ATI Quiz Questions A & B
A nurse is contributing to the plan care for a pt who practices islam. Which of the following questions should the nurse ask the pt to clarify her religious pref.?
" Do you consume pork any products?"
A nurse is reinforcing teaching with a pt who has insomnia. Which of the following statements by the pt indicates an understanding of the teaching?
" I should turn on the ceiling fan to block out unwanted noise."
A nurse is reinforcing teaching about the use of crutches w/ a pt who has a fractured right tibia & fibula. Which of the following statements by the pt indicates an understanding of the teaching?
" I will be sure to keep the crutch tips dry. "
A nurse is reinforcing teaching w/ a pt who is receiving PCA. Which of the following statements by the pt indicates an understanding of the teaching?
" I will not allow anyone to press the PCA button for me"
A nurse is collecting data from a client who is menopausal. Which of the following statements indicates that the nurse should screen the client for depression?
" My family doesn't need me anymore. I've failed them in so many ways."
A nurse is caring for a client who has metastatic cancer & practices Catholicism. The client asks the nurse to discuss the afterlife w/ her. Which of the following statements by the nurse assists in the meeting the clients spiritual needs?
" Tell me what the afterlife means to you."
A nurse is reinforcing teaching with a partner of a pt who immobile. Which of the following instructions should the nurse give the partner about turning the pt in bed?
" Tighten your stomach muscles. "
A nurse is caring for an older Pt & is concerned that the Pt may have a fecal impaction. Which of the following is the most important question for the nurse to ask?
"Have you had had small liquid stools?"
A nurse is speaking w/ a pt who has type 2 diabetes mellitus & a prescription for insulin. The pt verbalizes anger about having to take insulin. Which of the following responses should the nurse make?
"I see that you are angry. Lets sit down and talk."
A nurse is reinforcing teaching w/ a pt who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?
"I will place a gel pad directly above your pubic area before I place the probe."
A nurse is caring for a pt who is scheduled for surgery the following day. During the night, the pt is unable to sleep & is restless. Which of the following statements should the nurse make?
"It must be difficult facing this type of surgery."
A client who had a recent below the knee amputation says,"I don't know how i can continue to live my life without my leg." Which of the following responses should the nurse make?
"Tell me what concerns you have about your future."
A nurse is caring for a Pt who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?
"When i look at myself in the mirror , I dont know if i can go on."
A nurse is reinforcing teaching with a client about prevention of stress injuries. Which of the following instructions should the nurse include?
"When lifting a heavy object, keep it close to your body."
A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? Select all that apply.
- Ensure that the client is wearing nonskid slippers - Place the client in a room near the nurses station - Reinforce teaching about how to use the call bell
A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take?
- Evacuate clients from the area - Pull the lever on the fire alarm box - Close the fire doors on the unit - Use the fire extinguisher to put out the fire
A nurse is contributing to the plan of care for a Pt who is dying. which of the following interventions should the nurse recommend the Pts family's in the plan of care? ( select all that apply )
- Keep the family updated about the Pts status - Encourage the family to comb the Pts hair - Tell the Pts family what to expect as the Pts death nears
A nurse is caring for a client who is post-op and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply)
- decreased kin turgor - orthostatic hypotenstion - Flat neck veins
A nurse is reinforcing dietary teaching w/ a pt who has chronic kidney disease & requires a low potassium diet. Which of the following food choices by the pt demonstrates an understanding of the teaching?
1 cup of applesauce
A nurse is providing oral hygiene for a pt who is unconscious. ID the sequence of the steps the nurse should take.
1. Assess the Pts gag reflex 2. position the pt on his side w/ his head turned to the side 3. Place a towel under the Pts head w/ an emesis basin under his chin 4. Separate the upper and lower teeth w/ an oral airway device 5. Cleanse the Pts mouth using a toothbrush
A nurse is calculating the I&O's for a PT over the last 8 hr. The PT is receiving a continuous IV infusion at 150 ml/hr & had 4 oz of juice & 0.5 L of water. How many mL of fluid should the nurse document as the clients intake for the last 8 hr? (Round to the nearest whole number)
620 mL
A nurse is caring for four Pts. For which of the following Pts should the nurse use the therapeutic communication technique of silence?
A Pt who has just experience a death of a child
A nurse is reviewing the V/S of four PTs. Which of the following findings require further data collection by the nurse?
A client who has a pulse of 110/min
A nurse is collecting data from a pt who is 2 days post op following a colostomy. Which of the following findings should the nurse report to the provider?
A purple colored stoma
A nurse is providing wound care for a group of clients. Which of the following should the nurse identify is healing by secondary intention?
A stage 3 pressure ulcer on the coccyx
A nurse is caring for a pt who post op following a mastectomy. The Pt states, " I can barely look at myself in the mirror." The nurse should ID that the Pt is experiencing which of the following?
Actual loss
A nurse is assisting with a plan of care for a client who has a bacterial infection and is a persistent oral temperature of 38.9*C (102*F). Which of the following interventions should the nurse include in the plan of care to treat the fever?
Administer Acetaminophen
A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?
Administer an analgesic 30 min before starting procedure
A nurse is caring for a female pt who has a urinary incontinence. Which of the following actions should the nurse take?
Apply moisture skin barrier to the Pts perineal area
A nurse is caring for a client who is alert and in a long term care facility. Which of the following actions should the nurse take to protect the client's privacy?
Ask the client before discussing his condition when his family is present.
A nurse is assisting w/ the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client w/ communication?
Ask the client close ended questions
A nurse is reinforcing teaching about carb. counting w/ a pt who has a new dx of diabetes mellitus. Which of the following actions should the nurse take first?
Ask the pt what he already knows about meal planning.
A nurse is assisting w/ the admin of a pt who has active TB. Which of the following actions should the nurse plan to take?
Assign the pt to a negative pressure airflow room
A nurse is assisting w/ the plan of care for four pts. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
Assist a pt to get out of bed after a breathing treatment
A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?
Attend an exercise class
A nurse is explaining ethics & values to a newly licensed nurse. The nurse should explain that allowing a Pt to make a decision about treatment is an example of which of the following ethical principles?
Autonomy
A nurse is reviewing the medical record of a client who has heart failure. The nurse should ID which of the following lab results as an indication that the client has fluid volume excess?
BUN 8 mg/dL
A nurse is caring for a client who has a prescription for potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?
Beneficence (acting in the pts best interest)
A nurse is contributing to the plan of acre for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?
Check if the restraints are tied to a fixed frame of the bed
A nurse is preparing to admin an eternal feeding to a client who has an NG tube place. Which of the following methods should the nurse use to verify correct placement of NG tube?
Check the pH of the gastric aspirate
A nurse in a long term care facility is collecting admission data from a Pt who uses hearing aid. Which of the following actions should the nurse take?
Choose a private room for the interview
A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age related changes?
Circulation becomes less efficient with age
A nurse is contributing to the plan of care for client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
Compare the clients pedal pulses bilaterally every every 4 hr
A nurse is preparing to admin a topical med to a PT. Which of the following actions should the nurse take?
Compare the label of the med container w/ the med admin record x3.
A nurse is assisting with the admission of a pt who has brought her meds to the facility. Which of the following actions should the nurse take?
Compare the meds the provider has prescribed with the clients meds from home
A nurse is checking a Pt for a pulse deficit after detecting an irregular HR. Which of the following actions should the nurse take?
Count the pts radial & apical pulse simultaneously w/ another nurse
A nurse is caring for a pt who is receiving continuous NG tube feedings. The nurse listens to the pts bowel sounds. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.)
Decrease the rate of the feeding
A nurse is reinforcing teaching w/ a pt about using guided imagery. Which of the following actions should the nurse take?
Direct the client to visualize tension leaving the body.
A nurse is caring for a Pt who is refusing medical treatment. Which of the following actions should the nurse take?
Document the clients refusal of the treatment
A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct?
Donning a mask to measure the vital signs of a client who has pertussis
A nurse is palpating the pulse located on the top of the pts foot. Which of the following pulses should the nurse document that she is palpitating?
Dorsalis pedis
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection?
Drain urine from the tubing before ambulation
A nurse working in a community clinic is talking w/ an older adult pt who states that his life has no purpose. The nurse should ID that the Pt is in which of the following stages of Eriksons Theory of Psychosocial Development?
Ego Integrity vs. Despair
A nurse is contributing to the plan of care for a pt who has a positive throat culture for steptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?
Ensure that the pt wears a surgical mask during transportation throughout the facility
A nurse is caring for a Pt who has chronic pain. The nurse recommend s that the Pt concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?
Guided Imagery
A nurse is caring for a client who has an NG tube and is receiving a continuous enternal feeding. Which of the following actions should the nurse take?
