ATI

nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology? (a) Unilateral ptosis (b) Diminished hand-to-mouth coordination (c) Impaired voluntary cough (d) Altered level of consciousness

(c) Impaired voluntary cough

A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing. a. Erythema on the skin surrounding a client's wound b. Deep red color on the center of the clients wound c. Inflammation noted on the tissue edges of a client's woundd. Increase in serosanguineous exudate from the clients wound d. Deep red color on the center of the clients wound

d. Deep red color on the center of the clients wound

A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? [repeat] a. Discuss the time management strategies with the nurses b. Review facility policies for taking scheduled breaks c. Provide coverage for the nurses' breaks d. Determine the reasons the nurses are taking scheduled breaks

d. Determine the reasons the nurses are taking scheduled breaks

A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is the appropriate procedure for taking care of the clients' ring? (a) Agree to keep the ring for the client until after the surgery (b) Place the clients ring in the facility safe (c) Tape the ring securely to the client's finger (d) Place the ring in the bag with the clients' clothes

(b) Place the clients ring in the facility safe

A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experience to safely care for his assigned clients. Which of the following actions should the nurse take? (a) Document the concern in the nurse's notes. (b) Accept the assignment with help from assistive personnel on the unit. (c) Request that the charge nurse modify the assignment. (D) Notify the risk manager.

(c) Request that the charge nurse modify the assignment.

charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit? (a) A client who has gestational diabetes and is receiving biweekly nonstress tests (b) A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor (c) A client who is at 32 weeks of gestation and has premature rupture of membranes (d) A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump

(d) A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump

A nurse is preparing a teaching session with a client who speaks a different language than the nurse. Which of the following interventions should the nurse plan to include? (a) Involve the client9s partner to assist with the teaching session (b) Incorporate gestures and hand signals when presenting information (c) Validate understanding by interpreting the client9s body language (d) Provide and interpreter when obtaining consent for the client

(d) Provide and interpreter when obtaining consent for the client

A nurse tells the unit manager, "I am tired of all the changes on the unit. If things don‟tgetbetter, I‟m going to quit. "Which of the following responses appropriate? A. "So you are upset about all the changes on the Unit" B. "I think you have a right to be upset, I am tired of the changes too" C. "Just stick with it a little longer. Things will get better soon D. " You should file complaints with hospital administrator

A. "So you are upset about all the changes on the Unit"

A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? A. Prepare to administer antibiotics to the client. B. Wear an N95 respirator mask while caring for the client. C. Plan to administer an antiviral medication to the client. D. Place a surgical mask on the client during transfer to the unit.

A. Prepare to administer antibiotics to the client.

Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? A. Use clean gloves rather than sterile gloves for colostomy care. B. Wait to dispose of sharps containers until they are completely full. C. Return unused supplies from the bedside to the unit‟s supply stock. D. Store opened bottles of normal saline in a refrigerator for up to 48 hr.

A. Use clean gloves rather than sterile gloves for colostomy care.

A nurse on a MedSurg unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? A. A client who is scheduled for a tubal ligation in two hours and is crying B. A client who has PVD and absent pulse in right foot C. A client who has T1DMN needs first dressing change for ulcer D. A client who has MR essay and axillary temp of 38°C

B. A client who has PVD and absent pulse in right foot

A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority? A. A client who has active bleeding from a puncture wound of the left groin area B. A client who reports shortness of breath and left neck and shoulder pain C. A client who has a raised red skin rash on his arms, neck and face D. A client who reports right-sided flank pain and is diaphoretic

B. A client who reports shortness of breath and left neck and shoulder pain

A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body? Green Yellow Black Red

Black

A nurse witnesses a coworker not following facility procedure with discarding the unused portion of control substances, which of the following actions should the nurse take? (select all that apply) a. File an anonymous report of the incident to the nurse manager b. identify all witnesses to the incident c. request that the co-worker complete an incident report d. document a factual account of the incident e. submit an incident report to the risk management

E, D, B

A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? a. Discuss with the client her concerns regarding the procedure b. Provide the client with information on treatment options and outcomes c. Inform the client of the consequences of uterine prolapse and the need for intervention d. Initiate a mental health consult to determine the client's reasons for refusing surgery

a. Discuss with the client her concerns regarding the procedure

A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? a. Social worker b. Pharmacist c. Respiratory therapist d. Child protective services

a. Social worker

A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery. c. Ask the anesthesiologist to sign the consent. d. Transport the client to the operating room without verifying informed consent

d. Transport the client to the operating room without verifying informed consent

A nurse is working on a medical surgical unit and is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients? (A) A client who has type 1 diabetes an uses an insulin pump (B) A client who is receiving heparin and has an aPTT of 34 seconds (C) A client who has orthostatic hypotension and is receiving IV fluids (D) A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/d

(D) A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/d

A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report? (a) The client's vital signs (b) The client's code status (c) A prescribed consultation (d) The client's name

(a) The client's vital signs

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? (a) The time the client received his last dose of pain medication (b) The belief that the client has a difficult relationship with his son (c) The steps to follow when providing wound care (d) The clients preferred time for bathing

