks how he is going to die ‘ which 0f the following is an appropriate response by the 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?

A. I can apply lotion to soften the calluses as long as I don’t put lotion between my toes

B. I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly

C. I should soak my feet in warm water daily to soften corns and calluses

D. 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?

A. Tie the restraints to the side rale

B. Secure restraints with a square knot

C. Remove one restraint at a time

D. 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)

A. Wear a gown and gloves when providing client care.

B. Wash hands with soap and water after contact with the client.

C. Assign the client to a room with positive airflow.

D. Ensure the client does not receive fresh fruits.

E. Use an N95 respirator when providing client care

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?

A. Schedule the client as the first surgical procedure of the day

B. Cleanse the stoppers with primidone iodine for withdrawing medication

C. Remove the stop stocks from iv tubing

D. Ensure the gloves in the surgical suite are powdered gloves

22. A nurse is providing discharge to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

A- offer written instructions in the client’s language

B-Direct verbal discharge instructions to the interpreter

C- use proper medical terms when giving instructions to the client

D- request that an assistive personnel interpret the instructions for the client

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?

A,. The clients belief that his needs will be met through education

B.  The nurse explaining the need for education to the client

C.  The client seeking family approval by agreeing to a teaching plan

D.  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?

A. Maintain a lean body mass

B. Walk for 30 mins 3 to 5 times a week

C. Perform water aerobics 3 times each week

D. 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?

A. Heat the formula to 105 degrees Fahrenheit

B. Flush the tubing with 10 ml of water every 2 hours

C. Change the tubing every 72 hours

D. Aspirate residual volume every 4 hours

  1. 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?

 

  1. 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?

A. Would you like me to give you a back message

B. Im sure it will work if you just give it a chance

C. Why do you think pain medication is not going to help you

D. 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?

A. The client picks up the walker with each step

B. The client stoops slightly forward when moving the walker

C. The client stands with her elbows slightly flexed while holding the walker

D. 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?

A. Libel

B. Defamation of character

C. Assault

D. 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?

A. Stabilize the vein by applying traction above the insertion site

B. Engorge the vein by placing the arm in the dependent position

C. Use friction at the insertion site to increase venous distention

D. 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?

A. Prepare the client for a central venous line

B. Change the PN infusion bag every 48 hours

C. Administer the PN and fat emulsion separately

D. 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?

A. Provide brochures about the procedure

B. Notify the provider

C. Complete an incident report

D. 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?

A. False imprisonment

B. Invasion of privacy

C. Assault

D. 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?

A. Encourage fluid intake up to 1000 ml daily

B. Insert an indwelling urinary catheter and connect to gravity drainage

C. Allow the client to hear running water while attempting to void

D. 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?

A. Decrease the risk of injecting medication thru the blood vessels

B. It accelerates medication excretion

C. It delays medication absorption

D. 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?

A. Suctioning a clients tracheostomy tube

B. Changing the brief of an older adult client who has clostridium difficile infection

C. Emptying an indwelling catheter bag

D. 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?

A. Use the television to mask external noises

B. Listen to soft music before lying down

C. Exercise just prior to bedtime

D. 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?

A. Each element has a range 1 to 5 points

B. The higher the score the higher the pressure ulcer risk

C. The clients age is part of the measurement

D. 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?

A. Ensure the client is free of medal objects

B. Administer 240 ml (8oz) oral contrast before the procedure

C. Monitor the client for pain in the suprapubic region

D. 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

B. client who is receiving enteral tube feedings

C. Client who requires assistance to transfer from the bed to a chair

D. 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?

A. Place the cap of the sterile solution inside the sterile field

B. Don sterile gloves prior to opening sterile dressing supplies

C. Setup the sterile field above the waist level

D. 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?

A. I can arrange a referral to a Practioner for traditional Chinese medicine

B. You should ask your provider if she recommends traditional Chinese medicine

C. The FDA regulates traditional Chinese medicine

D. 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?

A. I will remove my gown before my gloves after client care

B. I will place the client in a private room

C. I will tell the client’s visitors to wear a mask when they are within 3 feet away of the client

D. 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?

A. Eat a light carbohydrate snack before bedtime

B. Exercise 1 hour before bedtime

C. Drink a cup of hot cocoa before bedtime

D.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?

A. Use full length side rales on the clients bed

B. Check on the client frequently while he is in the restroom

C. Encourage physical activity throughout the day to expand energy

D. 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?

A. I will have my partner help me change positions every 4 hours

B. I will hold my breath rising from a sitting positing

C. I will perform my ankle and knee exercises every hour

D. 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?

A. Client care provider

B. Client educator

C. Client advocate

D. 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?

A. The pad of the finger tip

B. The lateral aspect of the finger

C. The pinna of the ear

D. 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?

A. Use an extinguisher to put out the fire

B. Close the doors to the client’s room

C. Pull the fire alarm

D. 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?

A. Provide the client with a contact number for a diabetes education specialist

B. Make a copy of the medication record of the reconciliation for the client

c. Determine whether the client can afford the insulin administration supplies

D. 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?

A. Loss of appetite

B. Musculoskeletal weakness

C. Left lower extremity tenderness

D. 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?

A. Don protective eye wear before entering the room

B. Administer metronidazole

C. Wear a mask when working within 3 ft of the client

D. 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?

A. Evaluating healing of an incision.

B. Changing IV tubing.

C. Inserting a nasogastric tube.

D. Performing a simple dressing change

55. a nurse is teaching about home safety with a client . which of the following instructions should the nurse include?

A. Use electrical tape to secure extension cords next to base boards on the floor

B. Replace carpet floors with tiles

C. Unplug electronics by grasping the cord

D. 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?

A. Elimination needs

B. Comfort level

C. Peripheral pulses

D. 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?

A. Obtain an x-ray of the abdomen

B. Observing the color of the aspiration

C. Measuring pH of the aspirate

D. 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?

A. Hypoactive bowel sounds

B. No bowel movement for 48 hours

C. Persistent heart burn

D. 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?

A. Cotton tip applicator to clean the inside of the cannula

B. Soak the outer cannula in warm soapy tap water

C. Cleanse the skin around the stoma with normal saline

D. 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?

A. IM

B. q4h

C. stat

D. qd

 

61. a nurse is caring for a client who has a drainage evacuator. Which of the following is a appropriate action by the nurse?

A. Check the volume of the drainage every 24 hr

B. Ensure the drainage suction is set on high pressure

C. Discontinue the drainage when it becomes full

D. 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?

A. Position the chair next to the bed at a 90 degree angle

B. Stand with his feet together when lifting the client

C. Keep his knees straight when moving the client

D. 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?

A. Pain rating of 5 on a scale of 0-10

B. Code status do not resuscitate

C. Start first dose of penicillin

D. 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?

A. Time of the client’s last bath

B. Number of family members who hve visited

C. Effectiveness of the last dose of pain medication

D. 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?

A. Perform BSE 1 week prior to the onset of menses

B. Palpate I horizontal motion from the outer breast toward the nipple

C. Squeeze the nipple to see if discharge

D. 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?

A. Place the bell of the stethoscope on the clients chest

B. Instruct the client to sit erect with head tilted back

C. Ask the client to breath in deeply thru his nose

D. 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

A. Listen to bowel sounds after performing abdominal palpation

B. Place diaphragm of stethoscope over each quadrant

C. Ask client to cough upon auscultating

D. Auscultate for 2 mins to determine if bowel sounds are active

68. 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?

69. 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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Kaplan Fundamentals of Nursing ATI Proctored Exam

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