ATI Funds Review

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

• Locking the brakes on the bed & wheelchair before moving the client

• Lowering the footplates of the wheelchair before transfer

• Placing the wheelchair perpendicular to the bed

• Placing the wheelchair on the client's weaker side prior to transfer

Answer explanation

Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair.

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective?

• "I should expect my heart rate to take longer to return to normal after exercise as I get older."

• "Urinary incontinence is something I will have to live with as I grow older."

• "I can expect to have less ear wax as I get older."

• "My stomach will empty more quickly after meals as I grow older."

Answer explanation

Older adults experience decreased cardiac output, which causes an increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect?

• BUN 18 mg/dL

• Cap refill 1.5 sec

• Hct 55%

• Urine specific gravity 1.001

Answer explanation

An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

• Return the unused portion of the medication to the pharmacy

• Dispose of the wasted medication into a sharps container

• Record the amount of medication wasted on the controlled substance inventory record

• Ask an assistive personnel (AP) to witness the wasting of the controlled substance

Answer explanation

Two nurses should sign the controlled substance inventory record to document the amount of medication wasted.

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

• Hold the dropper 1 cm (0.5 in) above the ear canal during administration

• Apply pressure to the nasolacrimal duct following administration

• Place a cotton ball into the inner ear canal for 30 minutes following administration

• Straighten the ear canal by pulling the auricle down and back prior to administration

Answer explanation

The nurse should administer the otic medication by holding the dropper 1 cm (0.5 in) above the ear canal.

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?

• Sims'

• Prone

• Supine

• Fowler's

Answer explanation

This describes Fowler's position. Although various definitions exist for Fowler's position, generally a low Fowler's position means 30° of elevation, semi Fowler's is 45° to 60°, and high Fowler's is 60° to 90° of elevation.

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

• Fifth intercostal space just medial to the midclavicular line

• Second intercostal space to the left of the sternum

• Fifth intercostal space to the left of the sternum

• Second intercostal space to the right of the sternum

Answer explanation

APETM: The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• People who practice the Islamic faith pray over the deceased for a period of 5 days before burial.

• People who practice the Hindu faith bury the deceased with their head facing north.

• People who practice Judaism stay with the body of the deceased until burial.

• People who are practicing the Buddhist faith have the female family members prepare the body following death.

Answer explanation

In the Jewish faith, a family member often stays with the body until burial occurs.

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

• Allows minimal treatment

• Benefits the client's family

• Offers hope for a cure

• Supports self-determination

Answer explanation

The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right.

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

• Redness at the IV catheter entry site

• Palpable cord along the vein used for the infusion

• Taut skin around the IV catheter site that is cool to the touch

• Bleeding at the IV insertion site

Answer explanation

A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration).