ATI Practice Questions weeks 1-3

c. "I should tell the nurse if the pain doesn't stop while I am using the device."

A nurse is caring for a client who is receiving morphine via a PCA pump after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? a. "I'll wait to use the device until it is absolutely necessary." b. "I'll be careful about pushing the button too much so I don't get an overdose." c. "I should tell the nurse if the pain doesn't stop while I am using the device." d. "I will ask my adult child to push the dose button when I am sleeping."

a. Fever b. Malaise e. Increase in pulse and respiratory rate

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply). a. Fever b. Malaise c. Edema d. Pain or tenderness e. Increase in pulse and respiratory rate

a. Use a draw sheet or a friction reducing sheet to facilitate smooth movement.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement is correct regarding logrolling? a. Use a draw sheet or a friction reducing sheet to facilitate smooth movement. b. It is acceptable to twist the client's head, but not the hips, while logrolling. c. Logrolling can be performed by one experienced nurse. d. Logrolling will maintain straight alignment when the client is sitting in a chair.

b. Stage II

A nurse attempts to wake a patient who is scheduled for tests and is able to arouse him relatively easily. Which stage of sleep is this patient most likely experiencing? a. Stage I b. Stage II c. Stage III

c. Dorsal surface

A nurse in a family practice is performing a physical exam of an adult client. Which part of her hands should she use during palpation for optimal assessment of the skin temperature? a. Palmar surface b. Fingertips c. Dorsal surface d. Base of fingers

a. Posture b. Skin Lesion c. Speech

A nurse in a provider's office is documenting his findings following an exam he performed for a client new to the practice. Which of the following parameters should he include as part of his general survey? (Select all the apply.) a. Posture b. Skin Lesion c. Speech d. Allergies e. Immunization status

d. When asking the client if he took his medication this morning.

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors? a. When determining if the client is eating a well-balanced diet. b. When asking the client about his receptiveness to the transfer. c. When asking the client how he performs his ADLs. d. When asking the client if he took his medication this morning.

c. Sensory overload d. Sensory deprivation e. Sleep Deprivation

A nurse is assessing patients in the burn unit for sensory alterations. Which factors contribute to severe sensory alterations? (Select all that apply.) a. Sensory saturation b. Sensory discrepancies c. Sensory overload d. Sensory deprivation e. Sleep Deprivation f. Cultural overload

c. Provide a private room, and limit stimulation.

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment. b. Put the client in a room with a client who has hearing loss. c. Provide a private room, and limit stimulation. d. Speak at a higher volume to the client, and encourage ambulation.

b. Keep the client's bed linens dry.

A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? a. Apply an alcohol-water solution to the client's skin. b. Keep the client's bed linens dry. c. Apple ice packs to the groin. d. Limit the client's fluid intake to 1183ml of fluid per day.

b. Make sure only one person speaks at a time. d. Allow plenty of time for the client to respond. e. Use brief sentences with simple words.

A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with the client? (Select all that apply.) a. Increase the volume of your voice. b. Make sure only one person speaks at a time. c. Avoid discouraging the client by saying that you do not understand him. d. Allow plenty of time for the client to respond. e. Use brief sentences with simple words.

b. 45-year old female client following mastectomy c. 20-year old female client following left above-the-knee amputation e. 55-year old male client following stroke with right-sided hemiplegia

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at risk for body image disturbances? (Select all the apply.) a. A 30-year old male client following laproscopic appendectomy b. 45-year old female client following mastectomy c. 20-year old female client following left above-the-knee amputation d. 65-year old male following cardiac catheterization e. 55-year old male client following stroke with right-sided hemiplegia

c. The patient turns one ear toward the nurse during conversation.

A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaption to the sensory deficit? a. The patient frequently cleans out eyes with saline washes. b. The patient applies different spices during mealtimes to food. c. The patient turns one ear toward the nurse during conversation. d. The patient isolates self from social situations with groups of people.

b. Auscultation

A nurse is collecting data from a client's comprehensive physical exam. After the nurse inspects the client's abdomen, which of the following skills of the physical exam process should she perform next? a. Olfaction b. Auscultation c. Palpation d. Percussion

b. Use a mix of open- and closed-ended questions c. Reduce environmental noise e. Perform the general survey before the examination

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) a. Address the client with the appropriate title and her last name b. Use a mix of open- and closed-ended questions c. Reduce environmental noise d. Have a client complete a printed history form e. Perform the general survey before the examination

b. Ask the client if they are having pain.

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/90 mmHg and the client denies having a 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 they are having pain. c. Request a prescription for an antianxiety medication. d. Return in 30 mins to recheck the client's blood pressure.

c. Bradypnea d. Orthostatic Hypotension e. Nausea

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply). a. Urinary incontinence b. Diarrhea c. Bradypnea d. Orthostatic Hypotension e. Nausea

b. Wash the hands with soap and water for at least 15 seconds. d. Use a clean paper towel to turn off the hand faucets

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply). a. Apply 3-5 ml of liquid soap to dry hands. b. Wash the hands with soap and water for at least 15 seconds. c. Rinse the hands with hot water d. Use a clean paper towel to turn off the hand faucets e. Allow the hands to air dry after washing.

d. "I take the batteries out of my hearing aids when I take them off at night."

