good for us assort

Module 2 Med-Surge Ch. 58 10. A client fell when getting off the bus and fractured her right ankle. The nurse is performing a neurovascular assessment (NVA). Important aspects to remember when performing an NVA are: 1.Palpate the most distal pulse on the right lower extremity only using the nondominant hand 2.Assess for the client's ability to feel the nurse touching her feet 3.Ask the client to dorsiflex and plantar flex her left foot only 4.Compare the temperature of the left foot and toes to the left thigh

10. 2. Rationale: When performing a NVA you should always compare one extremity to another to observe for abnormalities.

Module 1 Fundamentals Ch. 26 15. A nurse orients an older patient to the safety features in her hospital room. What is a priority component of this admission routine? a. Explain how to use the telephone. b. Introduce the patient to her roommate. c. Review the hospital policy on visiting hours. d. Explain how to operate the call bell.

15. d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury.

Module 2 ATI Fundamentals 40 2. A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? A. Encourage isometric exercises. B. Suction every 8 hr. C. Give low-dose heparin. D. Promote incentive spirometer use.

2. A. Incorrect: Performing isometric exercises strengthens skeletal muscles. B. Incorrect: The nurse should not suction the client's airway routinely. C. Incorrect: Low-dose heparin helps prevent thrombus formation. D. Correct: Using an incentive spirometer helps keep the airways open and prevents atelectasis.

Module 2 Fundamentals Ch. 32 15. A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of an 80-year-old hospitalized female patient. During the patient interview the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6

15. b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

Module 2 NCLEX Ch. 62 16. A nurse receives a client from the emergency department (ED) in Buck's traction following fracture of the right femur. The nurse documents which of the following as a priority in the client medical record? 1. Status of skin underneath the traction and over bony prominences 2. Type of pin, wire, or tongs used 3. The effectiveness of pain medication given in the field 4. Medications given in the emergency departmen

16 Answer: 1 Rationale: IIt is essential to monitor the condition of the skin under traction, as well as bony prominences, because these areas are at risk for breakdown due to continuous friction and pressure from the skin traction device. Skeletal tractions use pins, wires, or tongs to aid in realignment. Buck's traction is a type of skin traction. Effectiveness of medication given in the field is not pertinent to the client's status after admission from the ED. Evaluating effectiveness of analgesia is appropriate, but the most essential documentation for a client with skin traction is the condition of the skin underneath the straps..Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Communication and Documentation Content Area: Adult Health: Musculoskeletal Strategy: The critical word in the question is priority, which indicates that all or more than one option are correct and that the most essential ones are correct. Use nursing knowledge about skin traction and the process of elimination to make selections.

Module 2 NCLEX Ch. 62 17 A client has been placed in balanced suspension traction after sustaining a fracture. The nurse explains to the family that which of the following is an advantage of this type of traction? 1. It eliminates the risk for skin breakdown. 2. It allows the client to raise the buttocks off the bed for bedpan use and skin care. 3. It is more effective in reducing hip contracture. 4. It requires only one weight to maintain traction.

17 Answer: 2 Rationale: Balanced suspension allows for ease with bedpan use and skin care without disturbing the line of traction. In this type of traction, the client's injured extremity is lifted off the bed and a straight pull is accomplished by the application of several forces and several weights. Skin breakdown is not eliminated with this type of traction because any immobile client can be at risk. Because the extremity is lifted with the traction, the hip is flexed, making hip contracture possible. The number of weights is determined by the total pounds necessary to reduce the fracture. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is knowledge of balanced suspension traction as a type of skeletal traction. Use nursing knowledge and the process of elimination to make a selection.

Module 1 NCLEX Ch. 7 17 A young man is brought to the emergency department as a victim of a multi-vehicle accident that caused multiple casualties. The man is awake and alert. He has a fracture of his right tibia and several small lacerations on his face. How will the triage nurse categorize this client? 1. Priority 1 (red tag) 2. Priority 2 (yellow tag) 3. Priority 3 (green tag) 4. Priority 4 (black tag)

17 Answer: 2 Rationale: The client is awake and alert. He does not have overt signs of cardiac or respiratory distress. This client can wait for treatment for 1-2 hours. Check on his status every 30-60 minutes. Depending on the status of the other incoming casualties, this client may move up in priority. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Adult Health Strategy: Recall the principles and protocols of triage. Eliminate priority 1, which is always life-threatening, and option 4, which indicates death. Choose priority 2 over 3 because fractures need attention within a few hours to reduce risk of complications.

Module 2 NCLEX Ch. 62 18. A client taking colchicine for gout reports weakness, abdominal pain, and nausea and vomiting for the past 2 days. How should the nurse interpret these symptoms? 1. Therapeutic effects of the medication 2. Signs of toxicity 3. Expected side effects 4. An allergic response

18 Answer: 2 Rationale: The symptoms described are signs of toxicity. The client should be instructed to stop the medication and be seen for follow-up treatment. The expected therapeutic effect of colchicine is to diminish the joint pain associated with the acute attack. The combination of symptoms are too severe to be expected side effects of the medication. The symptoms are not consistent with an allergic response. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of actions and adverse effects of colchicine. Use nursing knowledge and the process of elimination to make a selection.

Module 1 NCLEX Ch. 7 18 The nurse should explain to the mother of a 12-month-old infant that a forward-facing infant seat is safest once the infant weighs at least ____ pounds. Record your answer rounding to the nearest whole number. ____ pounds

18 Answer: 20 Rationale: The infant must weigh at least 20 pounds in order to be safe in a forward-facing infant seat and must be 1 year or older. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Teaching and Learning Content Area: Child Health Strategy: Because this item is a standard, it is necessary to commit this information to memory. A quick way to remember this requirement is that the number 20 is also the number of fingers and toes on an infant.

Module 1 NCLEX Ch. 7 19 The nurse is treating a client who continues to return to a violent relationship saying, "There is nothing I can do." What is the nurse's best response? 1. "You do have some choices; let's sit together and explore them." 2. "If you return you are at risk for further abuse." 3. "Here is the number of the crisis hotline." 4. "Do you have family or friends who can help?"

19 Answer: 1 Rationale: Helping the client to explore alternatives helps empower this client who is feeling powerless. Powerlessness is common in victims of ongoing violence, as the emotional component of the violence instills terror and helplessness. The client is ashamed and demoralized, criticized and controlled by the perpetrator, who often makes numerous serious threats and convinces the victim that there is no hope of escape. Teaching about further risk of violence, providing and/or mobilizing resources are appropriate interventions, but they will not be effective if the client feels powerless to act. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Strategy: Recognize the powerlessness of the client and choose an option that will allow the client to take action to combat this feeling and achieve a feeling of competence and control.

Module 2 NCLEX Ch. 62 19 An 87-year-old client who sustained a right hip fracture asks the nurse how long it will take for the fracture to heal. The nurse's response includes consideration of which client factor that influences the rate of bone healing? 1. Frequency of physical therapy 2. Age of the client 3. Weight of the client 4. Early ambulation

19 Answer: 2 Rationale: Age, site of the fracture, and blood supply to the affected area all affect the rate of bone healing. Younger and healthy clients will have faster bone healing than older adults and those with chronic illnesses. Although physical therapy will assist in mobility, it does not directly enhance bone healing. The weight of the client, unless accompanied by malnutrition, does not have a direct bearing on bone healing. The physician determines when ambulation is allowed and thus it is not a client factor. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is knowledge of possible threats to bone healing in an identified client. Use nursing knowledge and the process of elimination to make a selection.

Module 2 NCLEX Ch. 62 2 Which nursing diagnosis would the nurse choose as the priority for a client with Paget's disease? 1. Risk for Noncompliance 2. Disturbed Sleep Pattern 3. Impaired Physical Mobility 4. Disturbed Body Image

2 Answer: 3 Rationale: Impaired Physical Mobility is the appropriate priority nursing diagnosis for a client with Paget's disease. The client needs to remain active to decrease the complications associated with immobility and to maintain the ability to perform self-care activities. The other diagnoses, although they could be appropriate, are not the priority in clients with Paget's disease. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of priorities for the client with Paget's disease. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 59 2. A client has just been diagnosed with gout. Client teaching would include instructions to: 1.Check his feet every day for ulcers 2.Avoid alcohol and turkey 3.Avoid fats and milk products 4.Take his antigout medications only when his toe hurts

2. 2. Rationale: Alcohol and turkey contain purine, which can aggravate gout.

Module 2 Med-Surge Ch. 58 2. A 7-year-old boy fell while roller-skating and fractured his radius along the epiphyseal plate. What is a likely consequence of the fracture? 1.Fracture healing will proceed as normal and be fully remodeled in four weeks. 2.The arm will always have a noticeable deformity, even after the fracture is healed. 3.The fracture site has a 95% chance of developing an infection. 4.Growth in the arm may be delayed or stopped.

2. 4. Rationale: In a maturing child, the epiphyseal plate, or growth plate, is where active longitudinal growth occurs (until the age of maturity). If a fracture occurs in or through the epiphyseal plate, growth in that extremity can be delayed or stopped. When maturity is reached the epiphyseal plate merges the epiphysis and the metaphysis and the epiphyseal plate completely disappears.

Module 2 ATI Med-Surg 73 2. A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply.) A. Scrape the site with a wooden tongue depressor. B. Puncture the crusted area with a sterile needle. C. Swab the crusted area with a sterile cotton‑tipped applicator. D. Place cotton‑tipped applicator in culturette tube. E. Place culturette tube in ice.

2. A. A wooden tongue depressor is used to scrape cells of a skin lesion to test for a fungus. B. CORRECT: Exudate under the crusted area should be collected. The crust or scab should be punctured or lifted to obtain a reliable specimen. C. Swab the moist lesion bed under the crust with a sterile cotton‑tipped applicator to obtain a reliable specimen. D. CORRECT: The cotton‑tipped applicator is placed in liquid fixative within the culturette tube. E. CORRECT: The culturette tube is immediately placed in ice when obtaining a viral specimen.

Module 2 ATI Med-Surg 71 2. A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat emboli? A. Altered mental status B. Reduced bowel sounds C. Swelling of the toes distal to the injury D. Pain with passive movement of the foot distal to the injury

2. A. CORRECT: Altered mental status is an early manifestation of fat emboli. Other manifestations include dyspnea, chest pain, and hypoxemia. B. Reduced bowel sounds is an adverse effect of opioid narcotics and can result in constipation. C. Swelling of the toes distal to the injury is a manifestation of reduced circulation and can be the result of a tight cast. The nurse should elevate the extremity and apply ice. D. Pain with passive movement of the foot distal to the injury is an expected finding. Severe pain or pain unrelieved by narcotics is a manifestation of compartment syndrome.

Module 2 ATI Med-Surg 69 2. A nurse is assessing an older adult client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity? (Select all that apply.) A. Skin cool to touch from mid‑calf to the toes B. Lower leg appearing dusky when client is sitting C. Palpable pounding pedal pulse D. Lack of hair on lower leg E. Blackened areas on several toes

2. A. CORRECT: The client can have coolness of the affected extremity where decreased vascularization starts. B. CORRECT: The affected extremity can become dusky when sitting due to decreased vascularization of the extremity. C. The client will have a lack of or diminished pedal pulse of the affected extremity due to decreased vascularization. D. CORRECT: The client can have decreased hair growth on areas of the affected extremity due to decreased vascularization. E. CORRECT: The client can have blackened areas on several toes suggestive of gangrene due to decreased vascularization to the affected extremity.

Module 2 ATI Med-Surg 68 2. A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.) A. Check continuous passive motion device settings. B. Palpate dorsal pedal pulses. C. Place a pillow behind the knee. D. Elevate heels off bed. E. Apply heat therapy to incision.

2. A. CORRECT: The nurse should check the continuous passive motion device settings to determine if the settings are as prescribed. B. CORRECT: The nurse should assess the strength of the pulses of both lower extremities to help determine adequate circulation. C. The nurse should place one pillow under the lower calf and foot to cause a slight extension of the knee joint and to prevent flexion contractures. The knee can also rest flat on the bed. D. CORRECT: The nurse should prevent pressure ulcers on the client's heels by elevating the heels off the bed with a pillow. E. The nurse should apply cold therapy to reduce postoperative swelling.

Module 2 Fundamentals Ch. 32 2. A nurse is providing range-of-motion exercises for a 53-year- old female patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Re-evaluate the nursing plan of care. d. Move to the patient's other side to perform exercises. e. Encourage the patient to finish the exercises and then rest. f. Assess the patient for other symptoms.

2. a, c, f. When a patient complains of fatigue during range-of- motion exercises, the nurse should stop the activity, re-evaluate the nursing plan of care, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

Module 1 Fundamentals Ch. 26 2. A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. 60% of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Over 1/3 of fire deaths occur in a home without a smoke detector. e. Fires are more likely to occur in homes without electricity or gas. f. More fires occur in homes occupied by single parents.

2. c, d, e. Of all fire deaths in the United States, 85% occur in the home (CDC, 2011a). Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. More than one-third of home fire deaths occur in a home without a smoke detector (CDC, 2011a). People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Being a single parent is not a risk factor for fire occurrences.

Module 1 NCLEX Ch. 7 20 The nurse is assessing a school-age child. Which finding by the nurse may indicate physical neglect? 1. Not following instructions well 2. Boisterous activity 3. Stealing or hoarding food 4. Sudden onset of enuresis

20 Answer: 3 Rationale: Children who are physically neglected will often steal and hoard food because of inadequate nutrition. The child's level of physical activity and response to dis- cipline may be indicators of emotional or physical abuse. A sudden onset of enuresis is one possible indication of sexual abuse. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Assessment Content Area: Child Health Strategy: Look carefully at the options. Identify the one that has to do with meeting basic needs. This child has been neglected and is trying to cope with that and provide for own basic needs.

Module 2 NCLEX Ch. 62 20 A client is scheduled to have a closed reduction of a right ankle fracture. The nurse determines the client understands the procedure when the client states that it involves which of the following? 1. Using an arthroscope to realign the bones 2. Realigning the bone using surgery 3. Correcting the bone alignment using manual manipulation 4. Inserting pins, rods, or other implantable devices

20 Answer: 3 Rationale: In a closed reduction procedure, the physician applies traction and manipulates the bone until the broken ends are realigned. Arthroscopy is a surgical procedure for treating some types of joint problems. Open reduction is a realignment of bone with surgery. Internal fixation devices are surgically inserted during an open reduction to immobilize the fracture during the healing process. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of various approaches to correct bone fracture. Use nursing knowledge and the process of elimination to make a selection.

Module 2 NCLEX Ch. 62 21. A child is admitted to the hospital with a diagnosis of osteomyelitis. Which data would the nurse likely obtain during a nursing history? 1. History of an upper respiratory infection 2. History of gastroenteritis 3. History of Legg-Calve-Perthes disease 4. History of congenital hip dysplasia

21 Answer: 1 Rationale: The history of a child with osteomyelitis may include a recent upper respiratory infection (which may include an ear infection or sinus infection), skin infection, or blunt trauma to a bone. A recent history of gastroenteritis would not lead to osteomyelitis. Legg-Calve-Perthes disease is an aseptic necrosis of the femoral head that leads to pain and limping but osteomyelitis is a bone infection. Congenital hip dysplasia affects mobility but does not lead to osteomyelitis. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Child Health Strategy: The core issue of the question is the knowledge of risk factors for osteomyelitis. Use nursing knowledge and the process of elimination to make a selection.

Module 1 NCLEX Ch. 7 21 The nurse admits a female client to the emergency department who arrives with a black eye and reports of headache, chronic pain, GI problems, menstrual irregularities, and anxiety. A previous physical workup was negative. The nurse should assess the client for which priority problems? Select all that apply. 1. Premenstrual syndrome 2. Physical or sexual abuse 3. Irritable bowel syndrome 4. Self-destructive potential 5. Migraine headache

21 Answer: 2, 4 Rationale: Physical or sexual abuse and self- destructive potential are the priority assessments at this time. Anxiety, a black eye, and various somatic complaints, when combined, suggest unacknowledged violence against the client. The client's safety should be a priority. In situations where violence might have or actually has occurred, people can feel so trapped and desperate that suicide (or homicide) may seem the only way out of the situation. Providing for the client's safety includes assessing for suicidal and/or homicidal potential. After assessing for abuse and the risk of harm toward self or others, the nurse can then assess for other physical causes, such as premenstrual syndrome, migraine headache, and irritable bowel syndrome. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Assessment Content Area: Mental Health Strategy: Look beyond the physical and think what might, in the absence of physical explanations, be causing the client's symptoms. Remember that violence occurs in all strata of society.

Module 2 NCLEX Ch. 62 22 Two hours after a child had a cast applied for a fractured radius, the nurse assesses swelling in the hand, which is elevated higher than the heart. Ice has been applied continuously. The child denies an increase in pain but does report numbness and tingling. Which should the nurse do first? 1. Medicate the client for pain again. 2. Elevate the injured extremity even higher. 3. Call the physician. 4. Provide the child with diversional activities.

22 Answer: 3 Rationale: The client's symptoms are compatible with compartment syndrome, which can lead to neurological damage. This is a medical emergency, and the physician should be called immediately. Pain medication is not indicated based on the client's data and would not correct the current underlying problem. Elevating the arm further would worsen circulation to the area, which is already impaired. The nurse can provide diversional activities while waiting for definitive orders from the physician. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Child Health Strategy: The core issue of the question is recognition of a complication, compartment syndrome, that can lead to neurological damage. The correct answer is the one that provides for definitive treatment of the problem, which in this case is in the practice realm of the physician.

