ATI Test Question Review

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A. "is your pain constant or intermittent?" B. "what would you rate your pain on a scale of 0 to 10?" C. "does the pain radiate?" D. "is your pain sharp or dull?"

D. "is your pain sharp or dull?" Rationale: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least six air exchanges per hour B. Make sure the client wears a mask when outside her room if there is construction in the area C. Place the client in a private room with negative-pressure airflow D. Wear an N95 respirator when giving the client direct care

B. Make sure the client wears a mask when outside her room if there is construction in the area Rationale: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse in a long term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1. Place a name tag on the body 2. obtain the pronouncement of death from the provider 3. remove the tubes and indwelling lines 4. wash the client's body 5. ask the client's family members if they would like to view the body

2, 3, 4, 5, 1

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. turn the client every 2 hr B. administer an antiemetic every 6 hr C. hold oral care D. increase the room's temperature

A. turn the client every 2 hr Rationale: the nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing a nasotracheal suctioning for the client? A. insert the suction catheter while the client is swallowing B. apply intermittent suction when withdrawing the catheter C. place the catheter in a location that is clean and dry for later use D. hold the suction catheter with her clean, non dominant hand

B. apply intermittent suction when withdrawing the catheter Rationale: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. remove the outer cannula cautiously for routine cleaning B. use tracheostomy covers when outdoors C. use sterile technique when performing tracheostomy care at home D. cleanse irritated skin with full-strength hydrogen peroxide

B. use tracheostomy covers when outdoors Rationale: Tracheostomy covers protect the client's airways from cold air, dust, and other airborne products

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? A. assist the client into a prone position B. Place a sleeve over top of each leg with the opening at the knee C. make sure two fingers can fit under the sleeves D. set the ankle pressure at 65 mm Hg

C. Make sure two fingers can fit under the sleeves Rationale: The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position B. Instill 15 mL of irrigation fluid into the catheter with each flush c. Subtract the amount of irrigant used from the client's urine output D. Perform the irrigation using a 20 mL syringe

C. Subtract the amount of irrigant used from the client's urine output Rationale: The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. Combine client care tasks when caring for multiple clients B. Wait until the end of the shift to document client care C. Use the planning step of the nursing process to prioritize client care deliver D. Allow for interruptions in tasks to discuss client care issues with colleagues

C. Use the planning step of the nursing process to prioritize client care delivery Rationale: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. insert the needle at a 15 degree angle B. aspirate for blood return prior to administration C. administer the medication into the abdomen D. massage the site following the injection

C. administer the medication into the abdomen Rationale: The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. A. crackles B. rhonchi C. friction rub D. normal breath sounds

D. Normal breath sounds Rationale: These are normal brochovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration