ATI EXAM 2 PRACTICE QUESTIONS

a nurse is assessing a client who has impaired mobility. the nurse should monitor the client for a pressure injury due to which of the following factors? a. decreased circulation b. increased collagen c. decreased serum calcium d. increased muscle mass

decreased circulation

a nurse is assessing a client who has an oral temperature of 39°C (102.2°F). which of the following findings should the nurse expect? a. dilated pupils b. heart rate 108/min c. respiratory rate 10/min d. decreased peripheral pulses

heart rate 108/min

a nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. which of the following findings should the nurse expect? a. hypertension b. hypoglycemia c. decreased respiratory rate d. bradycardia

hypertension

a nurse is assisting an older adult client who sometimes loses her balance while walking. which of the following devices should the nurse use when helping the client ambulate? a. gait belt b. jacket harness c. four-wheel walker d. cane

gait belt

a nurse is changing the bed linen for a client who is on contact precautions. which of the following personal protective equipment should the nurse wear? a. N-95 respirator b. gloves c. goggles d. face shield

gloves

A nurse is caring for a client who required cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? a. apply the bag for 30 min at a time b. reapply the bag 30 min after removing it c. allow room for some air inside the bag d. place the bag directly on the skin

apply the bag for 30 min at a time

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angels should the nurse use for injection into the client's ventrogluteal muscle? a. 45° b. 60° c. 75° d. 90°

90°

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (select all that apply) a. bathe the client who had an amputation 2 days ago b. assist a client to ambulate using a gait belt c. review a low-sodium diet for a client who has hypertension d. explain oral hygiene to a client receiving chemotherapy e. feed a client who had a stroke 3 months ago

bathe the client who had an amputation 2 days ago; assist a client to ambulate using a gait belt; feed a client who had a stroke 3 months ago

A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first? a. document that the medication was administered b. determine the client's response to medication c. mix the medication at the client's bedside d. check the client for allergies

check the client for allergies

A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take? a. hold the tip of the syringe at least 1.3cm (0.5in) above the wound while irrigating b. flush the wound from the most contaminated area to the cleanest area c. irrigate the wound until the solution that is draining is clear d. chill the irrigant prior to the procedure

irrigate the wound until the solution that is draining is clear

a nurse is caring for a client who is a risk for a pressure injury. which of the following actions should the nurse take? a. reposition the client every 4hr b. massage the client's bony prominences c. elevate the head of the client's bed 45° d. provide the client with a high-calorie diet

provide the client with a high-calorie diet

a nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. which of the following actions should the nurse take? a. shake bed linens before placing them in a linen bag b. remove the protective gown before leaving the client's room c. remove protective gown before removing gloves d. use an electronic thermometer to take the client's temperature

remove the protective gown before leaving the client's room

a nurse is assessing a client who has a heart rate of 56/min. which of the following findings should the nurse expect? a. history of cigarette smoking b. temperature of 39°C (102°F) c. hypoglycemia d. report of dizziness

report of dizziness

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics? a. they twist their spine when lifting b. they keep their feet together c. they stand close to the object being moved d. they bend at the hip when lifting

they stand close to the object being moved

an infection control nurse is teaching a class about transmission of infectious agents. the nurse should include that which of the following diseases is transmitted via airborne transmission? a. varicella b. clostridium difficile c. rubeola d. staphylococcus aureus e. tuberculosis

varicella; rubeola; tuberculosis

a nurse is assessing a client who has an infection. which of the following findings is a manifestation of sepsis? a. vomiting b. hypoglycemia c. hypertension d. altered mental status e. elevated WBC count

vomiting; altered mental status; elevated WBC count

a nurse is caring for a group of clients. which of following clients should the nurse identify is at highest risk for developing a pressure injury? a. a client who makes frequent slight changes in position and walks occasionally b. a client who is unresponsive to verbal commands and changes position occasionally c. a client who is alert and responsive and eats 25% of each meal d. a client who is receiving enteral feeding and can change position independently

a client who is unresponsive to verbal commands and changes position occasionally

a nurse is working on an orthopedic unit is caring for four clients. which of the following clients should the nurse identify as being at greatest risk for skin breakdown? a. an adolescent who has a cervical fracture and is in a halo brace b. a young adult who has a femur fracture and is in skeletal balanced suspension traction c. a middle adult who has a fractured radius and an arm cast d. an older adult who has a hip fracture and is in Buck's traction

