ATI Quiz Questions

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Skin blanching

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.

Subtract the amount of irrigant used from the client's urine output.

A nurse is planning care to improve self-feeding for a client who has vision loss. Which. of the following interventions should the nurse include in the plan of care?

Use a clock pattern to describe food on the client's plate.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order."

A nurse is caring for a client who is terminally ill.

"This is a difficult time, but we are helping each other through this."

A nurse is caring for a client who has terminal liver cancer. Spiritual distress

"What could I have done to deserve this illness?"

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage.

A nurse is administering IV fluid to an older adult client. Adverse effects

Auscultate lung sounds.

A nurse is responding to a call light and finds a client lying on the bathroom floor.

Check the client for injury.

A nurse is reviewing practice guidelines with a group of newly licensed nurses.

Initiate an enteral feeding through a gastrostomy tube.

A nurse is performing a peripheral vascular assessment for a client. Sound

Narrowed arterial lumen

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

A nurse is preparing a change-of-shift report.

SBAR

A nurse is assisting a client who is postop with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

Semi-Fowler's

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take prevent skin breakdown?

Have the client use a trapeze bar when changing positions.

A nurse is caring for a client who has tuberculosis.

Place the client in a room with negative-pressure airflow Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position.

A nurse is reviewing a client's fluid and electrolyte status.

Potassium 5.4 mEq/L

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy.

Select a suction catheter that is half the size of the lumen.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons.

Withhold the blood transfusion

A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

• "I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I concentrate best in the morning."

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach."

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening, what does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse manager is overseeing the care on a unit. HIPAA guidelines states which is not acceptable...

A nurse asks a nurse from another unit to assist with her documentation.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

Acupuncture

A nurse is admitting a client who has varicella. Which precaution

Airborne

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions.

A nurse is preparing to transfer a client who has right sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?

Ask the client if he can bear weight. Position the chair on the left side of the bed. Have the client sit and dangle his feet at the bedside. Use the stand-and-pivot technique to move the client to the chair.

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 should the nurse take first?

Assist the client to an upright position.

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

Egg

A nurse is assessing an adult who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

Erythema on pressure points

A charge nurse is discussing the responsibility of nurses caring for clients who a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hour. At what rate should the nurse set the infusion pump?

8 mL/hr

A nurse is caring for a client who is postop and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water.

A nurse is performing a Romberg's test during the physical assessment of a client.

Have the client stand with her arms at her side and her feet together.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

Pupil clarity Visual fields Visual acuity

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days.

Rapid heart rate

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings.

Remove stockings at least once per shift.

A nurse is talking with the partner of an older adult male client who has dementia.

Role overload

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question?

The dose

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

Use progressive relaxation promotes sleep by decreasing stress and reducing muscle tension.