Fundamental Practices Questions for Capstone

ATI Capstone Fundamentals 31. a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse use? behavioral indicators, (increased agitation, restlessness) 32. a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should the nurse do first? recheck the clients BP, (reassess prior to any intervention) 33. a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify as a cath occlusion? bladder distention, (inability to empty the bladder, impaired elimination) 34. a nurse is discussing immunity with a client who has received an immunization, the nurse should identify that an immunization functions as part of which of the following types of immunity? acquired immunity, (artificial/acquired immunity occurs when antigens from toxoids or immunizations are ADMINISTERED to a client, once in the body, the stimulate the production of antibodies) 35. a nurse is reviewing the health history of an OA who has a hip fracture the nurse should identify what is a risk of developing pressure injuries? urinary incontinence, (r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction and shear, immobility, alterations in sensory perception) 36. a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red and there is warmth along the coarse of the vein, what should the nurse do? d/c the infusion, (assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start new IV) 37. a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding? Macule, (nonpalpable smaller than 1cm, ex: freckle) 38. a community health nurse is teaching a group of clients about first aid for different types of wounds. which of the following clieont statements indicates an understanding of the teaching? I should apply clean dressings over the top of blood saturated dressings and hold pressure, (to prevent disruption of wound tissue) 40. a nurse is sitting with the partner of a client who recently died. which of the following actions should the nurse take to facilitate mourning? encourage the partner to ask for help when needed 41. a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which of the following behaviors should the nurse identify as increasing the client's risk for constipation? urge suppression, history of chronic stimulant laxative use, inadequate fluid intake 42. a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the nurse do? ask the client to describe feelings 43. a nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. which of the following actions should the nurse take to prevent contamination during the dressing change? restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray, (if liquid comes in contact with the sterile field at any point it is considered contaminated and unsterile) 44. a nurse is caring for a pt who is scheduled for a cataract surgery, the client states "is see just fine and have decided to cancel my surgery". which of the following responses should the nurse make? share with me more about the thoughts that are concerning you 45. a nurse is teaching a client about the use of a MDI, which instruction should the nurse include in the teaching? inhale the medication deeply for 3-5seconds, (hold breath for 10s after inhalation, shake MDI vigorously, hold mouthpiece 2.5-5cm/1-2in in front of mouth) 46. a nurse is teaching a group of AP about the expected integumentary changes in Older Adult, which should the nurse include decrease in elasticity, (increase in pigmentation, decrease in subq and moisture levels) 47. a nurse is monitoring a client who has been receiving intermittent enteral feedings, what should the nurse identify as an intolerance to the feeding? Nausea, (vomiting, dumping syndrome-change the rate or type of formula) 48. a nurse enters a clients room and sees smoke coming from the trash can. which of the following actions should the nurse take first evacuate the room, (RACE) 49. a nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery, which of the following statements should the nurse make? the surgeon will answer your questions before surgery 50. a nurse is reviewing info about advance directives with a newly admitted client. which of the following statements by the client indicates an understanding of the teaching? i have a living will that outlines my wishes when i am unable to make a decision 51. a nurse is admitting a client who has meningococcal meningitis, what should the nurse do first? initiate droplet precaution, (put in private room and wear surgical mask within 3ft) 51. a nurse finds a client on the floor of their room experiencing a seizure, which of the following actions is the nurse's priority place the client on their sided with their head forward, (ABC) 53. a nurse is providing discharge teaching to a client who has a prescription for home O2, which info should the nurse teach? wear cotton socks when the O2 is in use, (other fabrics cause static) 54. a nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. which of the following client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness? the client has a history of recurring bowel inflammation, (GI issues decrease motility, decreasing med effectiveness, so oral meds should be avoided) 55. a nurse is teaching a client about the correct use of a cane, what should the nurse include? ensure the cane has a rubber cap, hold the can on the stronger side, flex the elbow slightly when using the cane, use a quad cane for increased support 56. a nurse is teaching about safety risks for