ATI Proctored Exam 2023
A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the inter professional team to evaluate the client for dysphasia? A) A speech-language pathologist B) Social worker C) Physical therapist D) Occupational therapist
A) A speech-language pathologist
During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager, identify as an acceptable place for discussing clients information? A) Areas with no public access B) Outside the door of a clients room C) In the cafeteria during break D) In the hallway near the nurses station
A) Areas with no public access
A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the follow interventions should the nurse include? A) Avoid IM injections B) Assess the client for ecchymosis once per shift C) Do not allow the client to have visitors D) Encourage daily flossing between teeth
A) Avoid IM injection
A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?" A) Clients level of comfort and ability to participate in the interview B) Previous illnesses and surgeries C) Events surrounding the clients recent illness D) Sociocultural history
A) Clients level of comfort and ability to participate in the interview
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? A) Consult the medication reference book available on the unit B) Ask a more experienced nurse for information about the medication C) Call the clients provider and verify the prescription D) Ask the client if she takes this medication at home
A) Consult the medication reference book available on the unit
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status? A) Daily weight B) Blood pressure C) specific gravity D) Intake and output
A) Daily weight
A nurse is reviewing the laboratory values of a client who has a positive Chvosteks sign. Which of the following laboratory findings should the nurse expect? A) Decreased calcium B) Decreased potassium C) Increased potassium D) Increased calcium
A) Decreased calcium
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A) Encourage the client to listen to soft music B) Instruct the client to practice tai chi C) Place a jasmine scented air freshener in the clients room D) Offer the client ginger tea
A) Encourage the client to listen to soft music
A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A) Establish client outcomes B) Collect information about past health problems C) Determine whether the client has met specific goals D) Identify the clients specific health problem
A) Establish client outcomes
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A) Evaluate pedal pulses B) Obtain a medical history C) Measure vital signs D) Assess for leg pain
A) Evaluate pedal pulses
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A) Increased blood pressure B) Decreased blood glucose C) Acute Decreased oxygen use D) Increased gastrointestinal motility
A) Increased blood pressure
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A) inspection B) Auscultation C) Percussion D)Palpation
A) Inspection
A nurse is a rehabilitation facility is observing an assistive personal (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task A) Locking the brakes on the bed and the wheelchair before moving the client B) Lowering the footplates of the wheelchair before the transfer C) Placing the wheelchair perpendicular to the bed D) Placing the wheelchair on the clients weaker side prior to the transfer
A) Locking the brakes on the bed and the wheelchair before moving the client
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A) Renew the prescription for the use of restraints within 24 hours B) Secure the restraints with the buckle side next to the clients skin C) Ensure 4 fingers can be inserted under the secured restraint D) Remove the restraint every 3 hours
A) Renew the prescription for the use of restraints within 24 hours
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A) Sit at the bedside while feeding the client B) Order puréed foods C) Make sure feedings are provided at room temperature D) Offer the client a drink after every bite
A) Sit at the bedside while feeding the client
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A) Test for the presence of the clients gag reflex B) Place the client in the supine position C) Use a firm toothbrush for tooth and gum care D) Use 2 gauze-wrapped fingers to hold the mouth open
A) Test for the presence of the clients gag reflex
A nurse is preparing to administer a unit of packed RBC to a client. Which of the following pieces of information must the nurse verify with another nurse prior to administration? (SATA) A) The clients ID number B) The clients room number C) The clients name D) ABO compatibility E) Rh compatibility
A) The clients ID number B) The clients name D) ABO compatibility E) Rh compatibility
A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Eriksons developmental task for her age group? A) "I am comfortable with my decision to choose a lifelong partner." B) "I think I have done a good job with my children since they are all independent now." C) "As I look back over my life, I can see that I have achieved most of the goals I set for myself." D) I love my work so much that it's difficult to think about retirement."
B) "I think I have done a good job with my children since they are all independent now."