Module 2 NCLEX Ch. 62 23 The pediatric nurse interprets that which infant is least likely to be diagnosed with developmental dysplasia of the hip (DDH)? 1. An infant with a family history of DDH 2. An infant with a birthweight of 10 pounds 3. The infant carried on the mother's hips 4. The infant who had frank breech position in utero

23 Answer: 3 Rationale: The infant who is carried with the hips abducted is at decreased risk for developing DDH. A family history of DDH would possibly increase the incidence of this defect. A large infant size at birth has been associated with DDH. Breech position is associated with increased incidence of DDH. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Child Health Strategy: The core issue of the question is recognition of which situation allows the infant to keep the hips abducted. Evaluate each option according to this criteria to make a selection.

Module 2 NCLEX Ch. 62 24. Which intervention would be essential for the nurse to implement to promote a stable respiratory status in an adolescent who recently had a spinal fusion for scoliosis? 1. Logrolling and repositioning every 4 hours 2. Coughing and deep breathing every 2 hours while awake 3. Assessing pain status and ensuring adequate pain relief 4. Encouraging use of incentive spirometry every 4 hours while awake

24 Answer: 3 Rationale: Pain must be managed properly in the child after spinal fusion in order for the client to participate in respiratory exercises. Logrolling and repositioning, as well as coughing, deep-breathing, and use of incentive spirometry should be done every 2 hours around the clock with this postoperative client. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Child Health Strategy: The core issue of the question is the ability to prioritize nursing activities. While the ABCs are quite important they must be timely. Also, the client cannot meet goals for the respiratory portion of ABCs unless pain relief is achieved. With this in mind, choose pain relief as the correct answer.

Module 2 NCLEX Ch. 62 25 An 8-year-old child presents to the emergency department with ankle pain and difficulty walking, although no injury is recalled. The triage nurse notes ankle redness, swelling, decreased mobility and range of motion, and pain with ankle movement. Temperature is 100.8 degrees F and heart rate is 140 beats per minute. Which health problem would the triage nurse suspect?

25 Answer: 4 Rationale: The symptoms described are symptoms of osteomyelitis. This disease can result from a penetrating wound, but it also may result from an infection elsewhere in the body that traveled to the bone. Osteomyelitis may follow an upper respiratory infection, which is common in school- age children. Legg-Calve-Perthes disease affects the femoral head, not the ankle. Slipped capitol femoral epiphysis affects the hip. An ankle fracture is generally associated with injury. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Child Health Strategy: The issue of the question is the ability of the nurse to analyze assessment data and compare it to typical data of childhood musculoskeletal problems. Note that the temperature is elevated to help choose the option related to infection.

Module 2 NCLEX Ch. 62 26. The nurse is preparing to help a client get up from a chair using crutches. Place in order the steps that the nurse outlines to the client to do this procedure correctly. 1. Legg-Calve-Perthes disease 2. Slipped capital femoral epiphysis 3. Fracture of the ankle 4. Osteomyelitis

26 Answer: 4, 1, 3, 2, 5 Rationale: The client moves first to the edge of the chair to move the center of gravity forward before trying to stand. Placing the unaffected leg slightly under or at the edge of the chair is done second to provide support to help the client to stand up from the chair and achieve balance. Grasping the crutches by the horizontal hand bars using the hand on the affected side is done third to provide support for the affected side before arising. Grasping the arm of the chair using the hand on the unaffected side is done fourth so that the body weight is supported on the armrest of the unaffected leg when the client rises to stand. Pushing down on the crutches and the chair armrest while raising the body out of the chair is done fifth once the body is fully positioned and supported. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Child Health Strategy: Visualize the procedure and think about principles of joint support and balance to complete the ordered steps.

Module 2 NCLEX Ch. 62 3 A client with a right arm cast for fractured humerus states, "I haven't been able to straighten the fingers on my right hand since this morning." What action should the nurse take first? 1. Assess neurovascular status to the hand. 2. Ask the client to massage the fingers. 3. Encourage the client to take the prescribed analgesic. 4. Elevate the right arm on a pillow to reduce edema.

3 Answer: 1 Rationale: This symptom suggests neurological injury caused by pressure on nerves and soft tissue because of swelling (compartment syndrome). Other symptoms of neurovascular compromise should be assessed and reported to the physician. Massaging the fingers will not help alleviate the problem. An analgesic will not help with mobility caused by neurological injury and there is no evidence that the client is experiencing pain. Elevating the limb could worsen the symptoms at a time when circulation is already impaired from swelling, which led to the neurological injury. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of priority assessments in a client with possible compartment syndrome. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 58 3. All of the following statements are true regarding bone growth and remodeling except: 1.Osteoblastic activity increases after the age of 30. 2.Remodeling of a fracture can take several months to several years. 3.Bones in children resemble cartilage more so than mature bone. 4.The inflammation stage of fracture healing is the initial phase.

3. 1. Rationale: Osteoblastic activity slows down between the ages of 30 and 40. After age 40, women lose approximately 8 percent of their bone mass every decade. In men the loss is 3 percent per decade.

Module 2 Med-Surge Ch. 59 3. A client with ankylosing spondylitis has been taking NSAIDs for years and finds they are no longer effective. A disease-modifying antirheumatic drug (DMARD) is now being prescribed. The nurse tells the client the following about DMARDs: 1.They will help to increase lubrication in the joint. 2.They are analgesics. 3.They assist with reducing inflammation. 4.They should be taken with milk.

3. 3. Rationale: DMARDs also reduce inflammation, as do NSAIDs, and may provide relief when NSAIDs are no longer effective.

Module 2 ATI Med-Surg 71 3. A nurse is assessing a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (Select all that apply.) A. Intense pain when the client's left foot is passively moved B. Capillary refill of 3 sec on the client's left toes C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

3. A. CORRECT: Intense pain of the left foot when passively moved can indicate pressure from edema on nerve endings and is a manifestation of compartment syndrome. B. Capillary refill of 3 seconds is within the expected reference range. Pallor is a manifestation of compartment syndrome. C. CORRECT: A hard, swollen muscle on the affected extremity indicates edema build‑up in the area of injury and is a manifestation of compartment syndrome. D. CORRECT: Burning and tingling of the left foot indicates pressure from edema on nerve endings and is an early manifestation of compartment syndrome. E. CORRECT: Minimal pain relief after receiving opioid medication can indicate pressure from edema on nerve endings and is an early manifestation of compartment syndrome.

Module 2 ATI Med-Surg 68 3. A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Clean the incision daily with soap and water. B. Turn the toes inward when sitting or lying. C. Sit in a straight‑backed armchair. D. Bend at the waist when putting on socks. E. Use a raised toilet seat.

3. A. CORRECT: The client should wash the surgical incision daily with soap and water to decrease the risk of infection. B. The client should externally rotate toes to prevent dislocation of the hip prosthesis. C. CORRECT: Using a straight‑backed armchair decreases the chance of bending at a greater than 90° angle, which can cause dislocation of the hip prosthesis. D. Bending at the waist places the hip in a position greater than a 90° angle, which can cause dislocation of the hip prosthesis. E. CORRECT: Using a toilet riser decreases the chance of bending greater than 90°, which can cause dislocation of the hip prosthesis.

Module 2 ATI Med-Surg 69 3. A nurse is caring for a client following a below‑the‑elbow amputation. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage dependent positioning of the residual limb. B. Inspect for presence and amount of drainage. C. Implement shrinkage intervention of the residual limb. D. Wrap the residual limb in a circular manner using gauze. E. Assess for feelings of body image changes.

3. A. CORRECT: The nurse should place the residual limb in a dependent position to improve circulation to the end of the stump and promote healing. B. CORRECT: The nurse should inspect the residual limb for the presence and amount of drainage to determine early manifestations of infection. C. CORRECT: The nurse should prepare the residual limb to include shrinkage interventions before fitting of the prosthesis. D. The nurse should wrap the residual limb with an elastic bandage in a figure‑eight manner to prevent restriction of blood flow before fitting for the prosthesis. E. CORRECT: The nurse should assess for feelings of depression, anger, withdrawal, and grief due to body image changes.

Module 2 ATI Fundamentals 40 3. A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to use the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change position often.

3. A. Incorrect: The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation. B. Correct: Elastic stockings promote venous return and prevent thrombus formation. C. Incorrect: A review of the client's total protein level is important for evaluating his ability to heal and prevent skin breakdown. D. Incorrect: Placing pillows under the knees and lower extremities further impairs circulation of the lower extremities. E. Correct: Frequent position changes prevent venous stasis.

Module 2 ATI Med-Surg 73 3. A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include in the teaching? A. Bathe daily with moisturizing soap. B. Apply antibacterial topical medication to the crusted exudate. C. Apply warm compresses to the affected area. D. Cover affected area with snug‑fitting clothing.

3. A. The client should use antibacterial soap to reduce the bacteria count on the skin. B. The client should apply topical medication directly to the moist lesion bed. The medication will not penetrate the crusted exudate. C. CORRECT: The client should apply warm compresses to the affected area to promote comfort. D. The client should wear loose‑fitting clothes to avoid irritating the lesion.

Module 1 Fundamentals Ch. 26 3. A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother's construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice

3. a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks.

Module 2 Fundamentals Ch. 32 3. A nurse is ambulating a 48-year-old female patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: a. Grasp the gait belt. b. Stay with the patient and call for help. c. Place feet wide apart with one foot in front. d. Gently slide patient down to the floor, protecting her head. e. Pull the weight of the patient backward against your body. f. Rock your pelvis out on the side of the patient.

3. c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor, protecting her head, and stay with the patient and call for help.

Module 1 NCLEX Ch. 7 4 Which snack would the nurse appropriately offer the hospitalized toddler? 1. Crackers 2. Peanuts 3. Grapes 4. Cereal bar

4 Answer: 1 Rationale: Crackers are of a soft consistency when chewed and swallowed. Toddlers can easily choke on small foods such as peanuts, popcorn, and grapes and firm- consistency foods such as cereal bars. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Child Health Strategy: Note that the question is determining risk for choking and select the option that has a food that will dissolve easily in the mouth.

Module 2 NCLEX Ch. 62 4 A client with an open fracture is at risk for developing osteomyelitis. Which classic symptoms would the nurse assess for to detect development of this complication? Select all that apply. 1. Increased pain at the fracture site 2. Elevated temperature 3. Acute respiratory distress 4. Shortening of the affected extremity 5. Increased swelling at the fracture site

4 Answer: 1, 2, 5 Rationale: Increased pain could indicate development of osteomyelitis. Elevated temperature is a classic symptom seen with osteomyelitis as a systemic"response to the invading organism. Increased swelling at the site of the fracture could indicate development of osteomyelitis. Acute respiratory distress is suggestive of fat embolism but not bone infection. The extremity does not shorten with osteomyelitis, although this is a classic finding with hip fracture. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of manifestations of osteomyelitis. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 59 4. A 10-year-old client is brought into the clinic. The parents state he has been complaining of pain in his knees and elbows for the past couple of days. On physical examination the nurse finds a bullseye-shaped rash on his upper back. Which of the following is suspected? 1.LD 2.Reactive arthritis 3.Fibromyalgia 4.Extra pulmonary tuberculosis

4. 1. Rationale: A bullseye rash is the classic symptom of LD.

Module 2 Med-Surge Ch. 58 4. A few of the main functions of skeletal muscle are to (select all that apply): 1.Store minerals 2.Maintain posture and body position 3.Produce enzymes responsible for movement 4.Guard entrances and exits to the digestive and urinary tracts

4. 2, 4. Rationale: The main functions of skeletal muscle are to produce movement, maintain posture and body position, support soft tissues, guard entrances and exits to the digestive and urinary tracts, and to assist in maintaining body temperature.

Module 2 ATI Med-Surg 71 4. A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include in the teaching? A. Antibiotic therapy should continue for 3 months. B. Relief of pain indicates the infection is eradicated. C. Airborne precautions are used during wound care. D. Expect paresthesia distal to the wound.

4. A. CORRECT: Treatment of osteomyelitis includes continuing antibiotic therapy for 3 months. B. Relief of pain does not indicate that osteomyelitis is resolved, and the client should continue antibiotic therapy as prescribed. C. When performing wound care contact precautions are implemented to prevent spread of the organism. D. The client should monitor and report manifestations of neurovascular compromise, such as paresthesia.

Module 2 ATI Med-Surg 69 4. A nurse is caring for a client who had an above‑the‑knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take? A. Facilitate counseling services. B. Encourage use of cold therapy. C. Question whether the pain is real. D. Administer an antiepileptic medication.

4. A. Counseling services can assist the client to cope with body image changes and is not prescribed for treatment of phantom pain. B. Heat therapy, not cold therapy, to the residual limb is an alternative therapy that the nurse can implement to relieve phantom pain. C. Phantom pain is related to the severed nerve pathways following the amputation. The nurse should not question whether the pain is real. D. CORRECT: An antiepileptic medication can relieve a sharp, stabbing type of phantom pain.

Module 2 ATI Fundamentals 40 4. A nurse is instructing a client who is postoperative about the sequential compression device the provider has prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

4. A. Incorrect: A sequential pressure device is a temporary intervention that remains in use only until the client is ambulatory. The device is not in place long enough to cause pressure ulcers. B. Correct: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation. C. Incorrect: Continuous passive motion machines, not sequential pressure devices, provide some muscle movement that may assist in preserving some muscle strength. D. Incorrect: Continuous passive motion machines, not sequential pressure devices, exercise the knee joint after arthroplasty.

Module 2 ATI Med-Surg 68 4. A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply.) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

4. A. Skin over the knee that is red can indicate infection and is not an expected finding. B. CORRECT: Pain when bearing weight is an expected finding due to degeneration of the joint. C. CORRECT: Joint crepitus due to degeneration of the joint tissue is an expected finding. D. CORRECT: Swelling of the affected joint due to degeneration of the joint tissue is an expected finding. E. CORRECT: Limited joint motion is due to degeneration of the joint tissue and is an expected finding.

Module 2 ATI Med-Surg 73 4. A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. The nurse should identify that which of the following client statements indicates that the teaching has been effective? A. "I can expect redness around the site for 5 to 7 days." B. "I will most likely have a fever for the first few days." C. "I should apply an antibiotic ointment to the area." D. "I will make a return appointment in 3 days for removal of my sutures."

4. A. The client should report redness, pain, drainage, or warmth at the biopsy site to the provider. B. A fever is an indication of an infection, and the provider should be notified. C. CORRECT: Antibiotic ointment is applied as prescribed by the provider to prevent infection. D. Removal of the sutures following a biopsy is done 7 to 10 days postprocedure.

Module 2 Fundamentals Ch. 32 4. A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? a. A 4-month-old infant who is unable to roll over b. A 6-month-old infant who is unable to hold his head up himself c. An 11-month-old infant who cannot walk unassisted d. An 18-month-old toddler who cannot jump

4. b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

Module 1 Fundamentals Ch. 26 4. While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired Gas Exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for Suffocation related to unfamiliarity with fire prevention guidelines d. Deficient Knowledge related to lack of follow-through of recommendation to stop smoking

4. c. Because Mrs. Fuller is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation.

Module 2 NCLEX Ch. 62 5. An obese client with degenerative joint disease is being treated with aspirin. The nurse concludes that additional client teaching is needed when the client makes which statement? 1. "I take aspirin only when I have extreme pain and stiffness." 2. "I use heat sometimes to help decrease my pain and joint stiffness." 3. "I frequently examine my stools for bleeding." 4. "I started an exercise program to lose weight."

5 Answer: 1 Rationale: Aspirin therapy for this condition is continuous and is effective only after a therapeutic level is reached. It should not be taken intermittently. Heat is a beneficial measure to increase client comfort. Aspirin is an antiplatelet agent and the client should monitor for blood in stools as an adverse effect of therapy. Losing weight is beneficial for the client because is decreases the stress on the joints, particularly in the lower limbs. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of appropriate self-management techniques for degenerative joint disease. Use nursing knowledge and the process of elimination to make a selection. Note the wording of the question indicates the correct option is an incorrect statement by the client.

Module 2 Med-Surge Ch. 58 5. The mineral necessary to trigger a muscular contraction is: 1.Potassium 2.Calcium 3.Magnesium 4.None of the above

5. 2. Rationale: During muscle contraction, the sarcoplasm reticulum releases large amounts of calcium into the vicinity of the myofibrils. This sudden rise in calcium concentration within the sarcoplasm initiates muscle contraction by removing the tropomyosin-troponin block.

Module 2 Med-Surge Ch. 59 5. A client is having a work-up for suspected fibromyalgia. The nurse knows the following about fibromyalgia: 1.The client will have pulmonary function tests performed. 2.The client will be tested for rheumatoid factor and serum complement. 3.The client will be tested for electrolyte panel and ESR. 4.The client will have a liver biopsy.

5. 3. Rationale: Baseline screening for fibromyalgia includes an electrolyte panel and ESR as markers of the inflammatory process that is occurring.

Module 2 ATI Med-Surg 68 5. A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.) A. Encourage complete autologous blood donation. B. Sit in a low reclining chair. C. Instruct the client to roll onto the operative hip. D. Use an abductor pillow when turning the client. E. Perform isometric exercises.

5. A. CORRECT: The nurse should encourage the client to donate blood that can be used postoperatively. B. The nurse should have the client sit in a hard back chair to keep the hip at a 90° angle. This prevents dislocation. C. The nurse should avoid turning the client to the operative side to prevent dislocation of the prosthesis. D. CORRECT: The nurse should place an abductor device or pillow between the client's legs when turning to prevent dislocation of the affected hip. E. CORRECT: The nurse should instruct the client to perform isometric exercises to prevent blood clots and maintain muscle tone.

