ATI - Testing and Remediation Beginning Test
17) A nurse is caring for a client who is receiving vancomycin for a beta hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? Respiratory Depression Hearing loss Hypertension Bradycardia
Answer: hearing loss Rationale: Hearing loss is correct. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect.
A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?
Answer: ¾ cup of canned tomato juice Rationale: The nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it.
14) A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the vetrogluteal muscle?
Answer: 1 ½ Rationale: 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.
18) A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed a dose of lorazepam (Ativan) preoperatively. Which of the following statement by the client indicates the medication has been effective?
Answer: I feel very relaxed now Rationale: "I feel very relaxed" is correct. Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective.
A nurse in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine (Benadryl) 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose?
Answer: 2 tsp Rationale: 12.5 x 2 = 25mg every 6 hours To answer this calculation fill in the blank question, the nurse should be able to convert 10 mL of medication into a household measurement (teaspoon). The child needs to receive 10 mL of diphenhydramine. There is 5 mL in one teaspoon, so 10 mL = (10 / 5) = 2 tsp. Therefore, you should enter the numeral 2 in the box without any units or spacing devices. STEP 1: What is the dose needed? Dose needed = Desired; 25 mg STEP 2: What is the dose available? Dose available = Have; 12.5 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 25 mg x 5 mL / 12.5 = x mL; 25 x 5 / 12.5 = 125 ÷ 12.5 = 10 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 10 mL / x; 5x = 10; x = 2 tsp. STEP 6: Reassess to determine if the amount to be given makes sense. If there are 12.5 mg/mL and the prescribed amount is 25 mg, it makes sense to give 10 mL, which equals 2 tsp. The nurse should teach the parents to administer diphenhydramine 2 tsp per dose.
A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the clients diet? Cooked oatmeal Grape juice Applesauce Ice cream Smooth peanut butter
Answer: Grape Juice, Ice Cream Rationale: Both of these items have a liquid consistency. Therefore it is safe enough for a client with a liquid diet to enjoy. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Grape juice is appropriate to include in both a clear liquid and a full liquid diet.
A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? Percussion Palpation Auscultation Inspection
Answer: Inspection Rationale: Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.
5) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
Answer: Sims Rationale: The proper position for a client who needs an enema is Sims. It allows for the most comfort and easy administration for the nurse. Sims' is correct. The left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution.
16) A nurse is preparing to transfer a client from a bed to a chair. The nurse should take which of the following actions to prevent a lift injury? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.
Answer: Stand close to the client Rationale: The nurse would know that this could provide adequate leverage in order to move the client smoothly.
A nurse on a pediatric unit is caring for an infant who is diagnosed with larynotrachebronchitis. While performing a respiratory examination the nurse hears which sound?
Answer: Stridor Rationale: Stridor is correct. Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. The breath sound on the audio clip is an example of stridor.
4)A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes.
Answer: Toward the back of the neck Rationale: This area, known as the posterior cervical, is correct. While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.
A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following? Mood Immunity Memory Vitality
Answer: Mood Rationale: Mood is correct. St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.
A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?
Answer: lying on side Rationale: This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.
19) A nurse is reinforcing a teaching to a client who has fractured ankle and is learning to walk up the stairs. Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait.
Answer: Bear weight on unaffected leg, transfer weight to crutches, advance unaffected leg, shift weight from crutches to unaffected leg, and go up stairs. Rationale the nurse would know that this is correct sequence of events for her client. The first action the client should be taught when using a 3-point crutch gait to go up stairs is to stand and bear weight on the unaffected leg. The second action the client should be taught when using a 3-point crutch gait to go up stairs is to transfer body weight to the crutches. The third action the client should be taught when using a 3-point crutch gait to go up stairs is to advance the unaffected leg between the crutches. The fourth action the client should be taught when using a 3-point crutch gait to go up stairs is to shift weight from the crutches to the unaffected leg. The fifth action the client should be taught when using a 3-point crutch gait to go up stairs is to align crutches on the stair.
12) A nurse in caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The clients states, I will quit smoking if the results don't come back positive for cancer. This statement indicates that the patient is in which of the following stages of grief? Anger Acceptance Bargaining Denial
Answer: Bargaining. Rationale: Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.
9) A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion?
Answer: Dullness Rationale: Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.
7) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?
Answer: partial thickness skin loss Rationale: Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.
A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Exhibit 1 Serum Laboratory Results: Hemoglobin 15.4 g/dL Protein 7.2 g/dL BUN 8mg/dL Glucose 72mg/dL Exhibit 2 Physical Assessment: 2+ peripheral edema Blood pressure 144/96 mm Hg Increased urinary output Respiratory crackles bilaterally Exhibit 3 Health History: Total hip arthroplasty 10 days ago 15-year history of diabetes mellitus 32-year history of heart failure
Answer: restrict fluid intake Rationale: The nurse would know that by restricting fluid intake the client might become more active and want to go home. Restrict fluid intake is correct. Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.
10) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading? Wrapping the cuff loosely around the arm Using a cuff that is too wide Leaving client's arm unsupported Taking client's blood pressure immediately after client sits down
Answer: Using a cuff that is too wide. Rationale: Using a cuff that is too wide is correct. Using a cuff that is too wide can result in a false low blood pressure reading.
13) A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways?
Answer: Vector Rationale: Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector.
