ATI Nursing Concepts Beginning Test

A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? a. Painful swallowing b. Hoarse voice c. Difficulty breathing d. Blood-tinged sputum

c. Difficulty breathing The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgement when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding can lead to hypoxia; therefore, immediate intervention is warranted. Th difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication.

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene? a. Including in a client's nurses' note that an incident report was completed after a medication error b. Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature c. Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet d. Documenting the provider was contacted to clarify a questionable prescription

a. Including in a client's nurses' note that an incident report was completed after a medication error The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record.

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? a. Lithotomy b. Dorsal recumbent c. Prone d. Lateral recumbent

a. Lithotomy The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is the appropriate position for the nurse to place the client. The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia. The nurse should drape the client appropriately to minimize exposure and embarrassment.

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? a. Loss of color discrimination b. Nausea and vomiting c. Red-orange discoloration to body fluids d. Edema of feet and hands

a. Loss of color discrimination The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops.

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? a. Speech pathologist b. Occupational therapist c. Social worker d. Respiratory therapist

a. Speech pathologist The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making as well as achieve continuity of care and positive client outcomes. A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting to address difficulty swallowing in a client who has had a cerebrovascular accident.

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? a. States that pain is an 8 on a scale of 0 to 10 b. States that her partner should be given the information c. Expresses concern about the exercises causing pain when performed after surgery d. Expresses uncertainty about the benefits of the exercises

a. States that pain is an 8 on a scale of 0 to 10 The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education.

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate? a. "I know this must be frightening, but you are going to be fine." b. "Let's talk for a minute about your concerns." c. "You were transferred because it is in your best interest." d. "Why do you feel a family member should be with you."

b. "Let's talk for a minute about your concerns." The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "Let's talk for a minute about your concerns" is an appropriate response by the nurse. Discussing the client's concerns and providing appropriate information will lower the client's anxiety level and establish an environment of open communication.

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? a. Justice b. Autonomy c. Veracity d. Fidelity

b. Autonomy The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustrating by making the referral as requested.

A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? a. Inform the nurse manager b. Determine the client's condition c. Notify the provider d. Complete an incident report

b. Determine the client's condition The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is the first action the nurse should take when discovering a medication error. The client is the immediate concern, and determining his conditions is crucial to the delivery of safe, effective care.

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? a. Blood glucose 150 mg/dL b. Potassium 2.5 mEq/L c. Total protein 5.2 g/dL d. Urine specific gravity 1.040

b. Potassium 2.5 mEq/L The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgement when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding requires immediate intervention. A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the priority at this time.

A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? a. "I should leave the patch on for 16 to 20 hours each day." b. "I will apply a new patch in the same location each day." c. "The patch should be effective within an hour of being applied." d. "The medication is not absorbed as well when placed on the abdomen."

c. "The patch should be effective within an hour of being applied." The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is true and indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? a. Placement of computer systems in restricted areas b. Installation of firewall software on each computer c. Ability of staff to access electronic health records of clients throughout the facility d. Occurrence of an automatic log-off after a period of inactivity

c. Ability of staff to access electronic health records of clients throughout the facility The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology, In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is not appropriate and can result in a violation of client confidentiality. The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works.

A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? a. Mammogram every year to detect breast cancer b. Colonoscopy every 10 years to detect colon cancer c. Dermatologist evaluation every 3 years to detect skin cancer d. Complete eye examination every year to detect eye disorders

c. Dermatologist evaluation every 3 years to detect skin cancer The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.

A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include? a. Medications will eliminate HIV in most clients b. Adolescents are at a lower risk for developing HIV c. Initial HIV symptoms are often similar to the flu d. Using condoms ensure the prevention of HIV during sexual intercourse

c. Initial HIV symptoms are often similar to the flu The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is appropriate for the nurse to include. HIV infection consists of three stages. The client typically experiences flu-like symptoms in the first or primary infection stage. Then, during the clinical latency stage, the client is asymptomatic. The final stage is characterized by the development of AIDS, which is when the client become symptomatic and has severely compromised immune system.

A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule? a. Use a filter needle to administer the promethazine b. Expel air bubbles back into the ampule c. Set the ampule on a flat surface to withdraw the promethazine d. Break the ampule toward the body

c. Set the ampule on a flat surface to withdraw the promethazine The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is appropriate. To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angel. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle.

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client? a. Acupuncture is loosely regulated by the federal government b. Acupuncture has been discredited by scientific research c. Acupuncture is though to be effective only as a placebo d. Acupuncture has been proven to reduce pain and increase function

d. Acupuncture has been proven to reduce pain and increase function The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgements and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client. Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia.

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following? a. Celecoxib is contraindicated in clients taking valproic acid b. Celecoxib is contraindicated in older adults c. Celecoxib is contraindicated in clients with a seizure disorder d. Celecoxib is contraindicated in clients with an allergy to sulfonamide

d. Celecoxib is contraindicated in clients with an allergy to sulfonamide The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore celecoxib is contraindicated in clients who have an allergy to sulfa.

A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective? a. Self-reporting the ability to perform the procedure b. Answering appropriately when questioned orally c. Responding accurately on a written examination d. Demonstrating independent performance of the procedure

d. Demonstrating independent performance of the procedure The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is the best indicator of teaching effectiveness. Return demonstration is the best evaluation tool for psychomotor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? a. Raising her voice level when speaking to the client b. Asking the client open-ended questions c. Clarifying client statements with the family as needed d. Having the client use eye blinks to indicate yes or no

d. Having the client use eye blinks to indicate yes or no The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client allows for appropriate communication, and reduces the risk for miscommunication.

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? a. Support the client's relationship with his caregivers b. Encourage the client to express his feelings c. Determine who is responsible for the abuse d. Protect the client from further abuse

d. Protect the client from further abuse The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.