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Virtual ATI Fundamentals
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- A nurse is preparing to assess a client’s cardiac function by auscultating heart sounds at the cardiac landmarks. Which of the following areas should the nurse identify as the pulmonic area? (Select only the hot spot that corresponds to your answer.)
a. A b. B c. C d. D
a; incorrect. Nurse should identify this area as the mitral area of cardiac landmarks, considered the point of maximal impulse. Also the area which apical heart rate is best auscultated, located in the 5 th intercostal space, to the left of the sternum, at the left midclavicular line.
b; incorrect. This area is the tricuspid area, located at the left 4 th or 5 th^ intercostal space, near the sternum.
c; correct. This area is the pulmonic area, located at left 2 nd intercostal space, near the sternum.
d; incorrect. This area is the aortic area, located in the right 2 nd intercostal space, near the sternum.
- A nurse is applying a new transdermal patch to a client. Which of the following actions should the nurse take?
a.Wear gloves when applying the patch.
b.Apply the patch to the client’s right or left forearm.
c.After applying a new patch, dispose of the old one in a waste container with a lid.
d.When replacing the patch, cut the old one in half before disposing of it.
a; correct. Nurse should apply the patch while wearing clean gloves to prevent transfer of the medication through the skin.
b; incorrect. Nurse should not apply patch to distal areas of the body, such as forearms. Nurse should apply patch to areas that do not move frequently such as lower abdomen or buttocks.
c; incorrect. When applying a new patch, nurse should fold the adhesive side of the old patch together and dispose of it in a childproof container.
d; incorrect. When replacing the patch, nurse should fold the adhesive side of the old patch together and dispose of it in a childproof container.
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- A home health nurse is making an initial assessment visit to an older adult client who has type 1 diabetes mellitus. Which of the following statements should the nurse make to evaluate the client’s ability to measure blood glucose accurately?
a; correct. Asking for a return demonstration is an effective way to assess a client’s ability to complete a psychomotor activity. The nurse should carefully observe the client using the glucometer to validate the client’s understanding of the procedure and evaluate
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b. “Please tell me how long you have been using this glucometer.”
c. “These blood glucose results you’ve written down do not seem correct.”
d. “Let me show you how to use this glucometer, so you can see if this is how you’ve been using it.”
b; incorrect. This statement does not provide information to the nurse about the client’s ability to perform the skill accurately. The client might have been using the device incorrectly, no matter how long they have been using it.
c; incorrect. Confrontation is a technique the nurse should use sparingly and only after establishing trust. This type of statement placed the client on the defensive. The problem could be actual fluctuations in blood glucose, a faulty glucometer, or faulty technique.
d; incorrect. Showing the client how to use the device does not provide necessary information about the client’s ability to perform the skill accurately. The nurse should ask the client to demonstrate the skill to ensure it is being performed correctly.
- A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?
a. Cover the pad with a pillowcase before application.
b. Apply the pad for 45 min per application.
c. Set the temperature of the a q ua t h e rmi a pa d t o 50 C (1 22 F).
d. Use safety pins to hold the pad in place.
a; correct. Nurse should cover the aquathermia pad with a thin towel or pillowcase before use because applying the pad directly to the skin could cause a burn injury.
b; incorrect. Application of aquathermia pad usually lasts 30 min. Prolonged application of pad paces client at risk for a burn injury.
c; incorrect. Nurse should set the temperature of aquathermia p a d t o 40 C ( 104 F).
d; incorrect. Nurse should not use pins to hold the aquathermia pad in place because they can cause a leak. Nurse should use tape or gauze ties to hold the pad in place.
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- A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)
mL
0.4 mL
- A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client’s safety. To which of the following parts of the bed should
a; incorrect. Attaching wrist restraints to the head of the bed is not an acceptable action by the nurse because it can injure the client.
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- A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients?
a. A client who has chronic back pain and a history of physical maltreatment. b. A client who has chronic joint discomfort and a history of mild dementia. c. A client who has chronic knee pain and a history of grand mal seizures. d. A client who has chronic hip pain and a history of uterine cancer.
a; correct. Therapeutic touch consists of using the nurse’s hands to harmonize energy fields and to facilitate relief of pain or anxiety, such as for a client who has chronic back pain. The nurse can touch the client with their palms or move the palms near, but not touching the client’s body. Prior physical maltreatment and some mental health disorders are a contraindications for therapeutic touch, because touch or near touch could cause severe anxiety.
b; incorrect. Therapeutic touch can provide comfort for clients who have chronic pain. It can also be a comforting therapy for clients who have dementia. Nurse should assess each client individually before using complementary therapies, such as therapeutic touch.
c; incorrect. The presence of a seizure disorder is not a contraindication for the use of therapeutic touch. The nurse should assess each client individually before using complementary therapies, such as therapeutic touch.
d; incorrect. The presence of cancer or a history of it is not a contraindication for the use of therapeutic touch. The nurse should assess each client individually before using complementary therapies, such as
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therapeutic touch.
