ATI Practice Exam 1

A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate?

An older adult client who has no family and is uncertain about moving to assisted living

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients. Which of the following clients should the nurse identify as being as greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the client's skin

A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Reaches over the bed to straighten the fitted sheet

Intermittent Pneumatic Compression (IPC)

to prevent DVT (used for edema)

three point gait

used when only one leg can bear weight

A nurse is completing an 8hr I&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL and 8 oz broth. The nurse should record how many mL of intake on the client's record?

740 mL - 100mL of ice chips = 50mL fluid volume

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Necrotic subcutaneous tissue

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I have a set of my brother's crutches in my basement I can also use"

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg. Rationale: A three-point gait is appropriate for this client. A three-point gait requires the client to bear all of his weight on one foot. With a three-point gait, the client bears weight on both crutches and then on the uninvolved leg, repeating the sequence. The affected leg does not touch the ground.

A nurse has received change of shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?

A client who was admitted for chest pain and is reporting a new onset of indigestion

Abduction pillow/wedge

A wedge made of foam used to help to immobilize a patient's legs after hip surgery

An assistive personnel reports a client's vital signs as tympanic temperature 37.1C (98.8F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mmHg. Which of the following vital signs should the nurse re-measure?

BP

A nurse is caring for a client who has indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation?

Clubbing of the fingers

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

Earlobe

A nurse is preparing an educational program for a group of new licensed nurses about client confidentiality. The nurse should explain that nurses may share a client's protected health information with which of the following groups?

Health care team members caring for the client

A nurse needs to lift a box in a supply room. Which of the following actions should the nurse take to prevent an injury due to lifting?

Keep the box close to his body as he lifts

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room. Rationale: This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the inter professional health care team?

Occupational therapist

Trochanter roll

Rolled towel support placed against the hips and upper leg to prevent external rotation of the legs.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie

A nurse in a long term care facility is caring for an older adult who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hr

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The client's current weight-bearing status

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

Urinary tract infection Rationale: A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCs, RBCs and bacteria. The urine often has an unpleasant odor.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed

Foot board

a piece of wood or plastic placed at the end of the hospital bed and used for positioning the resident's feet

BMAT

bedside mobility assessment tool

Hand roll

roll placed in the hand to prevent hand contraction

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? Select all that apply.

- Check for personal items when changing linens - Keep bath water temp between 110-115 deg - Shave hair in direction of growth

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? Select all that apply.

- Contractures of the extremities - Crackles in the lungs - Pressure ulcers

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

- Excessive laxative use - Ignoring the urge to defecate - Inadequate fluid intake

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? Select all that apply.

- Verify the oxygen flow rate every other day - Check the cannula position on a regular basis - Check the tops of the ears for skin breakdown - Post "no smoking" signs in a prominent location in the home

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following subtances?

Blood

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data

A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?

Delivers a low concentration of oxygen

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first?

Suction the tracheostomy of a client who has copious secretions

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

The client is 71 years old

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Veracity

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?

False imprisonment

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions?

Advocate

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mmHg, and temperature 36.8C (98.2F). Which of the following actions should the nurse perform?

Complete a neurological check

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

A nurse is preparing to exit the room of a client who has methicillin-resistant staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room.

Gloves Eyewear Gown Mask Hand hygiene

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

Grape juice

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?

Metabolic acidosis

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

Negligence

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Place clean linen that touched the floor in the soiled linen bag

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Places the client's arm above the level of the client's heart

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Wait 30 mins and return to measure the oral temperature

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Wear an N95 respirator mask

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while care for this client?

Protective Environment