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make? A) "It provides a distraction from the pain" B) "It modulates the transmission of the pain impulse" C) "It promotes increased circulation to the painful area" D) "It elicits a relaxation response"
B) "It modulates the transmission of the pain impulse"
A nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A) 6 B) 2 C) 10 D) 8
B) 2
A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A) Antigravity B) Antagonistic C) Synergistic D) Skeletal
B) Antagonistic
A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A) Placing an unused portion of the medication in a sharps box B) Asking another nurse to observe the disposal of an unused portion of the medication C) Counting the inventory of the available narcotic after administering the medication D) Ensuring that another nurse signs the control inventory form after disposal of an unused portion of medication
B) Asking another nurse to observe the disposal of an unused portion of the medication
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates the clients death is imminent? A) Urinary retention B) Cold extremities C) Hypertension D) Tachycardia
B) Cold extremities
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment (SATA) A) Gingivitis B) Dry, brittle hair C) Edema D) Spoon-shaped nails E) Poor wound healing
B) Dry, brittle hair D) Spoon-shaped nails E) Poor wound healing
A. Ruse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A) Redness at the infusion site B) Edema at the infusion site C) Warmth at the infusion site D) Oozing of blood at the infusion site
B) Edema at the infusion site
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration A) Irrigate the tubing with 30ml of sterile water B) Elevate the head of the bed to 30 degrees or 45 degrees C) Suggest changing the feeding to lactose - free formula D) Warm the enteral formula to room temperature before feeding
B) Elevate the head of the bed to 30 degrees or 45 degrees
A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following places the client at risk of impaired skin integrity? A) 3+ Achilles reflex B) Faint pedal pulses C) Feet warm to the touch bilaterally D) Capillary refill of <2 seconds
B) Faint pedal pulse
A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? A) Apply an alcohol-water solution to the clients skin B) Keel the clients bed linens dry C) Apply ice packs to the groin D) Limit the clients fluid intake to 1183 mL (40 oz) of fluid per day
B) Keep the clients bed linens dry
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choose for the nurse to use to decrease skin irritation? A) Abdominal binder B) Montgomery straps C) Hypoallergenic tape D) Plastic tape
B) Montgomery straps
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA) A) Bradycardia B) Nausea C) Hypertension D) Urticaria E) Stridor
B) Nausea D) Urticaria E) Stridor
A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? A) Given the client a bronchodilator immediately after the procedure B) Position the client for drainage of secretions by gravity C) Schedule postural drainage following meals D) Instruct the client regarding the importance of fluid restrictions
B) Position the client for drainage of secretions by gravity
A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse included in the teaching? A) "Support the majority of your weight on the axillae" B) "Keep your elbows extended" C) "Bear weight on both of your legs" D) "Move both crutches forward at the same time"
C) "Bear weight on both of your legs"
A newly admitted client who has major depressive disorder states to the nurse, "I'm a failure, I can't even cope with the little things anymore." Which of the following responses should the nurse provide? A) "What happened in your life to make you feel like such a failure?" B) "It sounds as if you are feeling pretty overwhelmed right now" C) "Do you feel like you don't deserve to feel good about yourself?" D) "I know you feel like that now, but you'll feel differently when you get better"
C) "Do you feel like you don't deserve to feel good about yourself?"
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A) "My parents are retired, and they have come to help with our children B) "I am going to ask my husband to go to counseling with me" C) "I keep having nightmares about my upcoming surgery" D) "My girlfriends bought me a nice wig"
C) "I keep having night,ares about my upcoming surgery"
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care A) "Social services can contact various community resources that will be helpful." B) "I will review the care plan to make the necessary changes." C) "Let's set up a meeting time with the doctor to discuss your options for home care." D) "I will make a list of things we need to do before discharge."
C) "Let's set up a meeting time with the doctor to discuss your options for home care."
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A) "Does the medication you're taking relieve the pain?" B) "Can you point to where the pain is the worst?" C) "What do you think caused the onset of your pain?" D) "Changing positions makes your pain worse, right?"
C) "What do you think caused the onset of your pain?"
