Fund: Exam 1- ATI Questions

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/minute

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? a. Face b. Feet c. Chest d. Arms

A

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a. Do not measure the client's temperature rectally b. Count the client's radial pulse for 30 seconds and multiply it by 2 c. Do not let the client know you are counting her respirations d. Let the client rest for 5 minutes before you measure her blood pressure

A

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? a. Turn the client's head to the side. b. Place two figure in client's open mouth c. Brush client's teeth 2x a day d. Inject a mouth rinse into the center of client's mouth

A

A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? a. Schedule rest periods during morning care b. Discontinue morning care for 2 days c. Perform all care as quickly as possible d. Ask a family member to come in to bathe client

A

The nurse is caring for patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmitted-based precautions will the nurse implement for the patient? a. Private room b. Private, negative-airflow room c. Mask worn by the staff when entering the room d. Mask worn by the staff and the patient when leaving the patient's room

A

Which cue by a patient can be validated by laboratory and diagnostic test results? a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet

A

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) a. Place the client in semi-fowler's position b. Have the client rest an arm across the abdomen c. Observe one full respiratory cycle before counting the rate d. Count the rate for 30 sec if it is irregular e. Count and report any sighs the client demonstrates

A, B, C

Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient e. Music preference of the patient

A, B, C, D

Which assessment findings indicate to a nurse that a patient has a surgical site infection? (select all that apply) a. Thick, white drainage in the Jackson-Pratt tubing b. Redness or warmth at the affected site c. Purulent drainage at the infection site d. Temperature 38C (100.4F) e. Tenderness and localized pain f. Wound with well-approximated edges g. Purulent drainage at the incision site

A, B, C, D, E, G

A nurse is instructing a client with diabetes mellitus about foot care? (Select all that apply) a. Inspect feet daily b. Use moisturizing lotion on feet c. Use over-the-counter products to treat abrasions d. Wear cotton socks

A, B, E

In which situations does the nurse wear clean gloves as part of standard precautions? (select all that apply) a. In the care of a patient diagnosed with an infectious process b. When the patient is diaphoretic c. During care of each individual under treatment in the facility d. In the presence of urine or stool e. When taking patients blood pressure

A, C, D

A nurse is caring for an 82 year-old client in the emergency department who has an oral body temperature of 38.3 degrees C (101 degrees F), pulse rate 114/ minute, and respiratory rate 22/minute. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply) a. Obtain culture specimens before initiating antimicrobials b. Restrict the client's oral fluid intake c. Encourage the client to rest and limit activity d. Allow the client to shiver to dispel excess heat e. Assist the client with oral hygiene frequently

A, C, E

Assessment

Assessment

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? a. Pull down and out at the back of the upper denture to remove b. Brush the dentures with a toothbrush and denture cleaner c. Rise the dentures with hot water after cleaning them d. Place the dentures in a clean, dry storage container after cleaning them

B

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first? a. Request a prescription for an antihypertensive medication b. Ask the client if she is having pain c. Request a prescription for an antianxiety medication d. Return in 30 minutes to recheck the client's blood pressure

B

The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? a. Virus b. Bacteria c. Fungus d. Spore

B

Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. Always position patients in a comfortable reclined position to ensure their comfort during questioning b. Ask which name a patient prefers to be called during care to show respect and build trust c. Quickly conduct a review of systems to determine the need for a complete or focused assessment d. Begin with questions about intimacy and sexuality to address sensitive issues first

B

Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. Summarizing previously discussed key topics b. Including selected family members in care planning c. Transferring care responsibilities to the home health nurse d. Verifying the name by which a patient prefers to be addressed

B

Which hospitalized patient is most at risk for acquiring a health care-- associated infection? a. 60-year-old who smokes two packs of cigarettes per day b. 40-year-old who has an indwelling urinary catheter in place c. 65-year-old who is vegetarian and slightly underweight d. 60-year-old who has a white blood cell count of 6000

B

A new patient is admitted to the medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective precautions

C

A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism? a. Direct contact b. Vector c. Vehicle d. Airborne

C

The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation c. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury

C

What is the proper order of removal of soiled personal protective equipment (PPE) when the nurse leaves the patient's room? a. Gown, goggles, mask, gloves, and exit the room b. Gloves, wash hands, remove gown, mask, and wash hands c. Gloves, goggles, gown, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands

C

When initiating a physical examination, which action should the nurse take first? a. Review of the patient's prior medical records b. Gather admission health history forms c. Assess the patient's vital signs d. Perform light and deep palpation for fluid

C

Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information

C

Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowing

C

Concepts of Sterility

Concepts of Sterility

A nurse is preparing to change a sterile dressing and has donned two sterile gloves. To maintain surgical asepsis, what else must the nurse do? a. Keep the amount of splashes on the sterile field to a minimum b. If a sneeze is imminent, cover the nose and mouth with a gloved hand c. With a moist slaine sponge, use the dominant hand to clean the wound and then apply a dry dressing d. Regard the outer 1 inch of the sterile field as contaminated

D

A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns model

D

If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient's left elbow to compare its appearance

D

Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?"

D

Eyes, Ears, Nose, Sinus, Mouth & Throat

Eyes, Ears, Nose, Sinus, Mouth & Throat

Hygiene

Hygiene

Infection Control

Infection Control

Skin, Hair, Nails, Head, Neck & Lymph Nodes

Skin, Hair, Nails, Head, Neck & Lymph Nodes

Transfer & Mobility

Transfer & Mobility

Urinary Elimination

Urinary Elimination

Vital Signs

Vital Signs