Hold the feeding for two consecutive gastric residuals greater than 250 ml
A nurse is caring for a Pt who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the Pt?
Instruct the Pt to tilt her head forward while eating.
A nurse is re-positioning a pt who has quadriplegia & is in the supine position. Which of the following actions should the nurse take to prevent pt musculoskeletal injury?
Internally rotate the pts hips by using a trochanter roll
A pt who has advanced cancer tells the nurse that he has a difficult time talking to anyone about illness. Which of the following actions should the nurse take to encourage therapeutic communication?
Let the pt know that he/she is available and willing to listen
A nurse caring for a Pt with CDIFF. Which of the following solutions should the nurse use to perform hand hygiene while caring for this Pt?
Mild Soap
A nurse is preparing to admin O2 to a Pt who has heart failure & is having severe difficulty breathing. Which of the following O2 delivery equipment should the nurse select to provide the highest concentration of O2 to the Pt?
Nonrebreather mask
A nurse is caring for an older pt who has advanced rheumatoid arthritis but seldom requests pain meds. Which of the following actions should the nurse take?
Obsv. the Pt for nonverbal indications of pain
A nurse caring for a Pt who has dyspnea caused by a respiratory infection. The nurse should assist the Pt into which of the following positions?
Orhtopneic
A nurse in long term care facility is contributing to the plan of care for a client who is at risk for a pressure ulcer. Which of the following recommendations should the nurse include in the plan of care?
Perform a thorough skin inspection each day
A nurse is moving a client up in bed w/ the assistance of a second nurse. Which of the following actions should the nurse take?
Place feet apart w/ the foot nearest the head of the clients bed in front of the other foot
A nurse is reinforcing teaching to a pt who has a prescription for transcutaneous electrical nerve stimulation (TENS) unit. Which of the following info should the nurse include in the teaching?
Place the electrodes near the pain site
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia ?
Positive Chvostek's sign * tap the clients facial nerve near the ear,If the clients facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels *
A nurse is reinforcing teaching w/ a client about smoking cessation. Which of the following should the nurse ID as first stage of health behavior change?
Precontemplation
A nurse is reinforcing pre-op teaching w/ a pt who does not speak the same language as the nurse. Which of the following actions should the nurse take?
Provide handouts written in the clients primary language
A nurse is caring for a client who is at risk for falls. Which of the following actions action should the nurse take?
Put the pts bed in the lowest position
A nurse is assisting w/ the care of a Pt who has a prescription for IV therapy. The Pt tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
Seafood
A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper?
Shred the paper in a secure container
A nurse reinforcing teaching with am older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep?
Sleep patterns change with age
A nurse is checking a Pts muscle strength. Which of the following techniques should the nurse use?
The Pt shrugs her shoulders while the nurse applies firm pressure over the mid-line of the shoulders
A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?
The client report urinary incontinence
A nurse is caring for a pt who has been vomiting excessively & has diarrhea. Which of the following find should the nurse ID as an indication of fluid volume deficit?
Urine specific gravity 1.045
A nurse is caring for a Pt who has limited mobility. Which of the following actions should the nurse take to maintain the Pts skin integrity?
Use warm water when bathing the Pt
A nurse is reinforcing teaching about hospice care measures with the fam of a pt who is dying. Which of the following statements by a member of the clients family indicates an understanding of the teaching?
We will keep her room cool to help her breathe better
A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?
Young adults should receive a dental assessment every 6 months
A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching?
a headache is a manifestation of carbon monoxide poisoning
A nurse is caring for a Pt who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take?
measure the Pts gastric before each feeding
A charge nurse is reinforcing teaching w/ an assistive personnel (AP) about performing pulse ox. Which of the following info should the nurse include in the teaching
remove polish from the clients fingernail before applying the oximentry probe
A nurse is preparing to remove staples from the pts incision. Which of the following actions should the nurse take?
remove the staple from the skin after both sides are visible
A charge nurse is reinforcing teaching w/ a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?
removing and inverting a lid before placing it onto a non sterile surface
A nurse is reinforcing teaching w/ an older adult about oral hygiene. Which of the following instructions should the nurse in the teaching?
replace her toothbrush following illness
A nurse is caring for a client who is receiving chemotherapy & has stomatitis. Which of the following actions should the nurse take to reduce the pts discomfort?
use 0.9% sodium chloride solution to rinse the pts mouth