- A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?
a. Move the client using a slider board. b. Use an air-assisted transfer device to
a; incorrect. Using a slider board to transfer a client who weighs 136 (300 lb) places the client and nurse at risk for injury. A slider board is used to transfer clients who weigh less than 90 kg (200 lb), are postoperative, or have experienced hemiparesis or amputation of a lower extremity.
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- A nurse receives a telephone prescription from the provider, who states, “Four milligrams of morphine diluted with five milliliters of sterile water intravenous each morning at nine o’ clock before client dressing changes.” Which of the following entries by the nurse indicates correct transcription of the prescription?
a. MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water. b. Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water c. Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water. d. MSO4 4 mg IV bolus daily @ 9 AM, dilute with 5 mL of sterile water
a; incorrect. This transcription contains unacceptable abbreviations and does not include all relevant information. “MSO4” and “cc” are not acceptable abbreviations according to The Joint Commission. The medication should also be diluted with sterile water.
b; correct. This entry by the nurse indicates correct transcription of the prescription. This transcription contains acceptable abbreviations according to The Joint Commission and includes complete information from the provider.
c; incorrect. This transcription contains unacceptable abbreviations and does not include all relevant information. “Q.D.” and “cc” are not acceptable abbreviations, and the nurse omitted the time of administration.
d; incorrect. This transcription contains unacceptable abbreviations and does not include all relevant information. “MSO4” is
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not an acceptable abbreviation for morphine according to The Joint Commission. Also, the time of administration should be “at 0900” not “@ 9 AM,” which is not an acceptable abbreviation. The nurse should also include that the medication is given before dressing changes.
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- A nurse is planning an in-service about foot care for a group of clients who have peripheral neuropathy. Which of the following information should the nurse include?
a. Apply foot cream between the toes. b. Use a pumice stone to soften calluses. c. Inspect the feet daily using a mirror. d. Round the toenail edges when clipping.
a; incorrect. The nurse should include in the program to apply foot cream to all areas of the feet but not between the toes. Moisture between the toes can increase the risk for infections.
b; incorrect. The nurse should include in the program to avoid using pumice stone or over the counter products to treat corns and calluses. Client should consult their primary care provider or a podiatrist for foot care.
c; correct. The nurse should include in the program to inspect the feet daily with a mirror for dryness, redness, lesions, or lacerations, which can place the client at risk for infection.
d; incorrect. The nurse should include in the program to square the edges of the toenails, rather than rounding them, when clipping
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to prevent a break in the skin by the nail, which can place the client at risk for infection.
- A nurse is planning care for a client who is receiving IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?
a; incorrect. Nurse should change the secondary IV infusion set every 24 hr if it is not attached to the primary IV infusion set to minimize the risk of contamination and infection.
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- A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy
a; incorrect. The nurse should instruct the client not to change the oxygen flow rate in order to
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using a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will regulate the oxygen flow rate as needed.” b. “I will store oxygen tanks in an upright
maintain the prescribed oxygen rate.
b; correct. This statement by the client indicates an understanding of the teaching. The nurse should instruct the client to store oxygen tanks in an upright positioning a holder to prevent damage to the tank and injury to the client and the client’s family.
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- A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following tasks should the nurse instruct the family to perform first? a. Place the client in a side-lying position. b. Clean the client’s mouth with foam swabs. c. Position an emesis basin under the client’s chin. d. Place a towel under the client’s head.
a; correct. The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse should instruct the family to perform is to place the client in a side-lying position. If the client should not be placed in a side-lying position, then the nurse should instruct the family to turn the client’s head to the side to allow fluid to run out of the client’s mouth.
b; incorrect. Nurse should instruct the family to clean the client’s mouth with foam swabs to prevent injury and for thorough and effective cleaning of the client’s mouth, gums, and tongue. However, there is another action the nurse should take first.
c; incorrect. Nurse should instruct the family to place an emesis basin
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under the client’s chin to collect any secretions and water for safe disposal and to keep the client’s bed dry. However, there is another action the nurse should take first.
d; incorrect. Nurse should instruct the family