A nurse is reviewing instructions with a client who has hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I use a damp cloth to clean the outside of my hearing aids." b. "I clean the ear molds of the hearing aids with rubbing alcohol." c. "I keep the volume of my hearing aids turned up so I can hear better." d. "I take the batteries out of my hearing aids when I take them off at night."

b. "I'll never be able to care for this at home. Can't you just send a nurse to the house?"

A nurse is teaching a group of clients how to care for their colostomies. Which of the following should alert the nurse that one of the client's is having an issue with self-concept? a. "I was having difficulty with attaching the appliance at first, but my wife was able to help." b. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" c. "I met my neighbor who also has a colostomy, and he taught me a few things." d. "It may take me a while to get the hang of this. I have to admit I am pretty nervous."

b. Activate the fire alarm and notify the appropriate person.

An acronym RACE is commonly taught as a means for remembering priorities for actions during a fire. The "A" in this acronym stands for which of the following? a. Attempt to extinguish the fire. b. Activate the fire alarm and notify the appropriate person. c. Alert the local fire department d. Answer the telephone calls and call bell.

b. Auscultation

Assessment of a client's bowel sounds is best obtained by performing which assessment technique? a. Percussion b. Auscultation c. Palpitation d. Inspection

a. Objective

At the end of the shift, the nurse documents that the client has voided 475ml during the shift via an indwelling catheter. What type of data has the nurse documented? a. Objective b. Covert c. Subjective d. Symptomatic

c. Normal Saline Solution

During morning care the nurse notices a glasslike appearance to the client's eyes and prepares to perform eye care. What solution should the nurse use to perform basic eye care to remove the excessive secretion related to the illness? a. Soap and Water b. Boric acid solution c. Normal Saline Solution d. Hydrogen Peroxide Solution

a. "Can you tell me what the pain felt like and show me exactly where it was?"

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? a. "Can you tell me what the pain felt like and show me exactly where it was?" b. "Did you report the chest pain episodes to your physician?" c. "Is there a history of heart disease in your family?" d. "Have you had this pain before?"

d. "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The nurse assistant is preparing to help the client make a lateral transfer from the bed to the stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurses help. What is the nurse's best response? a. "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." b. "I can only allow you to transfer without assistance based upon a physician's order, so I will help you." c. "You cannot transfer without my help because you need a friction reducing device to prevent harm to your skin". d. "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

b. Supplement the client's information by speaking with family or friends.

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required in the hospitals nursing admission history document. How should the nurse best proceed with this assessment? a. Perform the assessment in several short episodes rather than at one sitting. b. Supplement the client's information by speaking with family or friends. c. Limit the assessment to objective data. d. Obtain the client's records from admissions to other institutions.

d. Wash hands with antimicrobial soap and water.

The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? a. Clean hands with wipes from the bedside table. b. Wipe hands with a dry paper towel. c. Use an alcohol-based waterless hand gel. d. Wash hands with antimicrobial soap and water.

d. A person's culture may dictate the amount of stimulation considered normal.

The nurse takes into consideration factors that affect sensory stimulation in hospitalized patients when planning patient care. Which statement is true? a. Different personality types demand the same level of stimulation. b. Decreased sensory stimulation may be sought during periods of low stress. c. Illness does not affect the reception of sensory stimuli. d. A person's culture may dictate the amount of stimulation considered normal.

c. Jaundice

Upon assessment of an older adult, the nurse notes that the clients skin to have a yellow color. The nurse recognizes and documents the color of this skin as which of the following? a. Pallor b. Cyanosis c. Jaundice d. Ecchymosis

d. Do you usually go to bed and wake up about the same time each day?

What interview question would be the best choice for the nurse to use to assess for recent changes in a patient's sleep-wakefulness pattern? a. In what way does the sleep you get each day affect your everyday living? b. How much sleep for you think you need to feel fully rested? c. What do you usually do to help yourself fall asleep? d. Do you usually go to bed and wake up about the same time each day?

b. Have the patient eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle.

When caring for a patient with insomnia, the nurse would appropriately institute which intervention? a. Encourage the patient to nap frequently during the day for the loss of sleep at night. b. Have the patient eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle. c. Advise the patient to exercise vigorously before bedtime to promote drowsiness. d. Advise the patient to avoid food high in carbohydrates before bedtime.

c. Place a mask on the client to limit the spread of micro-organisms into the surgical wound.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6ft away from the client's bedside. b. Instruct the client to refrain from coughing and sneezing during the dressing change. c. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. d. Keep a box of facial tissues nearby for the client to use during the dressing change.

c. A thorough, mechanical cleaning.

When providing oral care, what does the nurse recognize as the most important component of the oral care process? a. Application of moisturizing ointment to the lips. b. Use of mouthwash or breath freshener. c. A thorough, mechanical cleaning. d. Selection of toothpaste.

a. Keeping medication in clearly labeled containers.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? a. Keeping medication in clearly labeled containers. b. Avoiding the use of alternative and complementary therapies. c. Hidden sources of lead in the household environment. d. Alternative to chemical-based cleaning supplies.