2024 ATI Proctored Exam Practice

A nurse is caring for a client who communicates an unmet spiritual need. Which of the following statements should indicate to the nurse that the client is experiencing spiritual distress?

"God is punishing me for something."

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates a potential problem with achieving Erikson's developmental task for this age group?

"I go home on the weekends to be with my family because I don't have any good friends here on campus."

A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task for her age group?

"I think I have done a good job with my children since they are all independent now."

A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will make sure to replace my pouch around 4 hrs after I eat."

A nurse is assisting with preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements indicates that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is reinforcing teaching with a client about how to remove a soiled dressing. Which of the following statements by the client indicate an understanding of the teaching?

"I'll wear nonsterile gloves."

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further instruction is required?

"If the client seems confused, I'll raise all 4 side rails to prevent injury."

A nurse is reinforcing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include in the teaching?

"Include 2.5 cups of vegetables in your daily diet."

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve the pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse."

A nurse is talking with the parent of a school-aged child who tells the nurse "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

"Keep a diary of the foods your child eats each day."

A nurse is caring for a client who has a terminal illness. The family wants to take care of the client at home. Which of the following statements indicates that the nurse understands family-centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care."

A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"Sometimes, I should use soap and water rather than hand-rub to clean my hands."

A middle adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is have difficulty achieving Erikson's developmental task for this age group?

"We miss our daughter so much that we are going to move closer."

A nurse is collecting data from a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?"

A nurse is collecting data about a client's spiritual wellbeing. Which of the following questions should the nurse ask?

"What is your source of strength and hope?"

A nurse is reinforcing teaching with a client about how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?

1) Hold the mouthpiece 1 to 2 inches in front of your mouth 2) Tilt your head back slightly and open your mouth wide 3) Depress the canister while taking a slow, deep breath 4) Hold your breath for 10 seconds

A nurse enters a client's room and finds smoke coming from under the bed. What sequence of actions should the nurse take in this situation?

1) Move the client out of the room 2) Pull the fire alarm 3) Shut all surrounding windows and doors 4) Attempt to put out the smoke with a fire extinguisher

A nurse is preparing to administer digoxin 0.125 mg PO daily to a client who has heart failure. The amount available is digoxin 0.0625 mg/tablet. How many tablets should the nurse administer per dose?

2 tabs/dose

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing ar 125 mL/hr, gentamicin 150mg in 100 mL at 1400, famotidine 20mg in 50 mL at 1000 and 1600, 250 mL of blood over 2hrs, and a nasogastric flush of 30 mL every 2 hrs. What is the total intake in mL's that the nurse should document for this client for this 12-hr period?

2130 mL

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8oz of milk, 10oz of water, 4oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake?

660mL

A nurse is reinforcing teaching with a preschooler about how to use a metered-dose inhaler. Which of the following methods should the nurse use during this instructional session?

A simple demonstration of inhaler use

A nurse is preparing a presentation for a group of older adults at a senior community center about nutrition and exercise. Which of the following strategies should the nurse use in preparing learning activities for this group of clients?

Allow rest periods during the presentation

A nurse on a pediatric unit is caring for a child who is 4 years old. To help with communication and play activities for this client, the nurse should consider which of the following characteristics of Piaget's preoperational period?

Animism

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual. Which of the following actions should the nurse take?

Apply light pressure to the scanner head once it is in position

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis on transmission based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority?

Assist the client to an upright position

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse perform to convey empathy when using the therapeutic communication technique of active listening?

Assume an open position

A nurse is collecting data about a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse in a provider's office is reinforcing reaching with a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching?

Black beans, whole-grain bread

A nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect that the client has an injury to which of the following parts of the brain?

Brainstem

A nurse is beginning her shift and reviewing the medication administration records (MAR's) for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage

A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse take?

Cleanse the wound with 0.9% sodium chloride irrigation

A nurse is assisting with the admission interview for a client. Which of the following items of data should the nurse collect during the introduction phase of the interview?

Client's comfort and ability to participate in the interview

A nurse is assisting with teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include?

Clients who are age 65 or older are reluctant to report pain

A nurse is preparing to administer medication to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

Compare the medical record number and the name on the MAR with the client's identification band

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?

Confirm unresponsiveness

A nurse is preparing to assist with discharge planning for a client with a new colostomy who has low health literacy. When reinforcing teaching about changing the appliance, which of the following guidelines should the nurse follow?

Connect new instructions with what the client already knows

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute and describe the rhythm in the chart

A nurse is reinforcing teaching for a client who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include?

