a nurse is caring for a client who requires a 24 hr urine collection which of the following statements by the client in
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ATI Fundamentals Proctored Exam Study Guide
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by
the client indicates an understanding of the teaching? Correct Answer: "I flushed what I urinated at 7:00
a.m. and have saved all urine since."
A nurse is assessing a client who has been on bed rest for the past month. Which of the following
findings should the nurse identify as an indication that the client has developed thrombophlebitis?
Correct Answer: Calf swelling
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse
manager identify as a violation of HIPAA guidelines? Correct Answer: A nurse asks a nurse from another
unit to assist with her documentation.
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings.
Which of the following actions should the nurse take? Correct Answer: Remove the stockings at least
once per shift.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority
assessment to monitor for adverse effects? Correct Answer: Auscultate lung sounds
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following
statements should the nurse identify as an indication that the client is ready to learn? Correct Answer:
"I can concentrate best in the morning."
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the
following techniques should the nurse use? Correct Answer: Have the client stand with her arms at her
side and her feet together.
A nurse is planning an deduction session for an older adult client who has just learned that she has type
2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
Correct Answer: Allow extra time for the client to respond to questions
A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular
physical activity. Which of the following types of activity should the nurse recommend? Correct Answer:
Walking briskly
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should
identify that which of the following findings requires further intervention? Correct Answer: Erythema
on pressure points
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the
following actions should the nurse take? Correct Answer: Gently shake the container of medication
prior to administration.
, A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following
actions should the nurse take first? Correct Answer: Check the client for injuries
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the
following actions should the nurse take? Correct Answer: Reassure the client that this is an expected
response to grief.
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an
average risk for colon cancer, I should have routine screening. What does that involve?" Which of the
following responses should the nurse make? Correct Answer: "You should have a fecal occult blood test
every year."
A nurse manager is preparing to review medication documentation with a group of newly licensed
nurses. Which of the following statements should the nurse manager plan to include in the teaching?
Correct Answer: "Use the complete name of the medication magnesium sulfate."
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
Correct Answer: Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
Use antimicrobial sanitizer for hand hygiene.
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile
infection. Which of the following information should the nurse include in the teaching? Correct Answer:
Have family members wear a gown and gloves when visiting.
A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In
preparation for the client's procedure, which of the following precautions should the nurse take?
Correct Answer: Wrap monitoring cords with stockinette and tape them in place.
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures
would the nurse recommend? Correct Answer: Use progressive relaxation techniques at bedtime.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH
insulin to mix together and administer subcutaneously. Determine the correct order of steps for this
procedure. Correct Answer: Air into NPH
Air into Regular
Draw up Regular
Draw up NPH
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following
interventions should the nurse include that is within the RN scope of practice? Correct Answer: Initiate
an enteral feeding through a gastrostomy tube.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the
following actions should the nurse take when inserting the NG tube? Correct Answer: Have the client
take sips of water to promote insertion of the NG tube into the esophagus.
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