adolescents, what should be included? at this age, peer influence to participate in high-risk behaviors can lead to injury 57. a nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. the nurse should instruct the client to avoid which of the following foods? orange slices, (membranes of the oranges are hard to swallow, so are other hard foods and raw fruits/veggies) 58. a nurse is reviewing the medical records of a group of OA clients. the nurse should identify that which of the following is a risk factor that places OA at an increased risk for developing infections? lowered immune system function, (manifest as fever, redness, confusion, agitation, general fatigue) 59. a nurse is caring for a client who has a prescription for a narcotic med, after admin the nurse is left with an unused portion, what should the nurse do? discard the med with another nurse as a witness, (2 person for controlled substance) 60. a nurse is performing a focused assessment for a client who has dysrhythmias, what indicates ineffective cardiac contractions? pulse deficit, (comparing apical and radial pulses at the same time can help detect pulse deficit indicating ineffective cardiac contraction and presence of cardiac dysrhythmias) 61. a nurse is preparing to transfer a client from a chair to the bed. the client can bear partial weight and has upper body strength. which of the following devices should the nurse use to transfer the pt? a stand-assist lif, (for pt with upper body strength and able to bear partial bodyweight) 62. a nurse is planning to administer several meds to a client through a ng tube, which actions should the nurse take? dissolve crushed tablet meds in sterile water, (in 15-30mL sterile water) 63. a nurse is teaching about measures to promote sleep with insomnia, what statement indicates understanding? i should reduce my fluid intake to 2 hours before bedtime, (2-4 hours before sleeping to prevent interruptions, a carb snack h.s., exercise 3h prior to, avoid naps) 64. a nurse is teaching about foot care to a client who has DM, what statement indicates understanding? i should wear my slippers whenever i am out of bed (barefoot poses risk of injury to feet, avoid lotion between toes, cut nails straight across, avoid soaking in warm water) 65. a nurse is preparing to perform a routine abdominal assessment for a client, which action should the nurse take? perform palpation afer auscultation 66. a nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3d, what lab results indicates the client is experiencing FVD? increased hematocrit (increased USG and BUN) 67. a nurse is updating a plan of care after an evaluation of a client who has dysphagia, which interventions should the nurse include in the plan? have the client sit upright for 1 hr following meals (facilitates swallowing of undigested food and reduce risk of aspiration) 68. a nurse is caring for a client who reports burning around the peripheral IV site, which finding should the nurse identify as a manifestation of infiltration? Edema (leakage of the IV solution into the extravascular tissue) 69. a charge nurse is making assignments for the upcoming shift, what assignments should the charge nurse assign to a LPN? a client who has dehydration and IBD (does not require complex med admin or assessment) 70. a nurse is in an ED monitoring the hydration status of a client receiving oral rehydration, what should the intervene for? heart rate 120/min (initiate IV fluid replacement) 71. a nurse is documenting client care, which of the following entries should the nurse identify as an example of implementation of client care? contacted the provider to report client findings 72. a charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. the charge nurse should identify that the nurse is accountable for which of the following torts? negligence 73. a nurse is completing an admission assessment for a client who has hearing lsos, what action should the nurse take? use written communication to assist with communication 74. a nurse is caring for a client who has dementia and frequently tries to get out of bed, which of the following actions should the nurse take? (SATA) turn on the bed alarm, maintain the bed in the lowest position, encourage the family to stay with the pt 75. a nurse is preparing a client for transfer to another unit? which finding does the nurse include in the transfer report? response to pain medication, review of ongoing discharge plan, recent physical changes 76. a nurse in a providers office is assessing the motor skill development of a 15 month old toddler during a well-child visit, what gross motor skills should the nurse expect? walks without assistance using a wide stance 77. a nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. which of the following actions should the nurse take first after obtaining the client's history and assessment? identify the client's needs 78. a nurse is planning a community education program about colorectal cancer. which of the following risk factors should the nurse identify as modifiable? Smoking, alcohol consumption, high-fat diet 79. a nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea, which of the findings should the nurse expect? flaring of the nostrils (increased RR, increased depth of R, expected pulse ox reading of <90) 80. a nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. which of the following should the nurse identify as examples of cultural variables? eye contact, personal space, touch