Do not use any materials containing oil or alcohol when using oxygen

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs

A nurse is contributing to the plan of care for a client who had a stroke and is scheduled to receive feeding via a gastrostomy tube. Which of the following should the nurse recommend prior to initiating each feeding?

Elevate the head of the bed

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music

A nurse is assisting with the administration of a client who will undergo a craniotomy. During the physical planning phase of the nursing process, to which of the following areas should the nurse contribute?

Establish client outcomes

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the healthcare facility?

Evacuate clients from the unit

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open

A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age?

Eye examination every 2 years

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is caring for a client who has the head of the bed elevated to a 45 degree angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?

Fowler's

A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowler's

A nurse is collecting data as a part of a comprehensive physical examination of a client. The nurse should use inspection to evaluate which of the following?

Gait

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personnel protective equipment (PPE) items should the nurse don prior to providing client care?

Gown, gloves

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?

Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back

A nurse in an urgent care center is caring for a 15 year old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Have the adolescent sign the consent form

A nurse is instilling antibiotic ear drops for a client who has an ear infection. Which of the following actions should the nurse take?

Have the client lie on the side opposite of the infected ear

A nurse on a same-day procedure unit is caring for several clients undergoing different types of procedures. A client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?

Hearing aids

As a nurse preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring

The nurse is caring for a client who has a stage II pressure ulcer. Which of the following dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure,which of the following actions should the nurse take first?

Identify the client using 2 identifiers

A nurse is collecting data from a client who is experiencing stress over a near fall out of bed. Which of the following physiological responses should the nurse expect to observe due to the client's fight-or-flight response?

Increased blood pressure

A nurse is reinforcing teaching with a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously

A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?

Inspect the eyes for drainage or redness

A nurse is assisting with the planning of an in-service training session about various dietary practices. Which of the following pieces of information should the nurse recommend including in the teaching?

Kosher diets involve restrictions regarding how food must be prepared

A nurse assisting with planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse suggest?

Limit drinking fluids when eating food

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

Lower abdomen

A nurse is initiating the use of a sequential compression device for a client who is postoperative following knee surgery. Which of the following actions should the nurse take?

Make sure 2 fingers can fit under the sleeves

A nurse is caring for a client who requires the insertion of a nasogastric tube. Which of the following actions should the nurse prepare to insert the tube?

Measure the distance from the nose to the earlobe to the xiphoid process

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants the surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse perform first when using the nursing process?

Obtain client information

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart foods first

A nurse is assisting with the initiation over seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse recommend having readily available at the client's bedside?

Oxygen equipment

A nurse is caring for a client who, after multiple less restrictive interventions, continues to pick at and dislodge his nasogastric tube. The provider has prescribed wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrists before applying the restraints

A nurse is collecting data from a client. Which of the following actions should the nurse take to determine the client's tissue perfusion?

Perform a blanch test

A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "Something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take?

Position the client supine with the knees in flexion

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups?

Preschoolers

A nurse is contributing to the planning of an in-service session about nutrition. Which of the following pieces of information should the nurse recommend for the teaching?

Protein serves as an energy source when other sources are inadequate

A nurse is collecting data from a client as part of a neurological examination. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?

Romberg

A nurse is collecting baseline data about a client's respiration as part of a comprehensive physical examination. Which of the following types of breath sounds should the nurse report to the provider?

Ronchi

A nurse is collecting data about a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding?

Sanguineous

A nurse is assisting with the screening of a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities?

Scoliosis

A nurse is caring for a client who is dehydrated. An insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organ?

Skin

A nurse is caring for a client who is exhibiting confusion. The nurse should identify which of the following laboratory values can cause confusion?

Sodium 123 mEq/L

A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse should identify that which of the following nutrients will be affected by the lack of salivary amylase?

Starch

A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about this procedure before. Which of the following should the nurse take?

Stop reinforcing the teaching and check with the surgeon about informed consent

A nurse on a medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priority to keep near the client at all times?

Suction equipment

A nurse is reinforcing teaching about nutrition with a middle adult client who has a sedentary job. Which of the following factors should the nurse consider?

The basal metabolic rate could decrease

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures

A nurse on a medical surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique?

The nurse washes her hands held higher than her elbows

A nurse is helping a client perform range-of-motion exercises for the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform?

Touching his chin to his chest

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include?

Try to block the urge to urinate until the next scheduled time

A nurse is administering an IM injection to a 5 month old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc

A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the surgeon?

WBC count 18,000/mm^3

A nurse is evaluating the development of a group of clients. The nurse should understand that, according to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

Young adulthood