(a) The time the client received his last dose of pain medication

A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practicing nurse and assistive personnel. Which of the following tasks should the nurse assign to the LPN? (a) Accompanying a client who just had a wound debridement to physical therapy (b) Obtaining a urine specimen from an older adult client (c) Providing postmortem care for a client that just died (d) Reinforcing dietary teaching with a client who has heart disease

(d) Reinforcing dietary teaching with a client who has heart disease

A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first? (a) A client is refusing care from assistive personnel of the opposite gender (b) No transport assistance is available to take a client to physical therapy (c) Two nurses had a heated disagreement about a scheduling issue (d) Three staff members have called to say they will be absent

(d) Three staff members have called to say they will be absent

A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique? a. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape b. Uses sterile forceps to pack sterile gauze into the wound c. Sets up the sterile field 30 min prior to performing the dressing change d. Uses a sterile-gloved hand to adjust the back of the sterile gown

b. Uses sterile forceps to pack sterile gauze into the wound

nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? A. Guardian consent is required for an emancipated minor B. Consent can be given by a durable power of attorney. C. A family member can answer any questions the client has about the procedure. D. The nurse can answer any questions the client has about the procedure

B. Consent can be given by a durable power of attorney.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? A) Bradycardia b) Blurry vision c) Decreased level of consciousness d) chills

c) Decreased level of consciousness

A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home: (Select all that apply.) a) Petroleum jelly b) Cotton balls c) Pipe Cleaners d) Obturator e) Oxygen tank

c, d,e

A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? a. Establish work initiatives to promote a positive environment b. Use root cause analysis to identify gaps in meeting standards c. Compare practices within the facility against other high-performing facilities d. Determine how current practice will affect future performance within the facility

c. Compare practices within the facility against other high-performing facilities

A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of thefollowing providers? a. Physical therapist b. Respiratory therapist c. Speech therapist d. Occupational therapist

c. Speech therapist

A nurse is participating on a committee that is considering the creation of a policy that will allow thenurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult inplanning for this policy? (2016 practice) a. ANA Standards of Practice b. ANA Code of Ethics c. State Nurse Practice Act d. Institute of medicine

c. State Nurse Practice Act

A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate? a) If you have the procedure now, you wont have to deal with pain and disability later. b) You'll be fine. You'll receive a prescription for pain medication. c) Why didn't you discuss your concerns with your provider? d) I understand and it's not too late to change your mind.

d) I understand and it's not too late to change your mind.

A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client9s feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make? (a) You should contact the provider about your wishes for your family member (b) You should speak with the facility9s ethics committee about your concerns (c) Well need to have the nursing supervisor review the client9s advance directives (d)As the health care surrogate, the client9s partner can make this decision

d)As the health care surrogate, the client9s partner can make this decision

A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? (a) A client who is postoperative following a laminectomy 12 hour and is unable to void (b) A client who is scheduled for a tubal ligation in 2 hours and is crying (c) A client who has peripheral vascular disease and has an absent pulse in the right foot (d) A client who has type 1 diabetes and needs the first dressing change for an ulcer (e) A client who has MRSA and has an axillary temperature of 100.4F

(a) A client who is postoperative following a laminectomy 12 hour and is unable to void

A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite.Which of the following nursing statements is an appropriate nursing response? a. "It's not too late to cancel the surgery if you want to" b. "Why did you make the decision to have this procedure?" c. "This won't take long and it will be over before you know it" d. "You shouldn't be worried because the procedure is very safe"

a. "It's not too late to cancel the surgery if you want to"

A charge nurse overhears a staff nurse discussing a client's diagnosis in the cafeteria. Which of the following responses should the charge nurse make? a. "Please stop discussing the client in a public area" b. "Do you understand the HIPAA regulations?" c. "We should discuss your concerns with the client's care team" d. "I will notify the client's provider about this breach of confidentiality

a. "Please stop discussing the client in a public area"

A hospice nurse is caring for a client who has terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? (a) Continue the medication dosages that relieve the clients pain (b) Contact the provider about replacing the opioid with an NSAID (c) Administer the benzodiazepine but withhold the opioid (d) Withhold the benzodiazepine but continue the opioid

(a) Continue the medication dosages that relieve the clients pain

A charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps for medication administration. Which of the following is priority action by the charge nurse? a. Assess the staff nurse's knowledge deficit. b. Pair an inexperienced nurse with an experienced nurse. c. Demonstrate use of the pump during medication administration. d. Plan an in-service education program on the unit

a. Assess the staff nurse's knowledge deficit.

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed indicates understanding of isolation guidelines? A. I will instruct visitors to wear a mask when visiting a client who is on contact precaution B. I will place a client who has compromised immunity in a negative-pressure airflow room C. I will wear N-95 respirator mask when caring for a client who is on droplet precaution D. I will have a client who is on airborne precautions wear a mask when out of her

D. I will have a client who is on airborne precautions wear a mask when out of her