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

a nurse is assessing a client who is a professional athlete. which of the following findings should the nurse expect? a. hypertension b. decreased oxygen saturation c. bradycardia d. hypothermia

bradycardia

a nurse is assessing a client who is experiencing complications due to immobility. which of following findings should the nurse expect? (select all that apply) a. contractures of the extremities b. polyuria c. diarrhea d. crackles in the lungs e. pressure ulcers

contractures of the extremities; crackles in the lung; pressure ulcers

a nurse is planning care for a client who has urinary incontinence. the nurse should plan to monitor the client for which of the following findings? a. hypoglycemia b. fluid volume overload c. dermatitis d. kidney stones

dermatitis

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? a. joint flexibility b. muscle strength c. bone density d. muscle mass

joint flexibility

a nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. the catheter site is cool and taut, and there is IV fluid leaking. the nurse should identify that the client has manifestations of which of the following complications? a. infiltration b. circulatory overload c. phlebitis d. infection

infiltration

a nurse is assessing a client who has a stage 1 pressure injury. which of the following findings should the nurse expect? a. full thickness skin loss with visible adipose tissue b. intact skin with localized erythema c. partial-thickness skin loss with red tissue in wound bed d. full thickness skin loss with visible bone

intact skin with localized erythema

a nurse is caring for a client who is immunocompromised following an allogenic hematopoietic stem cell transplant. the nurse should place the client on which of the following precautions? a. protective b. contact c. droplet d. airborne

protective

a nurse is teaching a class about reducing the risk of medication errors. which of the following information should the nurse include? a. provide the nurse administering the medications with an identifying vest b. wait to document medications given to clients until the end of a shift c. prepare medications for multiple clients at the same time d. remove medications from automatic dispensing symptoms before they are reviewed by pharmacists

provide the nurse administering the medications with an identifying vest

a nurse is assessing a client who received an opioid narcotic for incisional pain. which of the following findings is the priority? a. level of sedation b. pulse oximetry c. pain level d. blood pressure

pulse oximetry

a nurse is preparing to reposition a client. which of the following actions should the nurse take first? a. tighten their abdominal muscles b. pivot their feet in the direction of the move c. place their feet in line with their shoulders d. raise the height of the client's bed

raise the height of the client's bed

Which of the following findings require a follow-up? a. wound bed is red b. redness noted at wound border, skin surrounding wound is warm to touch, purulent drainage noted c. temp 38.9°C (102°F) d. Hct 37% (37%-47%) e. WBC 13,500/mm3 (5000-10,000mm3)

redness noted at wound border, skin surrounding wound is warm to touch, purulent drainage noted; temp 38.9°C (102°F); WBC 13,500/mm3 (5,000-10,000mm3)

A nurse is preparing to perform hand hygiene with soap and water. Which of the following actions should the nurse plan to take? a. wash hands for 10 seconds b. dry hands with a reusable towel c. use hot water to wash hands d. use a towel to turn off the water

use a towel to turn off the water

a nurse is teaching a newly licensed nurse about measuring body temperature in clients. the nurse should instruct to obtain an oral temperature in which of the following clients? a. a client who has hemorrhoids b. a client who had recent oral surgery c. a client who breaths through the mouth d. a client who is drinking ice water e. a client who has a coagulation disorder

a client who has hemorrhoids; a client who has a coagulation disorder

A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first? a. check the blood pressure with the client in a supine position b. determine the client's blood pressure 1 min after each position change c. place the client in a sitting position d. assist the client into a standing position

check the blood pressure with the client in a supine position

a nurse is preparing to change the linens on a client's bed. which of the following actions should the nurse take? a. shake soiled linens before placing them in a bag b. hold soiled linen away from the nurse's clothing c. place soiled linens on the floor while changing the client's bed d. place the client's bed height in the lowest position

hold soiled linen away from the nurse's clothing

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement? a. encourage the client to drink cold fluids b. request a prescription for mineral oil for the client c. increase the client's fluid intake rate d. place the client on a low-fiber diet

increase the client's fluid intake rate

a nurse is observing a newly licensed nurse set up a sterile field. which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. inspect the sterile package for holes before opening b. prepares the sterile field 2hr before it is needed c. opens the first flap of the sterile package towards the nurse's body d. places the sterile field against a wall in the client's room

inspect the sterile package for holes before opening

A nurse is caring for a client who has a Penrose drain. Which of the following action should the nurse take? a. empty the drainage device when it is half full b. place a perforated gauze pad around the drain c. connect the drain to a continuous low-pressure suction d. clean the skin near the drain in a circular motion from the outside to the inside

place a perforated gauze pad around the drain

a nurse is assessing a client who has opioid toxicity. which of the following findings should the nurse expect? a. blood pressure 168/90mm Hg b. respiratory rate 10/min c. temperature 38.2°C (100.8°F) d. heart rate 112/min

respiratory rate 10/min

a nurse is caring for a client who has postural hypotension. the nurse assists the client gradually from a lying down to standing position. the nurse should identify that which of the following findings indicates the intervention is effective? a. the client's heart increases from 100/min to 108/min b. the client reports nausea c. the client's systolic blood pressure decreases from 110mm Hg to 105mm Hg d. the client reports dizziness

the client's systolic blood pressure decreases from 110mm Hg to 105mm Hg

a nurse is preparing to move a client who is only partially able to assist up in bed. which of the following methods should the nurse plan to use? a. one nurse lifting as the client pushes with his feet b. two nurses lifting the client under the shoulders c. one nurse lifting the client's legs as the client uses a trapeze bar d. two nurses using a friction-reducing device

two nurses using a friction-reducing device

a nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. which of the following actions should the nurse take to maintain safety during the transfer? a. enlist help from another staff member b. adjust the bed to an appropriate height c. use a powered standing-assist lift d. avoid movements that twist the spine

use a powered standing-assist lift

a nurse is planning to perform perineal care for a female client. which of the following actions should the nurse plan to take? a. use the same section of washcloth for each area cleaned b. allow the client's perineum to air dry c. start at the client's rectum and clean to the client's perineum d. use soap and water to clean the client's perineum

use soap and water to clean the client's perineum

a nurse is assessing a client who is nonverbal for acute pain. which of the following findings is a manifestation of pain? a. elevated blood pressure b. constricted pupils c. reduced respiratory rate d. decreased heart rate

elevated blood pressure

a nurse is assessing a client who has pneumonia. which of the following findings should the nurse expect? a. tachypnea b. bradycardia c. pulse deficit d. hypothermia

tachypnea

a nurse administers the wrong medication to a client. which of the following actions should the nurse take first? a. check the client's vital signs b. document the client's condition in the electronic medical record c. fill out an incident report d. notify the provider

check the client's vital signs

a nurse is caring for a client who has Clostridium difficile (C.difficile). which of the following actions should the nurse take? a. place the client in a room with a negative pressure airflow b. wash hands for 10 seconds after caring for the client c. clean hands with soap and water after caring for the client d. apply a mask on the client when they are outside their room

clean hands with soap and water after caring for the client

a nurse is planning care for a client who has dehydration and hypotension. which of the following actions should the nurse plan to take? a. increase the client's fluid intake b. instruct the client to perform the Valsalva maneuver c. elevate the head of the client's bed d. encourage the client to use guided imagery to relax

increase the client's fluid intake

a nurse is assessing a client who has a stage 2 pressure injury. which of the following findings should the nurse expect? a. partial-thickness skin loss with red tissue in wound bed b. intact skin with localized erythema c. full thickness skin loss with visible one d. full thickness skin loss with visible adipose tissue

partial-thickness skin loss with red tissue in wound bed

A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain? a. the client rates their pain as an 8 on a scale of 0 to 10 b. the client states the pain is located on their abdomen c. the client reports a burning sensation d. the client grimaces when they move

the client grimaces when they move

a nurse is assessing a client for manifestations of pain. which of the following findings is a subjective indicator of pain? a. the client is grimacing b. the client's pupils are dilated c. the client is restless d. the client reports a burning sensation

the client reports a burning sensation

a nurse is caring for a client who is incontinent. which of the following actions should the nurse take? a. apply baby powder to the client's skin b. restrict the client's fluid intake c. dry between the folds in the client's skin d. clean the client's skin with hot water

dry between the folds in the client's skin

a nurse is observing a newly licensed nurse perform hand hygiene. which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. turn off the faucet with their hands b. holds their hands below the elbows while rinsing off soap c. uses hot water to wash their hands d. washes their hands for 10 seconds

holds their hands below the elbows while rinsing off soap

a nurse is teaching a newly licensed nurse about wearing medical masks. which of the following statements should the nurse include? a. "touch the front of your mask while wearing it" b. "remove your mask prior to removing your gloves" c. "position the mask on your face with the flexible metal piece at the bottom" d. "discard your mask after each use"

"discard your mask after each use"

a nurse is teaching a newly licensed nurse about pain. which of the following is an example of nociceptive pain? a. diabetic neuropathy b. strained muscle c. post-herpetic neuralgia d. phantom limb pain

strained muscle

a nurse is preparing to reposition a client towards the head of the bed. in which of the following positions should the nurse place the client before repositioning them to the head of the bed? a. high-fowler b. supine c. lateral d. prone

supine

The client is at risk for developing which due to immobility? a. diarrhea b. pressure injury c. footdrop d. anemia e. elevated platelet count

pressure injury; footdrop

a nurse is teaching a class about routes of medication administration. the nurse should include that which of the following routes has the fastest rate of absorption? a. intramuscular b. enteral c. intravenous d. topical

intravenous

A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection? a. WBC count 22,000/mm3 b. Creatine kinase 7 units/L c. Hgb 15g/dL d. Platelet count 200,000/mm3

WBC count 22,000/mm3

a nurse is assessing a client who was brought to the emergency department with an ankle injury. which of the following manifestations should the nurse identify as localized inflammation of the tissues? a. localized warmth at the site of the injury b. 3+ palpable pedal pulses below the affected injury site c. sanguineous drainage at the site of injury d. full range of motion at the site of injury

localized warmth at the site of the injury

a nurse is performing a pressure injury risk assessment for a client. which of the following findings increase the client's risk of a pressure injury? a. BMI of 20 b. peripheral neuropathy c. immobility d. hypoperfusion e. prealbumin level of 16mg/dL

peripheral neuropathy; immobility; hypoperfusion

a nurse is caring for a client with c.diff which of the following actions should the nurse take? a. wear a protective gown while caring for the client b. place the client in a private room c. wear an N-95 respirator while caring for the client d. place the client in a negative pressure room e. place a mask on the client when they leave their room

wear a protective gown while caring for the client; place the client in a private room

a nurse in a pediatric unit is planning care for a group of clients. which of the following clients should the nurse plan to sue the crying, requires oxygen, increased vital signs, expression, sleeplessness (CRIES) pain scale? a. a 4-day-old infant who had a repair of a birth defect b. a 3-year-old toddler who has a broken elbow c. a 4-year-old preschooler who had a tonsillectomy d. a 10-year-old client who had an appendectomy

a 4-day-old infant who had a repair of a birth defect