Module 2 ATI Med-Surg 73 5. A nurse is providing teaching to a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include in the teaching? A. "It reduces the discomfort of a herpetic infection but does not cure the infection." B. "This is a cream to treat a bacterial infection." C. "Apply the topical medication for up to 2 weeks after the fungal lesions are gone." D. "Apply the cream to lesions while they are moist."

5. A. Clotrimazole is not an antiviral medication to treat a herpetic infection. B. Clotrimazole is not an antibacterial medication. C. CORRECT: Clotrimazole is a medication used to treat a fungal infection and is applied for 1 to 2 weeks after the infection is resolved. D. Clotrimazole should be applied to clean, dry skin. Wash the skin gently and pat dry before applying.

Module 2 ATI Fundamentals 40 5. To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 15 inches in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

5. A. Correct: The client should hold the cane on the uninjured side to provide support for the injured left leg. B. Correct: The client should keep two points of support on the ground at all times for stability. C. Incorrect: The client should place the cane 6 to 10 inches in front of her feet before advancing. D. Correct: The client should advance the weaker leg first, followed by the stronger leg. E. Incorrect: The client should advance the stronger leg past the cane.

Module 2 ATI Med-Surg 71 5. A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? A. Skeletal traction B. Buck's traction C. Halo traction D. Bryant's traction

5. A. Skeletal traction is an immobilization device applied surgically to a long bone (femur, or tibia), and cervical spine. It is not used for a hip fracture. B. CORRECT: Buck's traction is a temporary immobilization device applied to a client who has a femur or hip fracture to diminish muscle spasms and immobilize the affected extremity until surgery is performed. C. Halo traction immobilizes the cervical spine when a cervical fracture occurs. D. Bryant's traction is used for congenital hip dislocation in children.

Module 2 ATI Med-Surg 69 5. A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below‑the‑knee amputation 24 hr ago. Which of the following actions should the nurse include in the plan of care? A. Limit any type of exercise to the residual limb for the first 48 hr after surgery. B. Position the client prone several times each day. C. Wrap the stump in a figure‑eight pattern. D. Encourage sitting in a chair during the day.

5. A. To avoid flexion contractures, the nurse should encourage the client to perform range‑of‑motion exercise to the residual limb to prevent flexion contractures. B. CORRECT: The nurse should have the client lie prone several times each day for 20 to 30 min to prevent flexion contractures. C. The client can have the residual limb wrapped in a figure eight to prepare for the prosthesis, but this action does not prevent flexion contractures. D. The client can develop flexion contractures by allowing the residual stump to hang in a bent position when sitting for an extended period following the amputation.

Module 2 Fundamentals Ch. 32 5. A nurse is caring for a 26-year-old male patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. Have the patient extend his arms outward and cross his legs on top of a pillow. b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. c. Have the patient cross his arms on his chest and place a pillow between his knees. d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

5. c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the draw- sheet taut to support the body, and turn the patient as a unit toward the two nurses.

Module 1 Fundamentals Ch. 26 5. A nurse working in a busy emergency department is caring for a teenage patient who presents with a burning pain in his mouth, edema of the lips, vomiting, and hemoptysis. The teen admits that he was playing a dare game with friends and was forced to swallow a drain opener preparation. What would be the nurse's priority intervention? a. Induce vomiting and call the primary care provider. b. Perform stomach lavage and call the poison control center. c. Give activated charcoal orally and call the physician. d. Dilute the poison with milk and call the primary care provider.

5. d. For the ingestion of drain opener, the nurse should never induce vomiting; instead, the poison should be diluted with milk or water and the primary care provider should be called. For vitamin preparations, stomach lavage is used to remove undigested pills and for acetaminophen poisoning, activated charcoal may be used.

Module 2 NCLEX Ch. 62 6 A client underwent a lumbar laminectomy today. Which nursing diagnosis has highest priority for this client? 1. Disturbed Body Image 2. Social Isolation 3. Ineffective Role Performance 4. Impaired Physical Mobility

6 Answer: 4 Rationale: Immediately after surgery, the client may be hesitant to move because of pain and fear of disturbing the operative site. Minimal scarring results from this surgery, so body image disturbance is not likely to be appropriate. Social isolation would be a lesser problem in the immediate postoperative period, since the priority is physiological status rather than psychosocial status. Because the client has just had surgery, ineffective role performance is a low priority concern at this time. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of the question is the knowledge of priority nursing diagnoses following musculoskeletal surgery. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 59 6. A client has progressively worsening pain in the lower back with numbness and pain down the right leg, reporting a one inch loss in height over the last 10 years. The nurse suspects spinal stenosis because: 1.Spinal stenosis causes impingement of the nerve roots and can lead to back and leg pain. 2.Disc space in the spinal column shrinks with spinal stenosis causing height loss. 3.The client was a long distance runner in her earlier years and the constant jarring from running causes spinal stenosis. 4.X-rays show hypokyphosis.

6. 1. Rationale: Spinal stenosis causes a narrowing of the spinal column where the nerves exit. Pressure on the nerves results in pain.

Module 2 Med-Surge Ch. 58 6. Ligaments have all the following characteristics except: 1.Strong bands of connective tissue 2.Give joints stability 3.Elasticity 4.Guide the joint movement

6. 3. Rationale: Ligaments help to give joints stability, guide the joint movement, and prevent excess motion within the joint.

Module 2 ATI Fundamentals 40 6. A nurse is reviewing the effects of immobility on the various body systems with a group of nursing students. Use the ATI Active Learning Template: Basic Concept to complete this item. Under Related Content, list at least two effects of immobility on the cardiovascular system and at least two on the respiratory system.

6. Using the ATI Active Learning Template: Basic Concept ●● Related Content ◯◯ Cardiovascular system Orthostatic hypotension Less fluid volume in the circulatory system Stasis of blood in the legs Diminished autonomic response Decreased cardiac output leading to poor cardiac effectiveness, which results in increased cardiac workload Increased oxygenation requirement Increased risk of thrombus development ◯◯ Respiratory system Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange Stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypostatic pneumonia Decreased cough response NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility

Module 1 Fundamentals Ch. 26 6. A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? a. Booster seats should be used for children until they are 4′9′′ tall and weigh between 80 and 100 pounds. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children older than 6 years may be restrained using a car seat belt in the back seat.

6. a. Booster seats should be used for children until they are 4′9′′ tall and weigh between 80 and 100 pounds. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat.

Module 2 NCLEX Ch. 62 7 A client had a left above-the-knee amputation today. For the first 24 hours postoperatively, the nurse performs which priority action to properly manage the surgical site? 1. Elevate the residual limb. 2. Loosen the dressing every 4 hours. 3. Maintain the residual limb in a dependent position. 4. Change the dressing as often as needed.

7 Answer: 1 Rationale: Elevating the limb during the first 24 hours facilitates venous return, decreases swelling, and promotes comfort. The dressing is usually a compression type to mold the residual limb and to decrease the edema associated with inflammation, so loosening the dressing is an inappropriate intervention. Placing the residual limb below"heart level increases risk of edema at the surgical site. The dressing would be changed as ordered but is not usually done for the first 24 hours to reduce edema which could disrupt the surgical incision. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of postoperative residual limb care and proper positioning to limit development of postoperative edema. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 58 7. The three classes of joints are: 1.Synarthrosis, amphiarthrosis, and diarthrosis 2.Synarthrosis, biarthrosis, and amphiarthrosis 3.Amphiarthrosis, biarthrosis, and lunarthrosis 4.Synarthrosis, acetylarthrosis, and diarthrosis

7. 1. Rationale: Classified according to the amount of movement, three classes of joints can be identified: synarthrosis (immovable), amphiarthrosis (slightly movable), and diarthrosis (freely movable).

Module 2 Med-Surge Ch. 59 7. A client with rheumatoid arthritis is admitted to the hospital. On physical examination of this client, the nurse should expect to find: 1.Asymmetrical joint involvement 2.Heberden's nodes 3.Obesity 4.Small joint involvement

7. 4. Rationale: Small joint involvement is common in rheumatoid arthritis. All the other symptoms are seen in osteoarthritis but not rheumatoid arthritis.

Module 1 Fundamentals Ch. 26 7. A nurse working with adolescents in a juvenile detention center teaches parents about behaviors that place adolescents at high risk for injury. Which statements accurately describe these risks? Select all that apply. a. Each year, underage drinking claims the lives of approximately 5,000 individuals under the age of 21. b. Approximately one in three high school students reported using some type of tobacco product. c. The CDC (2012i) lists motor vehicle accidents as the number-one cause of death for adolescents. d. Marijuana use among teenagers has been on the increase and the abuse of prescription medication and OTC drugs has remained at a high level. e. Homicide rates for adolescents are high, and youths aged 10-19 years committed almost 500 suicides using firearms. f. As many as 30% of children are bullied during their school years and cyber bullying is even more damaging to children.

7. a, c, d. Each year, underage drinking claims the lives of approximately 5,000 people under the age of 21. The CDC (2012j) lists motor vehicle accidents as the number one cause of death for adolescents. Marijuana use among teenagers has been on the increase and the abuse of prescription medication and OTC drugs has remained at a high level. Approximately one in five (20%) high school students reported using some type of tobacco product. Homicide rates for youths using firearms are higher than any other age group and the most recent statistics indicate that youths aged 10-19 years committed almost 1,500 suicides using firearms (Kagler, Annest, Kresnow & Mercy, 2011). According to the American Acad- emy of Child & Adolescent Psychiatry, as many as 50% of children are bullied during their school years and some experts believe that cyber bullying is more dangerous and damaging to children than bullying that occurs in the schoolyard.

Module 2 Fundamentals Ch. 32 7. A nurse is caring for a 73-year-old male patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. Lateral position c. Fowler's position d. Sims' position

7. c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

Module 2 NCLEX Ch. 62 8 A client with a femoral fracture is in Buck's traction. While making rounds, the nurse notices that the client's foot is touching the footboard of the bed. What is the appropriate action by the nurse? 1. Wedge a pillow between the footboard and the client's foot. 2. Praise the client for maintaining countertraction. 3. Center the client on the bed. 4. Ask the client to pull up in bed while holding the weights.

8 Answer: 3 Rationale: The aim in traction is to maintain a constant force to align the distal and proximal ends of a fractured bone. To be effective, traction must have an opposing force (countertraction). Centering the client in bed maintains the line of pull and ensures that countertraction is maintained. Placing a pillow between the foot and the footboard attempts to relieve pressure on the foot but ignores that this position interrupts the proper pull of the traction. The client's current position interrupts traction rather than maintaining proper countertraction. Holding the weight interrupts the line of pull of the traction and is contraindicated. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of proper use of traction. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 59 8. A client has suffered from low back pain and sciatica for over two years and is admitted to the hospital for evaluation and treatment. A thorough assessment is important primarily because: 1.This will provide a baseline for later comparison. 2.This is a method for identifying clients with low back neurosis. 3.Clients who have pain localized to the back and radiating to one extremity are probably not candidates for surgery. 4.Surgery is contraindicated for clients who have had pain for less than two years.

8. 1. Rationale: A baseline assessment of neurological signs is made so that deviation from the database can be noted. Once a pain assessment is complete, a plan for pain management can be developed.

Module 2 Med-Surge Ch. 58 8. Most clients come to a health care provider seeking assistance with musculoskeletal complaints because of: 1.Obvious defects 2.Limitation of movement 3.Increased flexibility 4.Decreased pain

8. 2. Rationale: When an individual seeks assistance with a musculoskeletal complaint, it is generally because the complaint has caused a limitation in movement or pain.

Module 2 Fundamentals Ch. 32 8. A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do which actions? Select all that apply. a. Do full-body pushups in bed six to eight times daily. b. Breathe in and out smoothly during quadriceps drills. c. Place the bed in the lowest position or use a footstool for dangling. d. Dangle on the side of the bed for 30 to 60 minutes. e. Allow the nurse to bathe the patient completely to prevent fatigue. f. Perform quadriceps 2 to 3 times per hour, 4 to 6 times a day.

8. b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps 2 to 3 times per hour, 4 to 6 times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

Module 1 Fundamentals Ch. 26 8. When describing safety issues and related mortality to a local senior citizens group, what would the nurse identify as the leading cause of hospital admissions for trauma in older adults? a. Fires b. Exposure to temperature extremes c. Intimate partner violence d. Falls

8. d. Falls among older adults are the most common cause of hospital admissions for trauma. Fires and temperature extremes are also significant hazard for older adults but are not the most common cause of trauma admissions. Intimate partner violence occurs more frequently in adults as opposed to older adults.

Module 2 NCLEX Ch. 62 9 A truck driver sees the primary care provider because of persistent back pain. The nurse explains that which client activity documented during the nursing history may contribute to further back injury? 1. Lifting objects close to the body 2. Shifting positions often when sitting for prolonged periods 3. Providing back support with a pillow when sitting 4. Prolonged standing or sitting

9 Answer: 4 Rationale: Prolonged sitting or standing aggravates back injury because of the additional stress placed on structures supporting the back. Lifting objects close to the body, shifting positions frequently, and providing back support are appropriate actions to maintain good body mechanics. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of risk factors and aggravating factors of low back pain. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 58 9. Physical assessment techniques used during the musculoskeletal system assessment include: 1.Palpation and auscultation 2.Inspection and range of motion 3.Observation and auscultation 4.Interview and palpation

9. 2. Rationale: There are three basic maneuvers used in assessing the musculoskeletal system: inspection, palpation, and assessment of range of motion (passive and active).

Module 2 Med-Surge Ch. 59 9. A client has RA and is taking prednisone. In creating a teaching plan, the nurse will be certain to tell the patient which of the following? 1.The client should expect to be on corticosteroids for years. 2.It may take three to six months for the client to notice any effect from the medication. 3.The client should notify the health care provider of any stomach upset. 4.The client should avoid bananas and spinach while taking this drug.

9. 3. Rationale: High dosage or long-term use of corticosteroids is associated with the development of gastric ulcers.

Module 2 Fundamentals Ch. 32 9. A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? a. Supination b. Dorsiflexion c. Hyperextension d. Abduction

9. b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion, and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

Module 1 Fundamentals Ch. 26 9. What consideration should the nurse keep in mind regarding the use of side rails for a confused patient? a. They prevent confused patients from wandering. b. A history of a previous fall from a bed with raised side rails is insignificant. c. Alternative measures are ineffective to prevent wandering. d. A person of small stature is at increased risk for injury from entrapment.

9. d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient's dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident.

Module 2 Fundamentals Ch. 32 6. A nurse is caring for an 82-year-old woman in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation

6. b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

Module 2 ATI Med-Surg 68 A nurse is preparing to administer enoxaparin to a client who had a total knee arthroplasty. What should the nurse consider before administering the medication? Use the ATI Active Learning Template: Medication and the Pharmacology Review Module to complete this item. EXPECTED PHARMACOLOGICAL ACTION: Define. NURSING INTERVENTIONS: List two nursing interventions. CLIENT EDUCATION: List three client teaching points.

EXPECTED PHARMACOLOGICAL ACTION: Enoxaparin is an anticoagulant. Use low molecular‑weight heparin after abdominal and orthopedic surgery to prevent deep vein thrombosis that may lead to pulmonary embolism. NURSING INTERVENTIONS ●● Do not expel the air bubble from the syringe before injection. It's nitrous oxide and allows the client to receive all the medication during the injection. ●● Rotate injection sites. ●● Monitor for manifestations of unexplained bleeding. CLIENT EDUCATION ●● Encourage the use of a soft toothbrush and shaving with an electric razor to prevent bleeding. ●● Avoid over‑the‑counter medication unless prescribed by a provider. ●● Don't take enoxaparin with garlic, ginger, ginkgo, or feverfew. These supplements may increase the risk of bleeding.

Module 2 NCLEX Ch. 62 1 The nurse provides teaching to an adolescent after removal of a short leg cast. The nurse should include which instruction in discussions with the client? Select all that apply. 1. Wash the skin with undiluted hydrogen peroxide. 2. Vigorously scrub the legs to remove dead skin. 3. Gently wash the leg to remove dead skin over time. 4. Avoid touching the leg for 2 days after cast removal. 5. Use a lubricant to moisten the skin for easier removal of dead skin.

1 Answer: 3, 5 Rationale: Dead skin and exudates often collect under the cast, and efforts to remove it should be done gradually. The client can use a lubricant which will soften dead skin cells for easier removal during cleansing. The use of undiluted peroxide is too harsh for the skin. The client should avoid any vigorous scrubbing of the skin to avoid interfering with skin integrity, which increases the risk for infection. There is no reason why the leg cannot be touched after removal of the cast. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of skin care following cast removal. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Med-Surge Ch. 59 1. A client is newly diagnosed with osteoarthritis of her knees and told the nurse that the health care provider prescribed acetaminophen or ibuprofen for pain. The client says she cannot afford this medication. Your best response would be: 1."Dr. Cho thinks your pain is only minimal, and the cheap drugs are a good way to keep you out of the office." 2."Dr. Cho knows that these medications will help your pain and are relatively inexpensive and available over the counter at your local grocery or pharmacy." 3."I'll call the social worker." 4."Dr. Cho knows that these medications are covered by insurance and you shouldn't worry."

1. 2. Rationale: Acetaminophen (Tylenol) and ibuprofen (Advil) are both available over-the-counter and are relatively inexpensive. The nurse corrected Mrs. Jones perception that these were prescription medications and provided additional information.

Module 2 Med-Surge Ch. 58 1. Wolff's law states what? 1.The direction of growth is in opposite proportion to the amount of physical force placed on the bone. 2.Bone forms and remodels itself in direct proportion to the amount and the direction of physical forces placed on it. 3.Muscle tone and muscle strength increase with use. 4.Myofibrils will contract with the release of actin and myosin.

1. 2. Rationale: Wolff's law states that bone forms and remodels itself in direct proportion to the amount and the direction of physical forces placed on it.

