ATI cumulative exams

A nurse is teaching a newly licensed nurse about reducing the risk for healthcare-associated infections. Which of the following instructions should the nurse include? use chlorhexidine gluconate to clean the skin on clients who are preoperative change a gauze dressing over central vascular access devices every 3 days irrigate indwelling urinary catheters daily provide mouth care every 8 hours for clients who require mechanical ventilation

use chlorhexidine gluconate to clean the skin on clients who are preoperative

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention? "does your skin condition keep you awake at night?" "have you had any changes in your diet?" "how do you handle stress?" "how does your skin condition make you feel?"

"how do you handle stress?"

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

4 mL

A nurse is preparing to administer furosemide 40 mg via IV bolus to a client. The amount available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

4 mL

A charge nurse is providing an in-service to a group of nurses on the differerent levels of illness prevention. The nurse should include which of the following as an example of secondary prevention? a client is scheduled to recieve an influenza vaccination a client who is asymptomatic is not scheduled for a series of tests a client who has a family history of breast cancer is scheduled for a mammogram a client who has heart failure is scheduled for an echocardiogram

a client who has a family history of breast cancer is scheduled for a mammogram

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? a client who makes frequent slight changes in position and walks occasionally a client who is alert and responsive and eats 25% of each meal a client who is recieving enteral feeding and can change posotion independently a client who is unresponsive to verbal commands and changes posotion occasionally

a client who is unreponsive to verbal commands and changes position occasionally

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? sleep on the abdomen to facilitate wound healing avoid lifting anything heavier than 10 lb for 1 week bend at the waist to pick objects up from the floor notify the surgeon is white drainage develops on the eyelids

avoid lifting anything heavier than 10 lb for 1 week

A charge nurse is providing an in-service to a group of nurses about self-care. Which of the following information should the nurse include in the teaching? get at least 5 hours of sleep every night exercise at least once a week restrict daily water intake bring healthy meals to work

bring healthy meals to work

A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first? place the collection tube in a specimen bag cleanse the area around the wound with sterile saline don sterile gloves swab the wound bed with a sterile cotton-tipped swab

cleanse the area around the wound with the sterile saline

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wounds has eviscerated. After calling for help, which of the following actions should the nurse take first? raise the head of the client's bed 15 to 20 degrees place the client supine with knees bent assess the client for manifestations of shock cover the earea with a sterile dressing, moistened with 0.9% sodium chloride irrigation

cover the area wuth a sterile dressing, moistened with 0.9% dosium chloride irrigation

A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include? decreased ability to hear high-frequency sounds decreased thickness of typanic membranes decreased tinnitus decreased ear wax

decreased ability to hear high-frequency sounds

A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take? clean the client's skin with hot water dry between fold in the client's skin restrict the client's fluid intake apply baby powder to the client's skin

dry between folds in the client's skin

A nurse in a community health clinic is administering seasonal inactive influenza vaccine. Before administering it, the nurse must confirm the client is not allergic to which of the following? shellfish eggs gelatin yeast

eggs

A nurse is assessing a client following the application of an aquthermia pad, Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? blistering erythema eschar absence of pain

erythema

A nurse is providing an in-service on th Healthy People 2030 framework. Which of the following information should the nurse include? monitors nonmodifiable risk factors utilizes health datat from the past 20 years identifies viruses across the world establishes health objectives for Americans

establishes health objectives for Americans

A nurse is caring for a client who has a moderate vision impairment. Which of the following actions should the nurse take? face the client when speaking open shades on windows in the client's room to provide direct lighting use gestures to communicate with the client speak loudly when talking to the client

face the client when speaking to them

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound? foam dressing film dressing alginate dressing hydrofiber dressing

film dressing

A nurse is instructing a client who has heart disease about ways to improve their health such as eating a heart healthy diet. Which of the following concepts is the nurse demonstrating to the client? holistic health primary prevention health education health promotion

health promotion

A nurse is assessing an older adult client. Which of the following findings should the nurse expect? increased sensitivity to touch increase in size of pupils increased peripheral vision increase in cerumen in the ear canal

increase in cerumen in the ear canal

A nurse is teaching a class about expected changes to the skin in older adults. Which of the following information should the nurse include? increase in skin thinning increase in skin elasticity decrease in subcutaneous tissue increase in blood supply to skin decrease in skin hydration

increase in skin thinning decrease in subcutaneous tissue decrease in skin hydration

A nurse is planning care for an older adult client. The nurse should plan to monitor the client for which of the following? widened peripheral vision infections of the eye increase in accomodation to near vision eyes with large pupils

infections of the eye

A nurse is administering a continous IV solution via a computerized infusion pump to a client who is dehydrated. Which of the QSEN competencies is the nurse demonstrating? patient -centered care informatics quality improvement teamwork and collaboration

informatics

A nurse is reviewing a client's medical record. Select the 3 findings that place the client at risk for hearing impairment. osteoarthritis occupation furosemide hyperlipidemia naproxen lovastatin

occupation furosemide naproxen

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? massage the client's bony prominences provide the client with a high-calorie diet elevate the head of the client's bed 45 degrees reposition the client every 4 hours

provide the client with a high-calorie diet

A nurse is providing discharge instructions to a client who lives in subsidized housing and is concerned about being able to afford their medications. Which of the following factors should the nurse identify as affecting the client's health? environmental cultural health literacy socioeconomic

socioeconomic

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease? age family history sunbathing genetics

sunbathing

A nurse is reviewing the medical history of a client who is scheduled for surgery. Which of the following findings places the client at risk for an incisional hematoma? the client takes anticoagulant medications the client has peripheral vascular disease the client is underweight the client has urinary incontinence

the client takes anticogulant medications

A nurse is preparing to administer ampicillin 500 mg via intermitten IV bolus over 30 min. Available is 500 mg ampicillin in 50 mL dextrose 5% in water (D5W). The nurse should set the pump to deliver how many mL/hr?

100 mL per hour

A public health nurse is preparing an educational session at a community health center about the social determinants of health (SDOH). Which of the following information should the nurse include? identifying SDOH increases disparities in healthcare SDOH include psychological factors SDOH are determined by an individual's ethnic background SDOH are conditions in an individual's environment that affect their well-being

SDOH are conditions in an individual's environment that affect their well-being

A nurse is caring for a client who had a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of whihc of the following visual impairments? glaucoma cataracts diabetic retinopathy macular degeneration

cataracts

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? abrasion contusion laceration puncture

laceration

A nurse is teaching a class aboutthe function of cells in the epidermis. The nurse should include that which of the following cells determine skin color? langerhans cells keratinocytes melanocytes merkel cells

melanocytes

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take? connect the drain to continuous low-pressure suction empty the drainage device when it is half full place a perforated gauze pad around the drain clean the skin near the drain in a circular motion from the outside to the inside

place a perforated gauze pad around the drain

A nurse working in a community helath center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening? infant toddler/preschool pre-adolescent/adolescent older adults

pre-adolescent/adolescent

A nurse is caring for a client who has a Jackson-Pratt (PJ) drain in place after the surgery for an open reduction and internal fixation. The nurse should undertstand that the JP drain was placed for which of the following purposes? to prevent fluid from accumulating in the wound to limit the amount of bleeding from the sugergical site to provide a means for medication administration to eliminate the need for wound irrigations

to prevent fluid from accumulating in the wound

A nurse is teaching a client about the Rinne test. Which of he following client statements indicated an understanding of the teaching? "small electrodes are placed on my scalp" "a small probe is placed inside my ear" "i will wear earphones during this test" "a tuning fork is placed on my head"

"a tuning fork is placed on my head"

A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? alcohol consumption family history diet sedentary lifestyle weight

alcohol consumption diet sedentary lifestyle weight

A nurse is teaching an adult client who has a low literacy level about self administration of a subcutaneous medication. Which of the following strategies should the nurse use to promote the client's understanding? simplify terms using acronyms ask the client to demonstrate the skill provide the client with written materials using large print provide a long teaching session

ask the client to demonstrate the skill

A nurse us assessing a client who has a stage 1 pressure injury. Which of the following findings shuld the nurse expect? partial-thickness skin loss with the red tissue in wound bed intact skin with localized erythema full thickness skin loss with visible adipose tissue full thickness skin loss with visible bone

intact skin with localized erythema

A nurse is assessing a client who is 48 hours postoperative following abdomina surgery. Which of the following findings should the nurse report to the provider? blood pressure 102/66 mm Hg straw-colored urine from an indwelling urinary catheter yellow-green drainage on the surgical incision respiratory rate 18/min

yellow-green drainage on the surgical incision

A nurse is teaching a client about the fluorescein angiography test. Which of the following client statements indicated an understanding of the teaching? "I will look at a grid made of lines during this test" "I will read letters off an eye chart during this test" "a dye is injected into my vein during this test" "my pupils will be dilated for this test"

"a dye is injected into my vein during this test"

A nursw is [roviding teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? "a weight loss program can decrease my LDL cholesterol level." "excersizing regularly will increase HDL cholesterol." "adding foods containing omega-3 fatty acids to my diet can lower my risk." "increasing my intake of foods containing trans-fatty acids can lower my risk"

"increasing my intake of foods containing trans-fatty acids can lower my risk"

A nurse is teaching a group of older adults about health tests and screenings. Which of the following information should the nurse include? "you should have a tetanus booster every 5 years" "you should have a single dose of teh shingles vaccine at age 60" "you should have a hearing screening every 3 years" "you should have the pneumococcal vaccine at age 65 and then every 10" "you should have visual acuity screening every year"

"you should have a single dose of the shingles vaccine at age 60" "you should have the pneumococcal vaccine at age 65 and then every 10" "you should have visual acuity screening every year"

A nurse is completing an assessment of a 1-month-old newborn. Which of the following developmental skills is an expected finding? displays a social smile follows movements of objects with eyes reacts to sound by turning head makes babbling sounds

follows movements of objects with eyes

A nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply. use clean technique when changing the catheter dressing change the catheter dressing every two days clean the access port on the CVAD line with povidone-iodine prior to use. perform hand hygiene for 10 sec prior to changing the catheter dressing use friction when cleaning the access port

change the catheter dressing every two days clean the access port on the CVAD line with povidone-iodine prior to use use friction when cleaning the access port

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III. testing visual acuity observing for facial symmetry eliciting the gag reflex checking the pupillary response to light

checking the pupillary response to light

A nurse is caring for a client with a wound requiring negative pressure wound therapy. Which of the following actions should the nurse take? cover the client's wound with an alginate dressing shave the hair on the client's skin surrounding the wound expect the inner dressing to expand after the vacuum pump is the initiated cut a round hold in the center of the outer dressing

cut a round hold in the center of the outer dressing

A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply. uses a cane to ambulate electrical cord on the floor over walkway throw rugs in the kitchen grab bar in the bathroom macular degeneration

electrical cord on the flood over walkway throw rugs in the kicthen macular degeneration