ATI Level 2 Exam A
A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make? A: "Let's talk about a few ways you have dealt with stress in the past." B: "I believe that you will regret that decision. Your family needs your support." C: "I agree that you have to do what is best for your well-being at this time." D: "I think you should try to put your feelings aside and focus solely on your child."
A: "Let's talk about a few ways you have dealt with stress in the past."
A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching? A: "Maintain bone health by eating fruits, vegetables, and protein." B: "Tamsulosin can slow the progression of bone deterioration." C: "Walk 20 minutes two times a week to manage osteoporosis." D: "Start to increase vitamin C and magnesium in your diet."
A: "Maintain bone health by eating fruits, vegetables, and protein."
A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching? A: "The adhesive bandages on my incision will fall off as the incision heals." B: "I will be able to take a shower in 1 week." C: "I will need to follow a liquid diet for the first 3 days after surgery." D: "I can begin to resume my normal activity level in 2 weeks."
A: "The adhesive bandages on my incision will fall off as the incision heals."
A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? A: Apply ice packs to the client's axillae, neck, groin, and chest. B: Administer aspirin to the client C: Initially offer the client cool, oral fluids. D: Continue cooling measures until the client's rectal temperature is 37.2º C (99º F).
A: Apply ice packs to the client's axillae, neck, groin, and chest.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.) A: Nocturia B: Dependent edema C: Dyspnea D: Hacking cough E: Anorexia
A: Nocturia C: Dyspnea D: Hacking cough
A nurse in a provider's office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse's intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1: Graphic record Oral temperature 36.9° C (98.4° F) Pulse rate 78/min Respiratory rate 17/min BP 134/86 mm Hg Oxygen saturation 95% Exhibit 2: Diagnostic results Hgb 15.1 g/dL Hct 42.4% Fasting glucose 106 mg/dL Potassium 4.5 mEq/L International normalized ratio (INR) 4.2 Exhibit 3: Medication administration record Enalapril 2.5 mg PO daily Atorvastatin 10 mg PO daily Hydrocodone 5 mg/acetaminophen 325 mg PO q 6 hr PRN for joint pain A: Oxygen saturation B: Potassium level C: ACE inhibitor therapy D: Coagulation time
D: Coagulation time
A nurse is teaching a client who has tuberculosis about taking rifampin. Which of the following instructions should the nurse include? A: "Expect this medication to give your urine a greenish tinge." B: "Do not drink alcohol while taking this medication." C: "Take this medication with food." D: "Take a stool softener for the duration of therapy with this medication."
B: "Do not drink alcohol while taking this medication."
A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make? A: "You'll need to take this medication once a day at bedtime." B: "This medication causes adverse effects if the dosage is too high or too low." C: "Continuing this medication therapy long-term will eventually cure your hypothyroidism." D: "Potassium supplements can reduce the effectiveness of this medication."
B: "This medication causes adverse effects if the dosage is too high or too low."
A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). Which of the following instructions should the nurse include to promote elimination? A: "Drink at least 24 ounces of water each hour." B: "Void as soon as you feel the urge." C: "Expect a prescription for a diuretic." D: "Take an antihistamine each night at bedtime."
B: "Void as soon as you feel the urge."
A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? A: Diminished peripheral pulsations in the right lower leg B: Discoloration and edema of the right ankle C: Atrophy of the skin and hair loss on the right leg D: Dependent rubor in the right leg
B: Discoloration and edema of the right ankle
A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take? A: Use a gait belt and stand on the client's right side to assist with ambulation. B: Encourage the client to use wide-grip utensils when eating with the right hand. C: Place personal items on the bedside table close to the bed on the client's left side. D: Remove rolled toilet paper from the holder for easier access for the client
B: Encourage the client to use wide-grip utensils when eating with the right hand.
A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect? A: Hyperreflexia B: Fruity breath odor C: Sweating D: Shallow respirations
B: Fruity breath odor
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? A: Melena stools B: Hemoglobin 7.6 mg/dL C: Weight gain of 1.4 kg (3 lb) in 2 weeks D: Dyspepsia during the day
B: Hemoglobin 7.6 mg/dL
A nurse is caring for a middle adult female client who has atrial fibrillation and is taking warfarin. The nurse should recognize which of the following as an adverse effect of the medication and notify the provider? A: Clay-colored stools B: Increased menstrual flow C: Overgrowth of gingival tissue D: Dry, non-productive cough
B: Increased menstrual flow
A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis
B: Metabolic alkalosis
A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A: Presence of a transparent cornea B: Presence of strabismus C: Pinna moderately extends outward from the skull D: Walls of peripheral aspect of auditory canal are pink
B: Presence of strabismus
A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as a priority?A: Reduce environmental stimulation. B: Protect the client from harm. C: Administer an anxiolytic. D: Encourage physical exercise.
B: Protect the client from harm.
A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take? A: Teach the client how to use breathing techniques while continuing the discussion. B: Remain with the client until manifestations subside. C: Speak in a high-pitched louder voice to gain the client's attention. D: Instruct the client to join another group who is practicing yoga
B: Remain with the client until manifestations subside.
A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? A: Becomes angry when it is time to perform colostomy care B: Touches the colostomy stoma when the bag is changed C: Looks away as the nurse empties the colostomy bag D: Tells others that it will be nice to have a normal bowel movement again
B: Touches the colostomy stoma when the bag is changed
A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record? A: Pyrophobia B; Agoraphobia C: Monophobia D: Astraphobia
B; Agoraphobia
A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching? A: "I will blow out as hard as I can before I use the peak flow meter." B: "I will not take my controller medication if my peak flow meter scores in the yellow zone." C: "I will base my peak flow meter score on the best of three attempts." D: "I will go to the emergency room if my peak flow meter is in the green zone."