Module 2 ATI Med-Surg 68 1. A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? A. Age 78 years B. History of cancer C. Previous joint replacement D. Bronchitis 2 weeks ago

1. A. Age greater than 70 is not a contraindication for a total joint arthroplasty unless there are comorbidity factors. B. History of cancer is not a contraindication for a total joint arthroplasty unless there are comorbidity factors. C. Previous joint arthroplasty surgery is a contraindication for total joint arthroplasty unless there are comorbidity factors. D. CORRECT: The client who recently had bronchitis or a recent infection can cause micro‑organisms to migrate to the surgical area and cause the prosthesis to fail.

Module 2 ATI Med-Surg 71 1. A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A. "I will clean the pins twice a day." B. "I will use a separate cotton swab for each pin." C. "I will report loosening of the pins to my doctor." D. "I will move my leg by lifting the device in the middle." E. "I will report increased redness at the pin sites."

1. A. CORRECT: Clean the external fixation pins one to two times each day to remove exudate that can harbor bacteria. B. CORRECT: Using a separate cotton swab on each pin will decrease the risk of cross‑contamination, which could cause pin site infection. C. CORRECT: Notify the provider if a pin is loose because the provider will know how much to tighten the pin and prevent damage to the tissue and bone. D. The external fixation device should never be used to lift or move the affected leg, due to the risk of injuring and dislocating the fractured bone. E. The client should report redness, heat, and drainage at the pin sites, which can indicate an infection that can lead to osteomyelitis.

Module 2 ATI Med-Surg 69 1. A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the follow information should the nurse provide? (Select all that apply.) A. Encourage clients who smoke to consider smoking cessation programs. B. Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range. C. Instruct clients to unplug electrical equipment when performing repairs. D. Encourage clients who have vascular disease to maintain good foot care. E. Advise clients to wait 2 hr after taking pain medication before driving.

1. A. CORRECT: The nurse should provide information about smoking cessation, which can decrease the development of arteriosclerosis and possible amputation of a lower extremity. B. CORRECT: The nurse should provide information about regulating blood glucose levels within a normal reference range to prevent the development of arteriosclerosis and possible amputation of a lower extremity. C. CORRECT: The nurse should provide information about unplugging electrical equipment when performing repairs to prevent electrocution and injury to an extremity, which can lead to amputation. D. CORRECT: The nurse should provide information about maintaining good foot care to prevent infection, which can result in amputation. E. Driving under the influence of pain medication can lead the client to an accident or injury to an extremity requiring amputation.

Module 2 ATI Med-Surg 73 1. A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate reviewing to confirm this diagnosis? A. Potassium hydroxide (KOH) B. Diascopy C. Tzanck smear report D. Biopsy

1. A. Findings of a potassium hydroxide (KOH) test reveal if skin lesions are fungal in origin. B. Diascopy provides increased visibility of a skin lesion by blanching the skin over the lesion, thus eliminating erythema which can obscure findings. C. CORRECT: A Tzanck smear report confirms whether a skin lesion is viral in origin. D. Findings of a biopsy report confirm or rule out if a lesion is malignant.

Module 2 ATI Fundamentals 40 1. A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is the client at risk for developing? A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction

1. A. Incorrect: Sitting up in a chair will help prevent stasis of secretions. B. Incorrect: Muscle atrophy is a complication for a client on prolonged bed rest, not for one who is sitting in a chair. C. Correct: Unrelieved pressure over a bony prominence for too long increases the risk for skin breakdown. D. Incorrect: Fecal impaction is a complication for a client on prolonged bed rest, not for one who is sitting in a chair.

Module 2 Fundamentals Ch. 32 1. A nurse is preparing an exercise program for a 65-year-old male patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. Instruct the patient to avoid sudden position changes that may cause dizziness. b. Recommend that the patient restrict fluid until after exercising is finished. c. Instruct the patient to push a little further beyond fatigue each session. d. Instruct the patient to avoid exercising in very cold or very hot temperatures. e. Encourage the patient to modify exercise if weak or ill. f. Recommend that the patient consume a high-carb, low protein diet.

1. a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

Module 1 Fundamentals Ch. 26 1. The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 60 years b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year old patient who is transferred to long-term care

1. b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.

Module 2 NCLEX Ch. 62 10. The nurse is assigned to the care of a client who underwent a lumbar laminectomy. Allowing which activity would be appropriate 4 hours postoperatively? 1. Sitting up in a chair to watch television 2. Sitting at the side of the bed 3. Lying in bed in good alignment with the head of bed flat 4. Using the side-rails for support to get out of bed

10 Answer: 3 Rationale: Physician orders after lumbar laminectomy include being kept flat or with head of bed slightly elevated to minimize stress on the suture line. The client is repositioned side to side using logrolling technique to maintain alignment of the vertebral column at all times. Using the side-rails to get out of bed causes shifting of the vertebral column. Sitting up in a chair or on the side of the bed is usually done the evening of the surgery or the first day following surgery, and it is for brief periods only. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is knowledge of postoperative activity that will not cause harm to the surgical area following laminectomy. Recall principles of proper body mechanics and use the process of elimination to make a selection.

Module 1 Fundamentals Ch. 26 10. When a fire occurs in a patient's room, what would be the nurse's priority? a. Rescue the patient. b. Extinguish the fire. c. Sound the alarm. d. Run for help.

10. a. The patient's safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate.

Module 2 Fundamentals Ch. 32 10. A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. Support weight on stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Do not use the cane to rise from a sitting position, as this is unsafe.

10. a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

Module 2 NCLEX Ch. 62 11 A 50-year-old male with chronic low back pain visits the outpatient clinic. The client weighs 200 pounds, works as a truck driver, sits for prolonged periods, and exercises only occasionally. The client smokes one pack of cigarettes and drinks six cans of beer per day. What priority risk factors should the nurse focus on during client teaching? Select all that apply. 1. Cigarette smoking 2. Age 3. Alcohol use 4. Insufficient exercise 5. Sitting for prolonged periods

11 Answer: 1, 4, 5 Rationale: Smoking has been found to contribute to intervertebral disc deterioration. Insufficient exercise predisposes the muscles of the back to strain and increases the risk of obesity, which places additional strain on back muscles. Occupations that require prolonged standing or sitting predispose to exacerbation of back pain. Although the risk of degenerative disk disease increases with age, this is not a priority in client teaching because this is a nonmodifiable risk factor. Alcohol use is not a healthy pattern but does not increase the risk of degenerative disc disease that can lead to chronic low back pain. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of factors that aggravate low back pain. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Fundamentals Ch. 32 11. A 17-year-old has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? a. Use the axillae to bear body weight. b. Keep elbows close to the sides of the body. c. When rising, extend the uninjured leg to prevent weight bearing. d. To climb stairs, place weight on affected leg first.

11. b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs.

Module 1 Fundamentals Ch. 26 11. When completing a safety event report, the nurse should: a. Include suggestions on how to prevent the incident from recurring. b. Provide minimal information about the incident. c. Discuss the details with the patient before documenting them. d. Objectively describe the incident in detail.

11. d. A safety event report is a legal document, which must be as objective and complete as possible. It is not a collaborative effort with the patient, and any suggestions to prevent the occurrence from happening again should be discussed at a postincident conference.

Module 1 NCLEX Ch. 7 12 A Code Red (fire) has been announced on the hospital unit. What is the nurse's first response? 1. Remove clients in danger from the fire. 2. Contain the fire. 3. Report fire to other staff. 4. Extinguish the fire.

12 Answer: 1 Rationale: The primary responsibility of the nurse is client safety. Removing a client from danger should be the priority. Next the alarm should be sounded. The nurse and others can then contain and possibly extinguish the fire. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Option one is client- focused. The other options are fire-focused. Remember the mneumonic RACE (remove, alarm, contain, extinguish).

Module 2 NCLEX Ch. 62 12 The nurse is teaching a postmenopausal client about the use of calcium to reduce the risk of osteoporosis. The client asks: "Why do I have to take vitamin D with my calcium?" What is the nurse's best response? 1. "Vitamin D prevents osteoporosis." 2. "Vitamin D increases intestinal absorption of calcium." 3. "You are most likely to be deficient in vitamin D." 4. "Using calcium and vitamin D supplements is the only prevention for osteoporosis."

12 Answer: 2 Rationale: A combination of calcium and vitamin D is recommended for the prevention of osteoporosis. Vitamin D increases the intestinal absorption of calcium and mobilizes calcium and phosphorus into the bone. Vitamin D alone does not prevent osteoporosis. While some older adults may be deficient in Vitamin D, a postmenopausal state does not necessarily cause the deficiency. Lifestyle modifications, such as smoking cessation and exercise, may also help reduce the risk of osteoporosis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of risk factors for and prevention of osteoporosis. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Fundamentals Ch. 32 12. A nurse working in a long-term care facility uses proper patient-care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? a. Carefully assessing the patient care environment b. Using two nurses to lift a patient who cannot assist c. Wearing a back belt to perform routine duties d. Properly documenting the patient lift

12. a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

Module 1 Fundamentals Ch. 26 12. When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. c. Even small doses of radiation result in bone marrow depression and cancer. d. Blast lung injury is a serious consequence following detonation of an explosive device.

12. d. Blast lung injury is a recognized consequence following exposure to an explosive device. The CDC is the federal agency that has collaborated with the pharmaceutical companies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one-third of survivors) may exhibit posttraumatic stress disorder.

Module 2 NCLEX Ch. 62 13 The nurse is caring for a client with a week-old cast. The client asks why the nurse touches the cast during an assessment. What is the most appropriate response by the nurse? 1. "I am making sure that the cast has dried." 2. "I am evaluating the strength of the cast." 3. "I am feeling for hot spots that might indicate infection." 4. "I am making sure that the cast is not too tight."

13 Answer: 3 Rationale: A complication of cast application is skin breakdown underneath the cast, which can lead to infection and subsequent heat in the infected area. A bad odor in the area may also be noted. A plaster cast dries in 24-48 hours and a fiberglass cast dries in 30 minutes to 1 hour. Evaluating cast strength is not part of nursing assessment and palpating the cast would not accomplish this anyway. If a cast is too tight, symptoms associated with neurovascular compromise will be noted, which include pain, paresthesia, pallor, diminished pulse distal to the cast, and paralysis. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Communication and Documentation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of various complications of casts. Use nursing knowledge and the process of elimination to make a selection.

Module 2 Fundamentals Ch. 32 13. A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation? a. Wait a few minutes and then continue the move to the chair. b. Call for assistance and continue the move with the help of another nurse. c. Lower the patient back to the side of the bed and pivot her back into bed. d. Have the patient sit down on the bed and dangle her feet before moving.

13. c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

Module 1 Fundamentals Ch. 26 13. An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? a. Sitting him in a geriatric chair near the nurses' station b. Using the sheets to secure him snugly in his bed c. Keeping the bed in the high position d. Identifying his door with his picture and a balloon

13. d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alternative would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall.

Module 2 NCLEX Ch. 62 14 A client is placed on a continuous passive motion (CPM) machine postoperatively after a total knee replacement. The nurse observes the client's knee is externally rotating during flexion. What should the nurse do next? 1. Move the client up in bed or move the CPM machine toward the foot of bed 2. Support the knee with sandbags to prevent external rotation 3. Assist the client to sit up in bed in a 45-degree position 4. Do nothing; the client's knee is properly aligned

14 Answer: 1 Rationale: The client's knee will externally rotate if there is insufficient space between the client's hip and the machine. The knee should be upright, facing the ceiling, as the machine moves the leg back and forth. Sandbags will not prevent external rotation because the issue is the position of the client relative to the CPM machine. Raising the head of bed will not correct external rotation of the leg. Taking no action places the client at risk for injury. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of appropriate care of the client using CPM. Use nursing knowledge and the process of elimination to make a selection.

Module 1 Fundamentals Ch. 26 14. The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a. The nurse positions a patient in a supine position prior to applying wrist restraints. b. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. c. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. d. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

14. b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.

Module 2 Fundamentals Ch. 32 14. A 49-year-old who injured his spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for him correctly tells the aide not to place him in which position? a. Side-lying b. Fowler's c. Sims' d. Prone

14. d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis, or forward curvature of the lumbar spine.

Module 2 NCLEX Ch. 62 15 A client in skeletal traction for a right femur fracture reports pain in the affected limb. After assessing that the right foot is pale without a pulse, what should the nurse do next? Select all that apply. 1. Ensure that the leg is not raised above heart level 2. Administer analgesics as ordered 3. Release the traction 4. Recheck the pulse in an hour 5. Document the findings and notify the physician.

15 Answer: 1, 5 Rationale: Pain and absent pulse indicate impaired circulation to the affected limb, which requires treatment to prevent damage to nerves and tissues, and necrosis requiring loss of limb (worst case). The nurse needs to ensure that the leg is not above heart level so no further damage occurs. Findings should always be documented and the physician needs to be notified of the complication, so further medical assessment and treatment can be done. Pain caused by tissue ischemia will not be relieved by analgesics. Releasing the"traction would be contraindicated. Rechecking the pulse in an hour is delayed and also fails to assist the client, whose symptoms will not reverse without treatment. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy: The core issue of the question is the knowledge of adverse neurovascular changes to a client in a cast. Recall principles of gravity and blood flow to aid in answering the question. Use nursing knowledge and the process of elimination to make a selection.

Module 2 ATI Med-Surg 69 A nurse is completing discharge planning for a client who had an amputation. What members of an interprofessional team should the nurse include in the discharge planning process? Use the ATI Active Learning Template: Basic Concept to complete this item. RELATED CONTENT: List three members of the interprofessional team and describe the principal purpose of each member.

RELATED CONTENT ●● Certified prosthetic orthotist fits the client with the prosthesis following healing and shrinking of the stump. ●● Physical therapist provides training for applying the prosthesis, assists in mobility training, and reviews mobility aids. ●● Psychologist assists the client and family in adjusting to the loss of an extremity. ●● Social worker provides referral information for financial assistance, resources and support groups, or organizations to help adjust to life‑changing physical conditions.

Module 2 ATI Med-Surg 71 A nurse is performing a neurovascular assessment on a client who has a cast applied following a right arm fracture. What interventions should the nurse take? Use the ATI Active Learning Template: Basic Concept to complete this item: RELATED CONTENT: Identify the purpose of neurovascular assessment. UNDERLYING PRINCIPLES: Identify the six components of a neurovascular assessment. NURSING INTERVENTIONS: Describe a nursing intervention related to each of the six components.

RELATED CONTENT: Neurovascular assessment is performed to monitor for any compromise in the affected extremity caused by edema and or immobilization device. UNDERLYING PRINCIPLES ●● Assess for pain level, location, and type and frequency. ●● Assess sensation of the distal extremity. ●● Assess skin temperature for warmth. ●● Assess capillary refill. ●● Assess the pulses distal to the fracture. ●● Assess finger movement. NURSING INTERVENTIONS ●● Pain: Administer pain medication, elevate the extremity, and apply ice. ●● Sensation: Notify the provider of numbness, tingling, or loss of sensation. ●● Skin temperature: Notify the provider if the affected extremity is cool compared to the unaffected extremity. ●● Capillary refill: Notify the provider if nail beds are cyanotic. ●● Pulses: Notify the provider if pulse is absent. ●● Finger movement: Notify the provider if the client is unable to perform passive or active movement of the fingers.

Module 2 ATI Med-Surg 73 A nurse is caring for a client who will have a biopsy of a skin lesion. What should the nurse consider in planning for the procedure? Use the ATI Active Learning Template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: List and describe the three types of integumentary biopsies. NURSING INTERVENTIONS: Describe two intraprocedure nursing actions.

UNDERLYING PRINCIPLES ●● Punch biopsy: A 2 to 6 mm plug of tissue is removed from the skin lesion, followed with or without suturing. ●● Shave biopsy: A scalpel or razor blade removes only the raised area of the lesion, with no suturing. ●● Excisional biopsy: A large, deep specimen of tissue is obtained, followed with suturing. NURSING INTERVENTIONS ●● Assist with setting up materials for placement of a local anesthetic. ●● Apply pressure to the biopsy site to control bleeding. ●● Place a sterile dressing over the biopsy site if needed.

Module 1 ATI Fundamentals 22 1. A nurse is talking with the father of a 12-year-old boy who is concerned that he hasn't observed any indications that his son is approaching puberty. The nurse should explain that the first sign of sexual maturation in boys is A. the appearance of downy hair on the upper lip. B. hair growth in the axillae. C. enlargement of the testes and the scrotum. D. deepening of the voice.

1. A. INCORRECT: Emerging facial hair is a later pubescent change. B. INCORRECT: Hair growth in nongenital areas is a later pubescent change. C. CORRECT: The first prepubescent change in boys is an increase in the size of the testicles along with a thinning and expanding of the scrotum. D. INCORRECT: Changing vocal quality is a later pubescent change. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 24 1. A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A. The client evaluates his behavior after a social interaction. B. The client states he is learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation.

1. A. INCORRECT: This is a task middle adults should have accomplished to master an earlier developmental stage. B. INCORRECT: This is a task middle adults should have accomplished to master an earlier developmental stage. C. INCORRECT: This is a task middle adults should have accomplished to master an earlier developmental stage. D. CORRECT: The task for a middle adult is generativity vs. stagnation. Concern for the next generation is a positive sign that the middle adult is meeting the task. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 NCLEX Ch. 7 10 Which of the following medication orders should the nurse question? 1. Morphine sulfate (Morphine) 4 mg IV every 3-4 hours as needed for pain 2. Ceftriaxone (Rocephin) IVPB every 8 hours 3. Furosemide (Lasix) 40 mg po daily 4. Metoprolol (Lopressor) 50 mg po twice a day

10 Answer: 2 Rationale: The ceftriaxone order does not have a medication dosage listed. All other options have required information for dispensing medications. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: Read all options carefully. Apply the five rights of medication administration.

Module 1 NCLEX Ch. 7 3 A newborn is scheduled for discharge from the birthing center tomorrow. When teaching the new parents about car seats, which characteristics of infant restraint systems would the nurse include as essential for the newborn? Select all that apply. 1. Forward-facing 2. Rear-facing 3. In the back seat 4. In the front seat 5. Of a solid and neutral color

3 Answer: 2, 3 Rationale: An infant child restraint system should always be in the back seat and rear-facing. After a child is 1 year of age and weighs 20 pounds, the seat may be in the rear and front-facing. Although bright colors are stimulating to an infant, the color of the system does not matter. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Teaching and Learning Content Area: Child Health Strategy: Choose between opposites, since usu- ally one of each is correct. Use the process of elimination and nursing knowledge of infant safety measures to make appropriate selections.

Module 1 ATI Fundamentals 14 5. A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly hired nurse indicates the need for further teaching? A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."

5. A. CORRECT: The line of gravity should fall within the base of support, not outside, which increases the risk of falling. B. INCORRECT: Being closer to the ground causes a lower center of gravity, which leads to greater stability and balance. C. INCORRECT: Spreading the feet apart increases and widens the base of support. D. INCORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity, which can prevent injury and instability. NCLEX® Connection: Safety and Infection Control, Ergonomic Principles

Module 1 NCLEX Ch. 7 13 A client on the hospital unit has fallen. Place the nursing interventions in order of priority. All options must be used. 1. Identify all witnesses. 2. Call the physician. 3. Assess and provide urgent care. 4. Notify the charge nurse. 5. Fill out the incident report. Fill in your answer below: Answer:

13 Answer: 3, 4, 2, 1, 5 Rationale: The primary actions of the nurse are emergency assessment and first aid. If the nurse notifies the charge nurse, there will be nursing help to contact the physician and speak with witnesses. After caring for the client and assessing the situation, the nurse is prepared to fill out the incident report. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Focus on the client first. Then obtain additional help, collect data, and do the paperwork last.

Module 1 ATI Fundamentals 13 4. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

4. A. CORRECT: A clinical manifestation of heat stroke is hypotension. B. INCORRECT: A clinical manifestation of heat stroke is tachycardia, not bradycardia. C. INCORRECT: A clinical manifestation of heat stroke is hot, dry skin, not clammy skin. D. INCORRECT: A clinical manifestation of heat stroke is tachypnea, not bradypnea. NCLEX® Connection: Physiological Adaptations, Pathophysiology

Module 1 ATI Fundamentals 18 5. A parent brings a 5-month-old infant to the clinic for a well-infant check. The infant weighed 3.2 kg (7 lb) at birth. If the infant has followed the usual pattern of growth for 5 months, how much should the infant weigh? (Round the answer to the nearest tenth.) _____lb

5. 14.5 lb: The infant should gain 0.7 kg (1.5 lb) per month in the first 6 months. 1.5 lb x Age 5 months + Birthweight 7 lb = 14.5 lb NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 21 6. A nurse is explaining to a group of parents in a community center what cognitive development characteristics they should expect of their school-age children. Use the ATI Active Learning Template: Growth and Development to complete this item. Under Cognitive Development, list at least eight cognitive and language development expectations during young adulthood.

6. Using the ATI Active Learning Template: Growth and Development ●● Cognitive Development ◯◯ See weight and volume as unchanging ◯◯ Understand simple analogies ◯◯ Understand time (days, seasons) ◯◯ Classify more complex information ◯◯ Understand various emotions people experience ◯◯ Become self-motivated ◯◯ Solve problems ◯◯ Define many words and understands rules of grammar ◯◯ Understand that a word may have multiple meanings ◯◯ Have a carbon monoxide detector in the home NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 NCLEX Ch. 7 9 The nurse would ask a client scheduled for a venogram about allergy to which substance before the procedure? 1. Peanuts 2. Shellfish 3. Eggs 4. Meat tenderizer

9 Answer: 2 Rationale: Iodine is used in many radiological procedures. Shellfish allergies may be an indicator of iodine allergy. Peanuts, eggs, and meat tenderizer do not pose a risk of cross-sensitivity to iodine. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: Knowledge of radiological procedures must be applied. In addition, recall that allergy to iodine or shellfish commonly applies to radiological procedures.

Module 1 ATI Fundamentals 12 6. A nurse educator is teaching about the safe use of seclusion and restraints to a group of newly licensed nurses. What should be included in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item. Under Nursing Interventions, describe six nursing responsibilities when caring for a client in either seclusion or restraints.

6. Using the ATI Active Learning Template: Basic Concept ●● Nursing Interventions ◯◯ Nursing responsibilities include knowing how often the client should be: -Assessed - Including neurosensory checks of affected extremities (circulation, sensation, mobility). These checks are usually done at least every 2 hr. -Offered food and fluid. -Provided with means for hygiene and elimination. -Monitored for vital signs. -Offered range of motion of extremities. ◯◯ Frequency of client assessments in regard to food, fluids, comfort, and safety should be performed and documented every 15 to 30 min. ◯◯ Other responsibilities include the following: - Explaining the need for the restraint to the client and family, emphasizing that the restraint is needed to ensure the safety of the client and will be used only as long as it is necessary. - Obtaining signed consent from client or guardian, if required. - Reviewing the manufacturer's instructions for correct application. - Removing or replacing restraints frequently to ensure adequate circulation to the area and allowing for full range of motion to the restricted limb. - Padding bony prominences. -Using a quick-release knot to tie the restraint to the bed frame where it will not tighten when the bed is raised or lowered. -Ensuring that the restraint is loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury. -Regularly assessing the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time. -Never leaving the client unattended without the restraint. -Completing documentation to include the following: -Precipitating events and behavior of the client prior to seclusion or restraint -Alternative actions taken to avoid seclusion or restraint -The time restraints were applied and removed (if discontinued) -Type of restraint used and location -Client's behavior while restrained -Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) -Condition of the body part being restrained -Client's response when the restraint is removed Medication administration NCLEX® Connection: Safety and Infection Control, Use of Restraints/Safety Devices

Module 1 ATI Fundamentals 15 6. A nurse educator is teaching a module on biological pathogens during orientation to a group of newly hired nurses. What information should the nurse educator include? Use the ATI Active Learning Template: Basic Concept to complete this item to include Related Content: List four clinical manifestations and the recommended treatment for anthrax, botulism, pneumonic plague, and tularemia.

6. Using the ATI Active Learning Template: Basic Concept ●● Related Content ◯◯ Anthrax -Clinical Manifestations Sore throat Fever Cough Shortness of breath Muscle aches Severe dyspnea Meningitis Shock -Nursing Interventions Oral ciprofloxacin (Cipro) IV ciprofloxacin One or two additional antibiotics, such as vancomycin or penicillin ◯◯ Botulism -Clinical Manifestations Difficulty swallowing Double vision Slurred speech Descending progressive weakness Nausea, vomiting, abdominal cramps Difficulty breathing -Nursing Interventions Airway management Antitoxin Elimination of toxin ◯◯ Pneumonic plague -Clinical Manifestations Fever Headache Weakness Rapidly developing pneumonia Shortness of breath Chest pain Cough Bloody or watery sputum. Progresses for 2 to 4 days May cause respiratory failure and shock. -Nursing Interventions Early treatment is essential. Administer antibiotics within 24 hr of first symptoms. Streptomycin, gentamicin, the tetracyclines, and chloramphenicol are all effective against pneumonic plague. ◯◯ Tularemia -Clinical Manifestations Sudden fever Chills Headache Diarrhea Muscle aches Joint pain Dry cough Progressive weakness If airborne, life-threatening pneumonia and systemic infection -Nursing Interventions Streptomycin IV or gentamicin IV or IM are the drugs of choice. In mass casualty, use doxycycline or ciprofloxacin. NCLEX® Connection: Safety and Infection Control, Handing Hazardous and Infectious Materials

Module 1 ATI Fundamentals 16 6. A nurse is caring for a client in a spinal cord injury rehabilitation center following head and neck injuries he sustained while riding his bicycle. The client had surgery during the acute phase of treatment to relieve intracranial pressure and to stabilize his cervical spine. Now, he and his spouse are learning essential self-management strategies. Use the ATI Active Learning Template: Basic Concept to complete this item. Under Related Content, list each of the three levels of prevention with an example of each level from this client's history or from what this client might have done to prevent this injury and its life-altering consequences.

6. Using the ATI Active Learning Template: Basic Concept ●● Related Content ◯◯ Primary: take various courses, read about bicycle safety (wear a helmet, use reflective accessories and lights for visibility to drivers, follow the rules of the road for cyclists) ◯◯ Secondary: emergency care, surgery ◯◯ Tertiary: rehabilitative care, learning self-management procedures, strategies NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 14 6. A nurse educator is teaching basic principles of proper lifting techniques to a group of newly hired nurses. Use the ATI Active Learning Template: Basic Concept to complete this item. Under the section Underlying Principles, list four key elements of proper lifting techniques.

6. Using the ATI Active Learning Template: Basic Concept ●● Underlying Principles ◯◯ Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles. ◯◯ Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and avoid strain on smaller muscles. ◯◯ When lifting an object from the floor, flex the hips, knees, and back. Get the object to thigh level, keeping the knees bent and the back straightened. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain. ◯◯ Use assistive devices whenever possible, and seek assistance whenever it is needed. NCLEX® Connection: Safety and Infection Control, Ergonomic Principles

Module 1 ATI Fundamentals 24 6. A nurse is explaining to a group of middle adults in a community center what moral and cognitive development characteristics they should expect at this stage of life. Use the ATI Active Learning Template: Growth and Development to complete this item to include the following: A. Cognitive Development: ●● List at least two moral development expectations during middle adulthood. ●● List at least five cognitive development expectations during middle adulthood.

6. Using the ATI Active Learning Template: Growth and Development A. Cognitive Development ●● Moral Development ◯◯ Spiritual beliefs and religion may take on added importance. ◯◯ Middle adults may become more secure in their convictions. ◯◯ Middle adults often have advanced moral development. ●● Cognitive Development ◯◯ Reaction time and speed of performance slow slightly. ◯◯ Memory is intact. ◯◯ Crystallized intelligence remains (stored knowledge). ◯◯ Fluid intelligence (how to learn and process new information) declines slightly. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 18 6. A nurse is explaining to the parents of a 4-month-old infant what milestones they can expect their infant to achieve during this first year of her life and what they can do to encourage her development. Use the ATI Active Learning Template: Growth and Development to complete this item. Include the following: A. Cognitive Development: ●● Name the developmental stage Piaget has identified for the first two years of life. ●● Identify three essential components that comprise this stage. B. Age-Appropriate Activities ●● Identify at least two toys and two activities the nurse should suggest that the parents provide for their infant.

6. Using the ATI Active Learning Template: Growth and Development A. Cognitive Development ●● Piaget's sensorimotor stage (first 2 years) ◯◯ Separation ◯◯ Object permanence ◯◯ Mental representation B. Age-Appropriate Activities ●● Toys and activities ◯◯ Rattles ◯◯ Mobiles ◯◯ Teething toys ◯◯ Nesting toys ◯◯ Playing pat-a-cake ◯◯ Playing with balls ◯◯ Reading books NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 19 6. A nurse is explaining to the parents of a 14-month-old toddler what physical and cognitive development they can expect from now until their son is 3 years old. Use the ATI Active Learning Template: Growth and Development to complete this item. Include the following: A. Physical Development: Identify at least four gross or fine motor skills the parents can expect at specific ages. B. Cognitive Development: Describe at least three parameters the parents can expect to observe during the toddler stage.

6. Using the ATI Active Learning Template: Growth and Development A. Physical Development ●● At 15 months, gross motor skills: walks without help, creeps up stairs ●● At 15 months, fine motor skills: uses cup well, builds tower of two blocks ●● At 18 months, gross motor skills: assumes standing position, jumps in place with both feet ●● At 18 months, fine motor skills: manages spoon without rotation, turns pages in book two or three at a time ●● At 2 years, gross motor skills: walks up and down stairs ●● At 2 years, fine motor skills: builds a tower with six or seven blocks ●● At 2.5 years, gross motor skills: jumps with both feet, stands on one foot momentarily ●● At 2.5 years, fine motor skills: draws circles, has good hand-finger coordination B. Cognitive Development ●● During toddler stage: object permanence, memories of events that relate to them, domestic mimicry (playing house), symbolization of objects and people, use of 400 words, use of two- to three-word phrases NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 22 6. A nurse on a pediatric unit is reviewing with a group of nursing students the cognitive developmental milestones to expect from adolescent clients. Use the ATI Active Learning Template: Growth and Development to complete this item. Under Cognitive Development, list at least five cognitive development expectations during adolescence.

6. Using the ATI Active Learning Template: Growth and Development ●● Cognitive Development ◯◯ Think at an adult level ◯◯ Think abstractly and deal with principles ◯◯ Evaluate the quality of their own thinking ◯◯ Have a longer attention span ◯◯ Are highly imaginative and idealistic ◯◯ Make decisions through logical operations ◯◯ Are future-oriented ◯◯ Are capable of deductive reasoning ◯◯ Understand how actions of an individual influence others NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 20 6. A nurse is making safety recommendations to the parents of a two preschoolers. Use the ATI Active Learning Template: Growth and Development to complete this item. Under Injury Prevention, list at least four key areas of safety and age-appropriate instructions for addressing each area.

6. Using the ATI Active Learning Template: Growth and Development ●● Injury Prevention ◯◯ Bodily harm Keep firearms in a locked cabinet or container. Teach stranger safety. Wear helmets when riding a bicycle or tricycle and during any other activities that increase head-injury risk. Wear protective equipment (helmet and pads) during physical activity. ◯◯ Burns Reduce the temperature setting on the hot water heater. Have smoke detectors in the home and replace the batteries regularly. Use sunscreen while outdoors. ◯◯ Drowning Do not leave children unattended in the bathtub. Closely supervise children at a pool or any other body of water. Teach children to swim. ◯◯ Motor-vehicle injuries Use a forward-facing car seat with a harness in the back seat. If weight or height exceeds the forward-facing limit, use a belt-positioning booster seat. ◯◯ Poisoning Avoid exposure to lead paint. Keep plants out of reach. Place safety locks on cabinets with cleaners and other chemicals. Keep a poison control number handy or program it into the phone. Keep medications in childproof containers out of reach. Have a carbon monoxide detector in the home. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 25 6. A nurse is reviewing safety precautions for older adults with a group of home health care nursing assistants. Use the ATI Active Learning Template: Growth and Development to complete this item. Under Injury Prevention, list at least 10 safety recommendations for older adults.

6. Using the ATI Active Learning Template: Growth and Development ●● Injury Prevention ◯◯ Install bath rails, grab bars, and handrails on stairways. ◯◯ Teach clients about safe medication use. ◯◯ Remove throw rugs. ◯◯ Eliminate clutter from walkways and hallways. ◯◯ Remove extension and phone cords from walkways and hallways. ◯◯ Instruct about how to use ambulationassistive devices (walkers, canes). ◯◯ Ensure adequate lighting. ◯◯ Remind clients to wear eyeglasses and hearing aids. ◯◯ Avoid drugs, including alcohol, to prevent substance use disorders. ◯◯ Avoid driving a vehicle during or after drinking alcohol or taking drugs that impair sensory and motor functions. ◯◯ Wear a seat belt when operating a vehicle. ◯◯ Wear a helmet while bike riding, skiing, and other recreational activities that increase head-injury risk. ◯◯ Install smoke and carbon monoxide detectors in the home. ◯◯ Secure firearms in a safe location. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 NCLEX Ch. 7 7 The home health nurse is visiting an older adult client with diabetes mellitus. The nurse becomes concerned and implements safety education when which of the following occurs? 1. Neighbors bring a warm lunch to client 2. Children install air conditioners in kitchen and bedroom 3. Grandchildren place baskets of folded laundry by bedroom door 4. Client stores diabetic testing supplies on kitchen table

7 Answer: 3 Rationale: Laundry baskets that are set on the floor will pose a risk for falling for the older client. All hallways, floors, stairways, and furniture should be free of clutter. Neighbors bringing lunch for the elderly client is a good safety intervention. Family controlling the climate for the elderly client is a good safety intervention. Keeping diabetic supplies on a kitchen table with easy access will facilitate diabetic testing. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: Focus on the critical word safety and choose the option that poses a risk to the client. Recall that older adults are at increased risk for falls, so this should guide your thought process as you make a selection.

Module 1 NCLEX Ch. 7 8 The nurse preceptor observes the new RN administering medications. The preceptor concludes there is a risk for medication error when the new RN takes which action? 1. Answers a physician's page while passing medications 2. Uses military time for documentation 3. Asks for help with a dosage calculation 4. Does not give a medication that the client questions

8 Answer: 1 Rationale: The nurse should never interrupt the medication administration process, because this increases the risk for errors. Military time is frequently used by institutions for documentation. The nurse should always ask for assistance with dosage calculations when in doubt. The nurse should never give a medication that a client questions; instead, recheck the order, dosage, and medication, and give the client an explanation. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: Focus on the risk for error and select the option that poses a threat to the safe administration of medications.

Module 1 NCLEX Ch. 7 1 The nurse determines a new mother is in greatest need of more education about infant care and safety when the mother makes which statement? 1. "I am pretty sure that I am going to breastfeed my baby." 2. "After feeding, I should put my baby on her tummy to prevent choking." 3. "Solid foods are unnecessary during the baby's first 4-6 months." 4. "I should wake my baby up every 3-4 hours for feeding."