C: "I will base my peak flow meter score on the best of three attempts."
A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? A: "Obtain a pneumococcal vaccination every 2 years." B: "Contact your provider if you have a fever that lasts 18 hours." C: "Wash your hands when you return home from running errands." D: "Avoid exposure to cold air by shopping inside enclosed malls."
C: "Wash your hands when you return home from running errands."
A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care? A: Position the affected leg flat when sitting up in bed. B: Instruct the client to perform weight-bearing activities on the affected leg. C: Check for paresthesia of the affected leg. D: Apply heat to the surgical incision area of the affected leg.
C: Check for paresthesia of the affected leg.
A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect? A: Increased deep tendon reflexes B: Hypoactive bowel sounds C: Decreased level of consciousness D: Bradycardia
C: Decreased level of consciousness
A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include? A: Apply heat for the first 48 hr. B: Wear a sling when resting in bed. C: Elevate the wrist above heart level. D: Use a soft-bristle toothbrush to relieve itching under the cast.
C: Elevate the wrist above heart level.
A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi? A: Maintain bedrest until calculi are expelled. B: Withhold thiazide diuretics. C: Encourage intake of at least 3 L of fluid each day. D: Collect all urine for 24 hr in a collection container
C: Encourage intake of at least 3 L of fluid each day.
A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect? A: Otitis media B: Parotitis C: Facial eruption D: Lymphadenopathy
C: Facial eruption
A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? A: Consume five to seven servings of red meat per week. B: Limit daily calorie intake from saturated fat to 18%. C: Increase fiber intake to at least 30 g per day. D: Exercise 2 days a week for at least 60 min
C: Increase fiber intake to at least 30 g per day.
A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? A: Place the child in a room equipped with a positive-pressure airflow system. B: Place the child in a room equipped with a negative-pressure airflow system. C: Initiate droplet precautions for the child. D: Initiate contact precautions for the child.
C: Initiate droplet precautions for the child.
A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching? A: Average body fat for women is 15%. B: Obesity can cause osteoporosis. C: Morbid obesity is measured as a BMI over 40. D: Coronary artery disease increases with a waist size of 81.28 cm (32 in).
C: Morbid obesity is measured as a BMI over 40.
A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection? A: Negative nitrites B: RBCs < 2 C: Positive leukocyte esterase D: Amber-colored urine
C: Positive leukocyte esterase
A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis
C: Respiratory acidosis
A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include in the plan? A: Direct the client to perform incentive spirometry every 2 hr. B: Titrate oxygen to maintain the client's oxygen saturation level at 90%. C: Teach the client how to cough up secretions. D: Maintain the client in a low-Fowler's position
C: Teach the client how to cough up secretions.
A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider? A: Urine color is light pink. B: The suprapubic area is soft to palpation. C: The catheter tubing has multiple red clots. D: The bowel sounds are hypoactive
C: The catheter tubing has multiple red clots.
A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? A: The stool is a dark green liquid with a small amount of blood. B: The ileostomy output is 1,000 mL for the past 24 hr. C: The stoma is purple in color. D: The output from the NG tube has decreased over the past 24 hr
C: The stoma is purple in color.
A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia? A: Feverfew B: Gingko C: Valerian D: Garlic
D. Garlic
A nurse is providing discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? A: "Notify your provider if you notice small pieces of tissue in your urine." B: "Any urinary incontinence will be permanent." C: "Expect to see an increase in the amount of semen produced." D: "Perform Kegel exercises several times throughout the day."
D: "Perform Kegel exercises several times throughout the day."
A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? A: Urine output 0.5 mL/kg/hr B: Capillary refill 3 seconds C: Heart rate 148/min D: Brisk skin turgor
D: Brisk skin turgor
A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include? A: Self-administer 1 mg of glucagon subcutaneously. B: Self-administer 20 units of regular insulin. C: Drink 120 mL (4 oz) of skim milk. D: Drink 120 mL (4 oz) of fruit juice.
D: Drink 120 mL (4 oz) of fruit juice.
A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect? A: Chest pain B: Hallucinations C: Feels unreal D: Follows directions
D: Follows directions
A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan? A: Shake the medication vial prior to drawing up the medication. B: Withhold epoetin if hemoglobin is less than 9 g/dL. C: Initiate contact isolation. D: Monitor for hypertension.
D: Monitor for hypertension.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? A: Drink tomato juice with the breakfast meal. B: Suck on peppermint when having indigestion. C: Elevate the head of the bed 10 cm (4 in) using wooden blocks. D: Plan to finish eating at least 3 hr before bedtime.
D: Plan to finish eating at least 3 hr before bedtime.
A nurse is admitting a client who has an acute bacterial wound infection and a temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take? A: Obtain a wound culture 30 min after initiating IV antibiotics. B: Place a fan on the lowest setting in the client's room. C: Apply a cooling blanket directly on the client's skin. D: Set the temperature of the client's room to 22.2° C (72° F).
D: Set the temperature of the client's room to 22.2° C (72° F).
A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take? A: Encourage the client to repeat what the nurse has said. B: Stand to the side of the client and speak directly into the client's ear. C: Talk to the client by speaking in a loud tone of voice. D: Avoid the use of hand gestures and motions when speaking with the client.
A: Encourage the client to repeat what the nurse has said.
A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect? A: Hypoglycemia B: Flushed skin C: Tachycardia D: Hypertonicity
A: Hypoglycemia