1 Answer: 2 Rationale: Infants should always be put to sleep on the back, indicating the need for further teaching about new- born care and safety. Breastfeeding is a nutrition choice. Solid foods are not needed in the first 4 to 6 months of infancy. Newborns do sleep frequently and should be awak- ened every 3-4 hours for feeding. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Maternal-Newborn Strategy: The wording of the question guides you to look for a false statement as the correct response. Use the process of elimination and nursing knowledge.

Module 1 ATI Fundamentals 21 1. A nurse is talking with parents of a school-age child who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." B. "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." C. "We think our son is trying too hard to excel in math just to get the top grades in his class." D. "Our son is always afraid the kids in school will laugh at him because he likes to sing and write little poems."

1. A. CORRECT: When using the urgent vs. nonurgent approach to client care, the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of the preschool stage to develop initiative vs. guilt. This school-age child is still trying to develop the physical abilities he needs to feel a sense of accomplishment. He is still struggling with this task and needs assistance with motor skills and agility. B. INCORRECT: It is common for school-age children to fail to understand the reasoning behind many rules and to try to find ways around them and make the best deal. This problem is not the priority for assessment and intervention. C. INCORRECT: It is common for school-age children, who are in the stage Erikson describes as industry vs. inferiority, to strive to develop a sense of industry through advances in learning. This problem is not the priority for assessment and intervention. D. INCORRECT: It is common for school-age children, who are in the stage Erikson describes as industry vs. inferiority, to face the challenge of acquiring new skills and achieving success socially. This problem is not the priority for assessment and intervention. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 19 1. A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) A. Keep toxic agents in locked cabinets. B. Keep toilet seats up. C. Turn pot handles toward the back of the stove. D. Place safety gates across stairways. E. Make sure balloons are fully inflated.

1. A. Correct: Parents must prevent toddlers from accessing dangerous substances. B. Incorrect: Easy access to the water in the toilet bowl could result in aspiration or drowning. C. Correct: If toddlers can reach a pot handle, they can pull the pot and its contents down on themselves and incur serious injuries. D. Correct: At the bottom of a staircase, they prevent toddlers from climbing stairs and falling backward. At the top of a staircase, they prevent toddlers from falling down the stairs. E. Incorrect: Toddlers should not have access to balloons at all, as balloons can easily burst and toddlers can put fragments of the balloon or the entire deflated balloon in the mouth and asphyxiate. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 18 1. A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply.) A. Rolls from back to front B. Bears weight on legs C. Walks holding onto furniture D. Sits unsupported E. Sits down from a standing position

1. A. Correct: The infant should be able to roll from back to front by 6 months. B. Correct: The infant should be able to bear weight on legs by 7 months. C. Incorrect: The infant should be able to do this by 11 months. D. Correct: The infant should be able to do this by 8 months. E. Incorrect: The infant should be able to do this by 12 months. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 20 1. A nurse is talking with the father of a 4-year-old child who states that his daughter goes to bed at 8:30 p.m. and wakes up at about 7:30 a.m., but she often lies in bed talking to herself or gets up a few times before falling asleep 40 min later. At her preschool, the children take a 2-hr afternoon nap. Which of the following recommendations should the nurse make to help improve the child's sleep behavior? A. Offer the child a snack of her favorite treat right before bedtime. B. Allow the child to watch an extra 30 min of TV in the evening. C. Change the child's bedtime to 9 p.m. on days she napped. D. Request that the preschool staff limit her nap time to 1 hr.

1. A. INCORRECT: Eating a snack, especially one with a high sugar content, is likely to provide stimulation that will make it more difficult for the child to fall asleep. B. INCORRECT: Watching TV is likely to provide stimulation that will make it more difficult for the child to fall asleep. C. CORRECT: Preschoolers start to need less sleep than they did in previous stages. Putting the child to bed 30 min later, when she might be more tired, could help her fall asleep more readily. D. INCORRECT: It is impractical and inappropriate to ask preschool staff to limit nap time because one child has difficulty falling asleep at night. Also, if the child is napping for that amount of time, she probably needs that rest during the day. NCLEX® Connection: Basic Care and Comfort, Rest and Sleep

Module 1 ATI Fundamentals 13 1. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

1. A. INCORRECT: Family members who smoke should do so outside. B. CORRECT: Nail polish and other flammable materials may cause a fire and should not be used. C. CORRECT: A "No Smoking" sign should be placed near the front door. A sign also may be placed on the client's bedroom door. D. INCORRECT: Woolen and synthetic materials create static electricity; cotton materials do not and should be used instead. E. CORRECT: A readily available fire extinguisher should be placed in all homes, including the home of a client who is receiving oxygen. NCLEX® Connection: Safety and Infection Control, Safe Use of Equipment

Module 1 ATI Fundamentals 23 1. A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "If I am having any discomfort, I'll just go to an urgent care center." D. "If I am feeling stressed, I will remind myself that this is something I should expect."

1. A. INCORRECT: For protection against a wide variety of communicable illnesses, adults should obtain the immunizations the CDC recommends throughout the lifespan, not just during childhood. B. CORRECT: Young adulthood is a time of relative health, but routine screenings and health care visits are still important. C. INCORRECT: Urgent care centers offer limited services, typically for acute injuries or problems that cannot wait until a primary care provider is available. Young adults should establish a relationship with a primary care provider to consult for nonurgent health problems. D. INCORRECT: Although it is true that stress is inevitable, chronic stress can lead to severe health alterations. Young adults who have stress that is recurrent or escalating should seek medical care. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 14 1. A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg

1. A. INCORRECT: In the supine position, the client lies on his back with his head and shoulders elevated on a pillow. This angle is not adequate to prevent regurgitation. B. CORRECT: In the semi-Fowler's position, the client lies supine with the head of the bed elevated approximately 30°. This position is frequently used to prevent regurgitation and aspiration in clients who have difficulty swallowing. This is the safest position for the client receiving a tube feeding. C. INCORRECT: In the semi-prone or Sims' position, the client is on his side halfway between lateral and prone positions. This position is not safe because it may promote regurgitation. D. INCORRECT: In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it may promote regurgitation. NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/ Treatments/Procedures

Module 1 ATI Fundamentals 12 1. A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in low position with full side rails up. C. Ensure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

1. A. INCORRECT: It is inappropriate to restrain this client and could be considered false imprisonment. B. INCORRECT: Full side rails for this client may put the client at greater risk for a fall because he may attempt to climb over the bed rails to get out of bed. C. CORRECT: Ensuring that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear may keep the client from slipping. E. CORRECT: A fall-risk assessment serves as the basis for an individualized plan of care. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 25 1. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."

1. A. INCORRECT: The client is at risk for social isolation and loss of independence because of retirement. However, another issue is the priority. B. INCORRECT: The client is at risk for loss of independence and reduced self-esteem due to dependence upon his son. However, another issue is the priority. C. INCORRECT: The client is at risk for social isolation due to the loss of a friend. However, another issue is the priority. D. CORRECT: The greatest risk to this client is injury from overdosing or underdosing his medications due to loss of short-term memory. The priority issue for the nurse is to assist the client to implement safe medication strategies. The nurse should assist the client to use a pill organizer to help him remember to take his medications and to keep a list of all current medications. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 15 1. A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia

1. A. INCORRECT: The nurse should give the lowest priority to a client who is not expected to live. The nurse should provide comfort measures for this client (Expectant Category - Class IV). B. INCORRECT: The nurse should give third priority to the client who has minor injury that is not life-threatening, such as a laceration to the head (Nonurgent Category - Class III). C. CORRECT: The nurse should give first priority to the client who has the greatest chance of survival with prompt intervention. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is still expected to live. Therefore, this client is the highest priority (Emergent Category - Class I). D. INCORRECT: The nurse should give second priority to the client who has major fractures (Urgent Category - Class II). NCLEX® Connection: Management of Care, Establishing Priorities

Module 1 ATI Fundamentals 17 1. When a nurse is observing a client drawing up and mixing insulin injections, which of the following best demonstrates that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique. C. The client states that he understands. D. The client is able to write the steps on a piece of paper.

1. A. Incorrect: Discussing the appropriate technique demonstrates learning, but it does not involve the use of motor skills. B. Correct: Demonstrating the appropriate technique indicates that psychomotor learning has taken place. C. Incorrect: Verbalizing understanding demonstrates learning, but it does not involve the use of motor skills. D. Incorrect: Writing steps on paper demonstrates learning, but it does not involve the motor skills essential for performing the procedure. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 16 1. A nurse is caring for a 19-year-old client who is sexually active and has come to the college health clinic for the first time for a checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A. Measure the client's vital signs. B. Encourage HIV screening. C. Determine the client's risk factors. D. Instruct the client to use condoms.

1. A. Incorrect: Vital signs are a part of any health care visit, but they are not the priority for a 19-year-old client. B. Incorrect: It might be appropriate to suggest HIV screening, but there is a higher priority action the nurse must take before doing this. C. Correct: The first action the nurse should take using the nursing process is assessment. The nurse should talk with the client first to determine what risk factors the client might have before initiating the appropriate health promotion and disease prevention measures. D. Incorrect: It might be appropriate to suggest condom use, but there is a higher priority action the nurse must take before doing this. NCLEX® Connection: Health Promotion and Maintenance, Health Screening

Module 1 NCLEX Ch. 7 11 The nurse has applied elbow splints on a confused client to prevent the client from removing the intravenous (IV) line. Which of the following interventions is required? 1. Document appearance of client's IV site every hour. 2. Remove elbow splints every 8 hours. 3. Ask for renewal of physician's restraint order every 72 hours. 4. Assess and document client's condition at least every hour.

11 Answer: 4 Rationale: The client should be checked at least hourly, and the nurse must document client status. The IV site should be checked every hour, but documentation may be done only once per shift unless a problem occurs. Because restraints may impede circulation, they should be removed according to agency policy, which is generally every 1-2 hours rather than every 8 hours. Physical restraints impede a client's freedom; their use needs to be ordered every 24 hours. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Utilize knowledge of common policy and procedures for use of physical restraints. Always consider an answer that contains assessment as an option.

Module 1 NCLEX Ch. 7 14 Which information would the nurse omit from written documentation when a reportable incident has occurred? 1. Names of witnesses on incident report 2. Nursing interventions in medical record 3. Time physician was called on incident report 4. That an incident report was submitted in medical record

14 Answer: 4 Rationale: The medical record belongs to the client and should contain all facts related to the client and the incident. The incident report belongs to the hospital and should contain all facts and supportive data related to the client and the incident. The medical record should not refer to the incident report. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Use knowledge of policy and procedure regarding incident reports to analyze this situation.

Module 1 NCLEX Ch. 7 15 Public health nurses have been activated to open a shelter due to an approaching hurricane. What most important items should families be encouraged to take to the emergency shelter? 1. Food and extra clothing 2. Cats and small dogs 3. Medication and vital records 4. Radios and small personal electronics

15 Answer: 3 Rationale: Client medications and vital records are needed for a short or extended stay at an emergency shelter. Because space is very limited, there is no provision for storing food, and animals are not allowed. Loud electronic devices may cause disturbance between families or individuals. Electricity may or may not be available. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: Focus on the required items for a stay in the emergency shelter. A client's medications are the only provisions listed that emergency personnel may not be able to provide.

Module 1 NCLEX Ch. 7 16 A major portion of a construction project has collapsed. The emergency department (ED) has been notified that numerous victims are being transported to the ED. What should be the first action of the ED nurses? 1. Assess department for resources—staff, beds, equipment. 2. Implement personnel recall system. 3. Discharge stable clients. 4. Set up a temporary morgue.

16 Answer: 1 Rationale: The nurses must first assess current ED resources. No decisions can be made without a comprehensive assessment of staff, beds, and equipment. The other options are not as encompassing, and a comprehensive assessment is needed with a possible impending disaster. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: Choose the option that is the most comprehensive or global of the option choices.

Module 1 NCLEX Ch. 7 2 The result of a toddler's lead screening is 12 mg/dL. What would the nurse say to the mother at this time? 1. "His lab values are just fine." 2. "Have you noticed any blood in his stools?" 3. "When were his last immunizations?" 4. "Tell me about where you live."

2 Answer: 4 Rationale: The lead value of 12 mg/dL is high. Lead levels below 10 mg/dL are acceptable. Levels of 10-19 mg/dL require an environmental history. Levels above 20 mg/dL require a full medical evaluation. Asking about the child's home is the first step in evaluating the environment. Older homes may have lead paint and lead in the plumbing. Blood in the stool and immunization status are unrelated to lead poisoning. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Assessment Content Area: Child Health Strategy: To answer the question it is required to know acceptable lead values. Notice that option 4 is related to an environmental assessment.

Module 1 ATI Fundamentals 21 2. A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for school-age children? (Select all that apply.) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Shaping modeling clay

2. A. CORRECT: Building simple models is appropriate for school-age children and helps develop fine motor and cognitive skills. B. CORRECT: Playing video games, especially educational and nonviolent ones, is appropriate for school-age children and helps develop fine motor and cognitive skills. C. CORRECT: Reading books is appropriate for school-age children and helps develop cognitive and communication skills. D. INCORRECT: Using toy carpentry tools is more appropriate for preschoolers. E. INCORRECT: Shaping modeling clay is more appropriate for preschoolers. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 25 2. A nurse is admitting an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following questions should the nurse ask to investigate the source of his weight loss? (Select all that apply.) A. "Do you eat alone or with someone?" B. "Do you watch television while eating your meals?" C. "Have you started any new medications in the past 6 months?" D. "What foods have you eaten within the past 24 hours?" E. "Are you on a fixed income?"

2. A. CORRECT: Clients who eat alone are more likely to skip or skimp on meals. B. INCORRECT: Determining if the client watches TV while eating is not relevant in this situation. C. CORRECT: Many medications affect the senses of taste and smell, as well as the abilities to tolerate food and to absorb nutrients. D. CORRECT: Asking about food the client ate within the last 24 hr will provide a basis to determine what he typically eats in a 24-hr period. E. CORRECT: Clients who receive a fixed income may not have enough money to buy food. NCLEX® Connection: Health Promotion and Maintenance, Health Screening

Module 1 ATI Fundamentals 20 2. A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.) A. Assembling puzzles B. Pulling wheeled toys C. Using musical toys D. Using finger paints E. Coloring with crayons

2. A. CORRECT: Putting puzzles together is appropriate for preschoolers and helps develop fine motor and cognitive skills. B. INCORRECT: Pulling or pushing toys with wheels is more appropriate for toddlers. C. CORRECT: Playing with musical toys is appropriate for preschoolers and helps develop fine motor skills and coordination. D. INCORRECT: Using finger paints is more appropriate for toddlers. E. CORRECT: Using crayons to color on paper or in coloring books is appropriate for preschoolers and helps develop fine motor skills and coordination. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 18 2. A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? A. "My baby loved to play with his crib gym, but I took it away from him." B. "I just bought a soft mattress so my baby will sleep better." C. "My baby really likes sleeping on the fluffy pillow we just got for him." D. "I just bought a child-safety gate that folds like an accordion."

2. A. Correct: Parents should remove gyms and mobiles by 4 months because injury can occur from choking or strangulation. B. Incorrect: The infant's crib mattress should be firm and fit tightly to prevent suffocation. C. Incorrect: Parents should not place any pillows in the crib, as they pose a risk for strangulation. D. Incorrect: Child-safety gates should expand by a horizontal mechanism and not like an accordion to prevent injury to hands and arms. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 16 2. A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

2. A. Correct: Starting at age 20, examinations for testicular cancer are appropriate, along with blood pressure and body mass index measurements and cholesterol determinations. B. Incorrect: Blood glucose testing begins at age 45. C. Incorrect: Testing for fecal occult blood usually begins at age 50. D. Incorrect: Testing for prostate-specific antigen usually begins at age 50. NCLEX® Connection: Health Promotion and Maintenance, Health Screening

Module 1 ATI Fundamentals 15 2. A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for a transurethral resection of the prostate (TURP) D. A client who is 24 hr postoperative following a mastectomy E. A client who is scheduled for an appendectomy

2. A. INCORRECT: A client who is dehydrated and receiving IV fluid and electrolytes is unstable for discharge. B. INCORRECT: A small bowel obstruction that is not treated could result in the death of the client. C. CORRECT: A client who is scheduled for a TURP could be safely discharged because a TURP is not an emergent surgery. D. CORRECT: A client who 24 hr postoperative following a mastectomy is stable and could be safely discharged. E. INCORRECT: A client who has appendicitis needs immediate surgery to prevent rupture of the appendix and subsequent peritonitis. NCLEX® Connection: Management of Care, Establishing Priorities

Module 1 ATI Fundamentals 24 2. A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following capabilities? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Feel frustrated that time is too short for attempting to start another life. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and activities.

2. A. INCORRECT: Acceptance of diminished strength and increased dependence is a developmental task crucial for older adults. B. INCORRECT: Feeling frustrated that time is too short affects adults who are having difficulties with the developmental tasks of middle age. C. CORRECT: Psychosocially healthy middle adults accept life's opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs. stagnation. D. INCORRECT: Seeking and forming friendships is a developmental task crucial for young adults. E. CORRECT: Psychosocially healthy middle adults achieve Erikson's stage of generativity vs. stagnation by contributing to future generations through community involvement as well as teaching and parenting. NCLEX® Connection: Health Promotion and Maintenance, Health Screening

Module 1 ATI Fundamentals 23 2. A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between and being responsible for two generations

2. A. INCORRECT: Active involvement in the next generation is a developmental task for middle adults. B. INCORRECT: Adjusting to major role changes is a developmental task for older adults. C. CORRECT: Exploring career options and then establishing oneself in a specific occupation is a major developmental task for a young adult. D. INCORRECT: Assuming responsibility for the previous as well as the next generation is a developmental task for middle adults. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 14 2. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.

2. A. INCORRECT: Although this might be a necessary assistive device for this client, it is not the priority action the nurse should take. B. INCORRECT: Although this might be necessary for a safe transfer, it is the not the priority action the nurse should take. C. INCORRECT: Although this might be a necessary assistive device for the transfer of this client, it is not the priority action the nurse should take. D. CORRECT: The first action the nurse should take using the nursing process is to assess/collect data from the client. The nurse should assess the client's ability to help with transfers (balance, muscle strength, endurance). Then the nurse can proceed with a safe transfer of the client. NCLEX® Connection: Safety and Infection Control, Ergonomic Principles

Module 1 ATI Fundamentals 13 2. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification and instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temperature of the water before placing my baby in the bath." D. "Once my infant starts to push up, I will remove the mobile from over the bed."

2. A. INCORRECT: It is recommended to begin swimming lessons when the infant's developmental status allows for protective responses such as closing her mouth under water. B. CORRECT: Although the baby can hold his head above the water by sitting up, this does not make the child safe in the bathtub. Parents should never leave an infant or toddler alone in the bathtub. C. INCORRECT: It is recommended to test the temperature of bath water prior to placing an infant in the bath. D. INCORRECT: It is recommended to remove crib toys, such as mobiles, from over the bed as soon as the infant begins to push up. NCLEX® Connection: Safety and Infection Control, Home Safety

Module 1 ATI Fundamentals 22 2. A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions are appropriate for this client? (Select all that apply.) A. Suggest that his parents room in with him. B. Provide a television and DVDs for him to watch. C. Limit visitors to immediate family. D. Devise a regular schedule for inpatient routines. E. Allow him to perform his own morning care.

2. A. INCORRECT: Rooming in is more appropriate for younger children. B. CORRECT: Nonviolent DVDs are appropriate diversional activities for an adolescent. C. INCORRECT: There is no reason to restrict visitors. Allowing his friends to visit helps prevent feelings of isolation. D. INCORRECT: Flexible routines and activities, such as wearing his own clothes and having his favorite snacks on hand, help adolescents feel more comfortable in inpatient settings. E. CORRECT: Allowing him to perform his own morning care helps promote a sense of independence. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 12 2. A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer medications as prescribed." D. "I will be prepared to insert an airway."

2. A. INCORRECT: When a seizure occurs, the client should be placed in a side-lying position to allow for drainage of secretions and to prevent the tongue from occluding the airway. B. CORRECT: During a seizure, the client should not be left alone. The nurse remains with the client and calls for assistance using the call light. C. INCORRECT: Administering medications is an appropriate action by the nurse. D. INCORRECT: Nothing should be placed in the client's mouth except an airway, if needed. A tongue blade can cause injury and airway obstruction. NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems

Module 1 ATI Fundamentals 17 2. A nurse in a provider's office is collecting data from the mother of a 1-year-old child. The client states that her child is old enough for toilet training. Following an educational session by the nurse, the client now states that her earlier ideas have changed. She is now willing to postpone toilet training until the child is older. Learning has occurred in which of the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic

2. A. Incorrect: An example of cognitive learning is stating the behavior the child will demonstrate when ready to toilet train. B. Correct: Affective learning has taken place, as evidenced by the client's changed ideas about toilet training. C. Incorrect: An example of psychomotor learning is performing the proper techniques for introducing the child to toilet training. D. Incorrect: Kinesthetic learning is a learning style, not a domain of learning. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 19 2. A nurse is planning diversionary activities for children on an inpatient unit. Which of the following should the nurse incorporate as appropriate play activities for a toddler? (Select all that apply.) A. Building simple models B. Working with clay C. Filling and emptying containers D. Playing with blocks E. Looking at books

2. A. Incorrect: This play activity is more appropriate for school-age children. B. Incorrect: Toddlers can easily swallow bits of clay. C. Correct: This activity is toddler-appropriate and helps develop fine motor skills and coordination. D. Correct: This activity is toddler-appropriate and helps develop fine motor skills. E. correct: This activity is toddler-appropriate and helps with preparation for learning to read. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 24 3. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretion D. Far vision E. Glomerular filtration

3. A. CORRECT: In middle adulthood, metabolism declines and weight gain is likely. B. INCORRECT: In middle adulthood, the ability to hear high-pitched sounds declines. C. CORRECT: In middle adulthood, decreases in secretions of bicarbonate and gastric mucus begin and persist into older age. This increases the risk of peptic ulcer disease. D. INCORRECT: In middle adulthood, near vision declines (presbyopia). E. CORRECT: Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 20 3. A nurse is caring for a 5-year-old client whose parents report that she fears painful procedures, such as injections. Which of the following strategies should the nurse use to try to help ease the child's fear? (Select all that apply.) A. Invite the child to assist with mealtime activities. B. Cluster invasive procedures whenever possible. C. Assign caregivers with whom the child is familiar. D. Have the parents bring in a favorite toy from home. E. Engage the child in pretend play with a toy medical kit.

3. A. CORRECT: Preschoolers enjoy mastering tasks they can perform independently. Assisting with routine, nonthreatening tasks can help improve their self-esteem during hospitalization. B. INCORRECT: This creates an unnecessarily lengthy painful period for the child, which is likely to increase her fear. C. INCORRECT: Preschoolers have less stranger anxiety than toddlers, so this is not necessary and not always possible on hospital units. D. CORRECT: Having familiar and cherished objects nearby is therapeutic for children during their hospitalization. E. CORRECT: Pretend play helps children determine the difference between reality and fantasy (imagined fears), especially with the assistance of the nurse during hospitalization. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 19 3. A nurse is talking with the parents of toddler. Which of the following should the nurse suggest regarding discipline? A. Establish consistent boundaries. B. Place him in a room with the door closed. C. Have him learn by trial and error. D. Use favorite snacks as rewards.

3. A. Correct: Toddlers need to have consistent boundaries for discipline to be effective. B. Incorrect: Placing toddlers in a room with the door closed may cause anxiety and fear. C. Incorrect: Trial and error lacks consistent boundaries and increases the risk for harmful consequences. D. Incorrect: Using favorite foods as rewards may promote unhealthy eating habits. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 12 3. A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A. Extinguish the fire. B. Pull the fire alarm. C. Evacuate the clients. D. Close all open doors on the unit.

3. A. INCORRECT: Although extinguishing the fire is part of the fire response, it is not the priority action. B. INCORRECT: Although pulling the fire alarm is part of the fire response, it is not the priority action. C. CORRECT: Rescue is the first action in the fire response. Protecting and evacuating clients in close proximity to the fire is the priority action. D. INCORRECT: Although containing the fire by closing doors is part of the fire response, it is not the priority action. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 21 3. A nurse is reviewing nutritional guidelines with the parents of an 11-year-old child. Which of the following parents' statements should indicate to the nurse that they understand the guidelines for school‑age children? A. "She wants to eat as much as we do, but we're afraid she'll soon be overweight." B. "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." C. "We limit fast-food restaurant meals to three times a week now." D. "We reward her school achievements with a point system instead of a pizza or ice cream."

3. A. INCORRECT: By the end of the school-age stage, parents should expect children to eat adult-size portions of food. B. INCORRECT: Skipping meals can lead to unhealthful snacking and overeating later in the day. C. INCORRECT: Parents should avoid fast-food restaurants completely to keep children from eating food high in sugar, fat, and starches. D. CORRECT: Parents should avoid rewarding children with food for good behavior or achievements. Associations children form between food and feeling good can lead to weight problems. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Module 1 ATI Fundamentals 13 3. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

3. A. INCORRECT: Carbon monoxide cannot be seen, smelled, or tasted. B. INCORRECT: Gas-burning furnaces, water heaters, and appliances should be inspected annually. C. INCORRECT: Although carbon monoxide reduces the amount of oxygen supplied to the body, the lungs are not damaged. D. CORRECT: Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body. NCLEX® Connection: Safety and Infection Control, Home Safety

Module 1 ATI Fundamentals 25 3. A nurse is planning a presentation to a group of older adults at a senior community center about the essential screening tests and preventive procedures during this stage of life. Which of the following should the nurse include? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Eye examination D. Mental health screening E. Dual-energy x-ray absorptiometry (DEXA) scanning

3. A. INCORRECT: HPV typically affects people in their teens and early 20s, so it is not a recommendation for older adults. B. CORRECT: Older adults are especially susceptible to pneumococcal infections, so this is an essential preventive measure for this stage of life. C. CORRECT: Screening for glaucoma via regular eye examinations is essential for older adults. D. CORRECT: Screening for depression via mental health assessments is essential for older adults. E. CORRECT: Screening for osteoporosis via DEXA scanning is essential for older adults. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 15 3. A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) A. Open doors to client rooms. B. Place blankets over clients who are confined to beds. C. Move beds away from the windows. D. Draw shades and close drapes. E. Relocate ambulatory clients in the hallways back into their rooms.

3. A. INCORRECT: In the event of a tornado, the nurse should close all client doors to minimize the threat of flying glass and debris, not open them. B. CORRECT: In the event of a tornado, placing blankets over clients protects them from shattering glass or flying debris. C. CORRECT: In the event of a tornado, the nurse should move all beds away from windows to protect clients from shattering glass or flying debris. D. CORRECT: In the event of a tornado, the nurse should draw shades and close drapes to protect clients against shattering glass. E. INCORRECT: In the event of a tornado, the nurse should relocate ambulatory clients to the hallways, away from windows. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 22 3. A nurse is talking with an adolescent who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I kind of like this girl in my class. She doesn't like me back, though, not that way." B. "I like hanging out with the guys in the science club, but the jocks pick on them." C. "I just don't seem to be any good at anything. I can't play any sports at all." D. "My dad wants me to be a lawyer like him, but I don't want to learn all that stuff."

3. A. INCORRECT: It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of forming peer relationships and dating relationships. This problem is not the priority for assessment and intervention. B. INCORRECT: It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of becoming part of a peer group and establishing a group identity. This problem is not the priority for assessment and intervention. C. CORRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of the school-age years to develop industry (such as by learning new skills and experiencing achievements in them) vs. inferiority. This adolescent is still struggling with this task and needs assistance in working through that dilemma. D. INCORRECT: It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of forming an identity that will lead to higher education and a career. This problem is not the priority for assessment and intervention. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 23 3. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."

3. A. INCORRECT: It is common for young adults to face the challenge of leaving home and establishing independent living. This problem is not the priority for assessment and intervention. B. INCORRECT: It is common for young adults to face the challenge of transitioning from being single to being a member of a new family. This problem is not the priority for assessment and intervention. C. CORRECT: When using the urgent vs nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of adolescence to develop identity vs role confusion. This young adult is still struggling with this task and needs assistance in working through that dilemma. D. INCORRECT: It is common for young adults to face the challenge involved in questioning their ability to parent. This problem is not the priority for assessment and intervention. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 14 3. A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A. lie on my back with my head and shoulders elevated on a pillow." B. lie flat on my stomach with my head to one side." C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table." D. lie on my side with my weight on my hips and shoulder with my arms flexed in front of me."

3. A. INCORRECT: The client is describing the supine position, not the orthopneic position. B. INCORRECT: The client is describing the prone position, not the orthopneic position. C. CORRECT: The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial to clients who have COPD. D. INCORRECT: The client is describing the lateral or side-lying position, not the orthopneic position. NCLEX® Connection: Safety and Infection Control, Ergonomic Principles

Module 1 ATI Fundamentals 18 3. A nurse is reviewing car-seat safety with parents of a 1-month-old infant. When reviewing car-seat use, which of the following instructions should the nurse include? A. Use a car seat that has a three-point harness system. B. Position the car seat so that the infant is rear-facing. C. Secure the car seat in the front passenger seat of the vehicle. D. Put soft padding in the car seat behind the infant's back and neck.

3. A. Incorrect: A three-point harness system protects the upper body only. Infants should have car seats with five-point harness systems. B. Correct: Infants in a car seat should face the rear of the vehicle until age 2 or until they reach the maximum height and weight for the seat. C. Incorrect: Infants in a car seat in the front passenger seat are at risk for injury from the airbag in the event of a crash. D. Incorrect: Padding creates some slack in the harnessing, which could allow the infant to slip out of the harness in a crash. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 16 3. A nurse at a provider's office is talking with a 45-year-old client who has no specific family history of cancer or diabetes mellitus about planning her routine screeings. Which of the following client statements indicates that the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 or 3 years." B. "For now, I should continue to have a mammogram each year." C. "Because the doctor just did a Pap smear, I'll come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again till next year."

3. A. Incorrect: Clients who have no specific family or personal history of colorectal cancer should begin screening procedures at age 50. B. Correct: Between the ages of 40 and 50, women should have a mammogram annually. C. Incorrect: Between the ages of 30 and 65, women with no family or personal history of cervical cancer should have a Pap smear and a human papilloma virus test every 5 years. D. Incorrect: Starting at age 45, clients should have a blood glucose test at least every 3 years. Unless there is a specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 17 3. A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy the next day. Which of the following client statements indicates that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you be able to give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say."

3. A. Incorrect: The client's concern about her spouse seeing the incision may indicate anxiety or depression. B. Incorrect: The client's request for pain medicine may indicate fear and anxiety. C. Correct: Asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer may cause anxiety, fear, or depression, all of which can interfere with the learning process. D. Incorrect: The lack of privacy due to the presence of a roommate may be a barrier to learning. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures

Module 1 ATI Fundamentals 14 4. A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.

4. A. CORRECT: It is preferred that two or more personnel assist with any positioning in order to reduce the risk of injury. B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the nurse's risk for injury. C. INCORRECT: When sitting for long periods of time, the nurse should keep knees slightly higher than, not lower than, the hips in order to decrease strain on the lower back D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements is recommended to prevent injury E. INCORRECT: The nurse should take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles. NCLEX® Connection: Safety and Infection Control, Ergonomic Principles

Module 1 ATI Fundamentals 19 4. A mother tells the nurse that her 2-year-old child has temper tantrums. The child says "no" every time the mother tries to help her get dressed. The nurse explains that, developmentally, the toddler is A. trying to increase her independence. B. developing a sense of trust. C. manifesting an anger management problem. D. attempting to finish a project she started.

4. A. Correct: Toddlers express a drive for independence by opposing the desires of those in authority and attempting to do everything themselves. B. Incorrect: Developing trust is a developmental task for infants. C. Incorrect: This behavior is expected for a 2-year-old child and does not indicate an anger management problem. D. Incorrect: Finishing a project is a developmental task of school-age children. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 23 4. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home.

4. A. INCORRECT: Although bath rails and grab bars add a measure of safety to bathing activities, this recommendation is specific for the older adult population due to their risk for falls. B. CORRECT: Wearing a helmet while skiing helps reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports, so this is an age-appropriate recommendation for this developmental group. C. CORRECT: Having a carbon monoxide detector in the home is an essential safety precaution for young adults as well as for all other developmental stages. D. CORRECT: Securing firearms in a safe location helps reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age-appropriate recommendation for this developmental group. E. INCORRECT: Although throw rugs can pose a safety hazard, this recommendation is specific for the older adult population due to their risk for falls. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 12 4. A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station? A. A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B. A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C. A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle D. A 79-year-old client who is postoperative following a below-the-knee amputation

4. A. INCORRECT: Although this client just had surgery, risk factors for falls are low based on the client's age and type of surgery. B. INCORRECT: Although this client is on telemetry, this client does not display as many risk factors as another client who is to be admitted. C. INCORRECT: Although this client just had surgery, this client does not display as many risk factors as another client who is to be admitted. D. CORRECT: This client should be assigned to a room near the nurses' station due to risk factors that include client's age, mobility, and balance issues related to the surgery, and potential side effects, such as drowsiness, as a result of analgesic medication. NCLEX® Connection: Reduction of Risk Potential, System Specific Assessments

Module 1 ATI Fundamentals 15 4. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. C. Brush the chemical off the skin and clothing. D. Apply a neutralizing agent.

4. A. INCORRECT: In a dry chemical exposure, it is not recommended to wet the skin. B. INCORRECT: Washing the skin with antibacterial soap is not recommended in the event of a dry chemical exposure. C. CORRECT: In the event of a dry chemical exposure, the recommendation is to brush the chemical off the skin and clothing. D. INCORRECT: The nurse should not apply a neutralizing agent until after the chemical is identified. NCLEX® Connection: Safety and Infection Control, Handing Hazardous and Infectious Materials

Module 1 ATI Fundamentals 25 4. A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase iron intake to prevent anemia. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

4. A. INCORRECT: Older adult women do not need as much iron as they did when they were menstruating. B. INCORRECT: Older adults should increase fluid intake to prevent dehydration and constipation. C. CORRECT: Older adults are at risk for osteoporosis. Increasing calcium intake is one way to help prevent it. D. CORRECT: Older adults are at risk for edema and hypertension. Limiting sodium intake is one way to help prevent them. E. CORRECT: Older adults should increase fiber intake to prevent constipation. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Module 1 ATI Fundamentals 24 4. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a middle adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type b B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza

4. A. INCORRECT: The CDC recommends Haemophilus influenzae type b immunizations during infancy and not generally beyond 18 months of age B. CORRECT: The CDC recommends varicella (chickenpox) immunizations during middle adulthood. C. CORRECT: The CDC recommends herpes zoster (shingles) immunizations during middle adulthood, typically one dose at age 60 or beyond. D. INCORRECT: The CDC recommends human papilloma virus (genital warts) immunizations during adolescence and young adulthood. E. CORRECT: The CDC recommends seasonal influenza immunizations during middle adulthood. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Module 1 ATI Fundamentals 20 4. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of two preschoolers. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type b B. Varicella C. Polio D. Hepatitis A E. Seasonal influenza

4. A. INCORRECT: The CDC recommends Haemophilus influenzae type b immunizations during infancy, but not generally beyond 18 months of age. B. CORRECT: The CDC recommends a varicella (chickenpox) immunization during the preschool years. C. CORRECT: The CDC recommends a polio immunization during the preschool years. D. INCORRECT: The CDC recommends hepatitis A immunizations during infancy, but not generally beyond 24 months of age. E. CORRECT: The CDC recommends seasonal influenza immunizations during the preschool years. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 22 4. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza

4. A. INCORRECT: The CDC recommends rotavirus immunizations during infancy and not generally beyond 8 months of age. B. CORRECT: The CDC recommends varicella (chickenpox) immunizations during adolescence. C. INCORRECT: The CDC recommends herpes zoster (shingles) immunizations during middle adulthood, typically one dose at age 60 or beyond. D. CORRECT: The CDC recommends human papilloma virus (genital warts) immunizations during adolescence. E. CORRECT: The CDC recommends seasonal influenza immunizations during adolescence. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 21 4. A nurse is talking with the parents of a 10-year-old child who express concern that their son is suddenly becoming secretive, for example, closing the door when he showers, dresses, and does his homework in his room. Which of the following responses by the nurse is appropriate? A. "Perhaps you should try to find out what he is doing behind those closed doors." B. "Suggest that he leave the door ajar for his own safety." C. "At this age, children tend to become more modest and value their privacy." D. "Tell him it's okay to close the door when he is undressed, but he has to do his homework where you can see him."

4. A. INCORRECT: This response unnecessarily casts suspicion and implies that the child is doing something wrong. B. INCORRECT: This response unnecessarily suggests that the child has something to fear in his own home. C. CORRECT: From a developmental perspective, it is an expectation that school-age children develop privacy. They have their own way of doing things and spend more time alone. D. INCORRECT: This suggestion sounds like a punishment, and the parents have not presented any evidence that the child is doing anything wrong. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 17 4. A nurse is preparing an instructional session about managing stress incontinence for an older adult. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and the client agree are reasonable. D. Determine what the client knows about stress incontinence.

4. A. Incorrect: Active participation in the learning process is essential for the success of the session. However, this is not the priority action. B. Incorrect: It is essential for the nurse to prepare and select instructional materials appropriate for the client's age, developmental level, and other parameters. However, this is not the priority action. C. Incorrect: Establishing mutually agreeable goals is essential for the success of the session. However, this is not the priority action. D. Correct: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine how much the client knows about stress incontinence, the accuracy of this knowledge, and what the client needs to learn to manage this condition before proceeding to instructing the client. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 16 4. A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. His total cholesterol result from the screening was 248 mg/dL, so he saw his provider and received a medication prescription to improve his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities of this client is an example of primary prevention? A. Cholesterol screening B. Nutrition presentation C. Medication therapy D. Cardiac rehabilitation

4. A. Incorrect: The cholesterol screening is an example of secondary prevention. B. Correct: Primary prevention encompasses strategies that actually help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness. C. Incorrect: The medication therapy is an example of secondary prevention. D. Incorrect: Cardiac rehabilitation is an example of tertiary prevention. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 18 4. The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses by the nurse are appropriate? (Select all that apply.) A. "It might be good to add bananas, as they can help with loose stools." B. "Let's make a list of the foods he is eating so we can spot any problems." C. "Did the changes begin after you started one particular food?" D. "Has he been vomiting since he started these new foods?" E. "Most babies react with a little indigestion when you start new foods."

4. A. Incorrect: This response is an attempt to eliminate a symptom without attempting to determine if there is a problem that requires intervention. B. Correct: Before the nurse can determine that there is a problem, such as a food allergy or intolerance, she should determine the components of the child diet. C. Correct: Fussiness and diarrhea, as well as a rash and vomiting or constipation, can all be signs of a food allergy or intolerance. Before the nurse can intervene, she has to collect data that can help her plan the appropriate interventions. D. Correct: Vomiting and constipation can also be signs of a food allergy or intolerance. Before the nurse can intervene, she has to collect data that can help her plan the appropriate interventions. E. Incorrect: This response is nontherapeutic because it offers false reassurance without any attempt to determine if there is a problem that requires intervention. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Module 1 NCLEX Ch. 7 5 What is the best method for the nurse to use to encourage the use of bicycle helmets by school-age children? 1. Advocate for legislation on helmet laws. 2. Teach parents to role-model helmet use while riding bicycles. 3. Verbally reprimand children who report not wearing helmets while riding. 4. Recommend the parents purchase stylish helmets to increase compliance.

5 Answer: 2 Rationale: Parent role models of behavior are most effective in fostering good habits in children. Legislative action provides legal support for helmet use, but this is not a direct motivator for children. Reprimands for lack of use may be effective on a case-by-case basis, but make less of an impression than positive role modeling. Stylish helmets may be effective on a case by case basis, but make less of an impression than positive role modeling. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Child Health Strategy: Note the critical word best, indicating that all answers could be correct, but one is better than the others. Consider that legislation is a positive step but may not change behaviors. Reprimanding is a negative behavior. The style of helmet may be effective but may not be realistic for all families depending on financial circumstances.

Module 1 ATI Fundamentals 22 5. A nurse is preparing a wellness presentation for families at a community center. When discussing health screenings for adolescents, which of the following information about scoliosis should the nurse include? (Select all that apply.) A. Scoliosis is more common among girls than it is among boys. B. Loss of height is often the first sign of scoliosis. C. Scoliosis screening is essential during the adolescent growth spurt. D. Slouching is a common cause of scoliosis, especially in adolescents. E. Scoliosis is a forward curvature of the spine.

5. A. CORRECT: Girls are more likely than boys to have adolescent idiopathic scoliosis. B. INCORRECT: Loss of height is often the first sign of osteoporosis. Asymmetry in shoulder or hip height is a sign of scoliosis. C. CORRECT: Idiopathic scoliosis is most noticeable during the adolescent growth spurt. D. INCORRECT: In most cases, scoliosis has no apparent cause. E. INCORRECT: Scoliosis is a lateral curvature of the spine. NCLEX® Connection: Health Promotion and Maintenance, Health Screening

Module 1 ATI Fundamentals 21 5. A nurse at an elementary school is planning a health promotion and primary prevention class. Which of the following topics are appropriate to include for the parents of school-age children? (Select all that apply.) A. Childhood obesity B. Substance use disorders C. Scoliosis screening D. Front-seat seatbelt use E. Stranger awareness

5. A. CORRECT: Parents of school-age children need to be aware of nutritional strategies for preventing childhood obesity. B. CORRECT: Parents of school-age children need to know how to teach children to say no to illegal drugs, alcohol, and all other harmful or addictive substances. C. CORRECT: School-age children and adolescents require screening for scoliosis. D. INCORRECT: Children younger than 13 years are safest in the back seat. E. CORRECT: Parents need to reinforce stranger safety as soon as their children are old enough to understand it, and throughout all stages of childhood. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 23 5. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio

5. A. CORRECT: The CDC recommends human papillomavirus immunizations during adulthood. This virus, which causes genital warts, is most prevalent during adolescence and young adulthood. B. CORRECT: The CDC recommends measles, mumps, rubella immunizations during adulthood. C. CORRECT: The CDC recommends varicella (chickenpox) immunizations during adulthood. D. INCORRECT: The CDC recommends Haemophilus influenzae type b immunizations during infancy and not generally beyond 18 months of age. E. INCORRECT: The CDC recommends polio immunizations during childhood, but not generally beyond 18 years. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 12 5. A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A. Complete a fall-risk assessment. B. Educate the client and family on fall risks. C. Complete a physical assessment. D. Survey the client's belongings.

5. A. CORRECT: The greatest risk to this client is injury due to a fall. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures. B. INCORRECT: It is important for family members to be aware of the client's risk for falls. Providing instruction to the client and family is an appropriate nursing action, but this is not the priority action. C. INCORRECT: Completing a physical assessment will help to identify further risk for injury and provide baseline physical data, but this is not the priority action. D. INCORRECT: Surveying the client's belongings (glasses, medications, hearing aids, canes, walkers) may provide clues to potential fall risks. However, this is not the priority action. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

Module 1 ATI Fundamentals 16 5. A nurse in a clinic is caring for a client who has multiple risk factors for cardiovascular disease. When planning health promotion and disease prevention strategies for this client, which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of her actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

5. A. Correct: The nurse should help the client recognize the benefits of her health-promoting actions while also overcoming barriers to taking implementing actions. B. Correct: Once the nurse has collected information about who can help the client change her unhealthful behaviors, she can suggest ways the client's supportive friends and family can get involved. C. Correct: The nurse should promote the client's use of any available community or online resources that can help her progress toward meeting her goals. D. Incorrect: The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable. E. Correct: Stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 25 5. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

5. A. INCORRECT: Aging brings decreases in skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, thin, transparent skin. B. CORRECT: With aging, height decreases due to the thinning of intervertebral disks. C. INCORRECT: Saliva production diminishes with age, making xerostomia (dry mouth) a common problem. D. CORRECT: Aging brings thickening of the nails of the fingers and toes, and also changes their shape, color, and growth rate. E. CORRECT: While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 15 5. A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will use overhead paging to alert the entire facility." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."

5. A. INCORRECT: In the event of a bomb threat, the nurse should keep the caller on the line in order to trace the call and to collect as much information as possible. B. INCORRECT: The nurse should avoid announcing that a bomb threat has occurred using the paging system because it could cause mass panic. C. INCORRECT: It is recommended to ask to caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible. D. CORRECT: In order to identify the location of the caller, the nurse should listen for background noises such as church bells, train whistles, or other distinguishing noises. NCLEX® Connection: Safety and Infection Control, Handing Hazardous and Infectious Materials

Module 1 ATI Fundamentals 24 5. A nurse is counseling a middle adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my son expects me to relive my parenting days."

5. A. INCORRECT: It is common for middle adults to face the challenge involved in adjusting to and caring for aging parents. This problem is not the priority for assessment and intervention. B. CORRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of young adulthood to develop intimacy vs. isolation. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others. C. INCORRECT: It is common for middle adults to face the challenge involved in contributing to their community. This problem is not the priority for assessment and intervention. D. INCORRECT: It is common for middle adults to face the challenge involved in questioning their ability to contribute to future generations in a grandparenting role. This problem is not the priority for assessment and intervention. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 20 5. A nurse is talking with parents of a preschooler who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A. "Our son will only eat a few things, like burgers and bananas, and pretty much refuses everything else." B. "Our son has these temper tantrums every time we tell him to do something he doesn't want to do." C. "We think our son truly believes that his toys have personalities and talk to him, especially at night." D. "We feel bad when we see our son trying so hard to button his shirt. We just tell him this is something he'll just have to learn to do."

5. A. INCORRECT: It is common for preschoolers to continue to be picky eaters, as in the toddler stage. This usually resolves by the end of the preschool stage and is not the priority for assessment and intervention. B. CORRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of the toddler stage to develop autonomy vs. shame and doubt. This preschooler is still acting out with negativism, which is a persistent negative response to requests, often manifested in tantrums. He is still struggling with this task and needs assistance in working through that stage. C. INCORRECT: It is common for preschoolers to manifest misperceptions in thinking, such as animism - the belief that inanimate objects are alive. This problem is not the priority for assessment and intervention. D. INCORRECT: It is common for preschoolers, who are in the stage Erikson describes as initiative vs. guilt, to face the challenge of mastering activities they can perform independently, such as dressing themselves. This problem is not the priority for assessment and intervention. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 13 5. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.

5. A. INCORRECT: Most food poisoning is caused by bacteria such as Escherichia coli, Listeria monocytogenes, and Salmonella. B. CORRECT: Very young, very old, and immunocompromised individuals, as well as pregnant women, are at risk for complications from food poisoning. C. CORRECT: Clients who are especially at risk are instructed to follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, or other dairy products. D. INCORRECT: Healthy individuals usually recover from the illness in a few days. E. CORRECT: Performing proper hand hygiene, ensuring that meat and fish are cooked to the correct temperature, handling raw and fresh food separately to avoid cross contamination, and refrigerating perishable items may prevent food poisoning. NCLEX® Connection: Physiological Adaptations, Pathophysiology

Module 1 ATI Fundamentals 17 5. A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluating the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select or prepare meals. C. Encourage the client to fill out an evaluation form. D. Ask the client if she has resources for further instruction on this topic.

5. A. Incorrect: The client stated that she understood the content, so she might not ask any questions that would help the nurse evaluate learning. B. Correct: A useful strategy for evaluating learning is to ask the client to explain in her own words how she will implement what she learned. C. Incorrect: An evaluation form usually gives the client a means of evaluating the teaching. It might not offer clues about what the client has learned. D. Incorrect: The nurse should identify the client's resources early in the instructional process. At this point, the exploration of resources does not help the nurse evaluate the client's learning. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 19 5. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parents' statements should indicate to the nurse that they understand the feeding guidelines for this age group? A. "I should keep feeding my son whole milk until he is 3 years old." B. "It's okay for me to give my son a cup of apple juice with each meal." C. "I'll give my son about 2 tablespoons of each food at mealtimes." D. "My son loves popcorn, and I know it is better for him than sweets."

5. A. Incorrect: When toddlers turn 2 years old, the parents should give them low-fat or fat-free milk, not whole milk. This reduces fat and cholesterol intake and helps prevent childhood obesity. B. Incorrect: Toddlers should have 4 to 6 oz of juice per day. Juices do not have the whole fiber that fruit has, plus they contain sugar, so parents should limit their use. C. Correct: Serving sizes for toddlers should be about 1 tbsp of solid food per year of age, so 2-year-olds should have about 2 tbsp per serving. D. Incorrect: Popcorn poses a choking hazard, so it is an inappropriate snack food for toddlers. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 NCLEX Ch. 7 6 A school nurse is planning a health class on accidents and injuries for high school students. Which topic is most important to include? 1. Occupational-related injuries at work 2. Motor vehicle-related injuries 3. Fall-related injuries 4. Injury due to residential fires

6 Answer: 2 Rationale: Driving a car and having the independence to ride with friends are important milestones for high school-age adolescents. Some adolescents experiment with alcohol and drugs, putting them at increased risk for motor vehicle accidents, in addition to inexperience. Occupational injury is a risk for the working adult. Falls are risk factors for the older adult. Residential fires can affect any age. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Child Health Strategy: Use knowledge of the principles of growth and development to aid in answering this question.

Module 1 ATI Fundamentals 23 6. A nurse is explaining to a group of young adults in a community center what physical and cognitive development characteristics they should expect at this stage of life. Use the Growth and Development ATI Active Learning Template to complete this item. Under Physical Development, list at least five physical development expectations. Under Cognitive Development, list at least three cognitive development expectations during young adulthood.

6. Use the Growth and Development ATI Active Learning Template ●● Physical Development ◯◯ Completion of growth ◯◯ Peak in physical senses ◯◯ Peak in cardiac output, efficiency ◯◯ Optimal muscle function ◯◯ Gradual decline in metabolic rate ◯◯ High libido (men) ◯◯ Eventual peak in libido (women) ◯◯ Optimal childbearing ◯◯ Pregnancy-related changes ●● Cognitive Development ◯◯ Improvement in critical thinking ◯◯ Peak in memory ◯◯ Increased ability for creative thought ◯◯ Relevance of values/norms of friends NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

Module 1 ATI Fundamentals 17 6. A nurse is preparing a presentation at a community center for a group of parents who are interested in learning how to prevent childhood obesity. Use the ATI Active Learning Template: Basic Concept to complete this item. Include the following Related Content: A. List at least three factors the nurse should consider when incorporating ways to enhance learning. B. List at least three barriers the nurse might encounter among the attendees.

6. Using the ATI Active Learning Template: Basic Concept A. Factors that enhance learning ●● Perceived benefit ●● Cognitive and physical ability ●● Health and cultural beliefs ●● Active participation ●● Age ●● Educational level-appropriate methods B. Barriers to learning ●● Fear ●● Anxiety ●● Depression ●● Physical discomfort ●● Pain ●● Fatigue ●● Environmental distractions ●● Health and cultural beliefs ●● Sensory and perceptual deficits ●● Psychomotor deficits NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

Module 1 ATI Fundamentals 13 6. A nurse educator is teaching a module on the basic principles of creating a home safety plan during nursing orientation to a group of newly appointed home health nurses. Use the ATI Active Learning Template: Basic Concept to complete this item. Under Nursing Interventions, list four key elements that a home safety plan should include.

6. Using the ATI Active Learning Template: Basic Concept ●● Nursing Interventions ◯◯ A home safety plan should include: -Keeping emergency numbers near the phone for prompt use in the event of an emergency of any type. -Ensuring that the number and placement of fire extinguishers and smoke alarms are adequate, that they are operable, and that family members know how to operate. ---Set a specific time to routinely change the batteries in the smoke alarms (for example, in the fall when the clocks are set back to standard time and spring when reset at Daylight Saving Time). -Having a family exit plan for fires that the family reviews and practices regularly. Be sure to include closing windows and doors if able and to exit a smoke filled area by covering the mouth and nose with a damp cloth and getting down as close to the floor as possible. -Reviewing with clients of all ages that in the event that the client's clothing or skin is on fire, the client should use the mnemonic "stop, drop, and roll" to extinguish the fire. -Reviewing oxygen safety measures. Because oxygen can cause materials to combust more easily and burn more rapidly, the client and family must be provided with information on use of the oxygen delivery equipment and the dangers of combustion. NCLEX® Connection: Safety and Infection Control, Home Safety