A nurse is preparing to assess the function of the clients trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A) Sugar B) Coffee C) Cotton wisps D) Snellen chart
C) Cotton wisps
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A) Increased intestinal motility B) Respiratory alkalosis C) Decreased cardiac output D) Hypocalcemia
C) Decreased cardiac output
A nurse is assisting a client who is eating at mealtime. Suddenly the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first A) Place an oxygen mask on the client B) Check the clients pulse C) Determine whether the client is able to breathe D) Wrap arms around the client from behind
C) Determine whether the client is able to breath
A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A) Supine B) Lateral C) Fowlers D) Trendelenburg
C) Fowlers
A nurse is caring for a client who has a fecal impact ion. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A) Carminative B) Hypertonic C) Oil retention D) Sodium polystyrene sulfate
C) Oil retention
A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A) Deltoid B) Ventrogluteal C) Vastus lateralis D) Dorsogluteal
C) Vastus lateralis
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A) Place the client supine B) Keep both side rails up C) Raise the level of the bed D) Inspect the clients mouth using a finger sweep
C)Raise the level of the bed
While in the hospital , a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide? A) "Everyone dies sometimes, some die sooner than others" B) "Who do you think deserves to die more than you?" C) "It does seem unfair, doesn't it" D) "Tell me more about how you feel about dying"
D) "Tell me more about how you feel about dying"
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A) "You look just fine to me." B) "Nobody expects you to look beautiful in the hospital." C) "I understand how you feel. I would feel the same way." D) Would you like to talk about how you feel?"
D) "Would you like to talk about how you feel?"
A nurse is preparing to insert an indwelling urinary catheter for s female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A) Swallow water B) Prepare for a painful sensation C) Hold her breath D) Near down gently
D) Bear down gently
A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last, and her an,les are edematous. Which of the following findings is another clinical manifestation of fluid volume excess A) Sunken eyeball B) Hypotension C) Poor skin turgor D) Bounding pulse
D) Bounding pulse
A nurse is caring for a client who is unstable and has vital sign measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A) Turn on the machine every 15 min to measure the clients blood pressure B) Record only the blood pressure reading needed for 15 min intervals C) Obtain manual and automatic readings and compare them D) Disconnect the machine and measure the blood pressure manually every 15 min
D) Disconnect the machine and measure the blood pressure manually every 15 min
A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety A) Varenicline B) Clonidine C) Buprenorphine D) Disulfiram
D) Disulfiram
A nurse is auscultating a clients lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A) Limit the clients fluid intake B) Assist the client into a supine position C) Administer oxygen at 2 L/min D) Encourage the client to cough
D) Encourage the client to cough
A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A) Liver size B) Pedal edema C) Skin texture D) Gait
D) Gait
A nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A) Tenderness when touched B) Pink, shiny tissue with a granular appearance C) Serosanguineous drainage D) Halo of erythema on the surrounding skin
D) Halo of erythema on the surrounding skin
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A) Tenderness when touched B) Pink, shiny tissue with a granular appearance C) Serosanguineous drainage D) Halo of erythema on the surrounding skin
D) Halo of erythema on the surrounding skin
A nurse is caring for a client who is 48 hours post op following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A) Blood loss B) NPO status after surgery C) Nasogastric tube suctioning D) impaired peristalsis of the intestines
D) Impaired peristalsis of the intestines
A nurse is preparing a plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invoice decides should the nurse expect the client to have? A) Chest tube B) Indwelling urinary catheter C) Nasogastric tube D) Jackson-Pratt drain
D) Jackson-Pratt drain
A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A) Eggs B) Soybeans C) Lentils D) Yogurt
D) Lentils
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include. A) Serve foods at warm or hot temperatures B) Offer the client low-density foods C) Make sure the client lies supine after meals D) Limit drinking liquids with food
D) Limit drinking liquids with food
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A) Midsternal chest pain B) Thrill C) Pitting edema in lower extremities D) Lower back discomfort
D) Lower back discomfort
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications A) Skeletal muscle relaxants B) Beta-adrenergic blockers C) Broad-spectrum anti-infective agents D) Plasma volume expanders
D) Plasma volume expanders
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the clients medical record? A) the client refuses to take medication today B) The client states, "I will not take this pill." C) The client seemed angry and hostile D) The client threw the medication on the floor
D) The client threw the medication on the floor
A nurse is preparing to administer an IM injection to a young adult client. Which of the following injection sites is the safest to this client? A) Vastus lateralis B) Dorsogluteal C) Deltoid D) Ventrogluteal
D) Ventrogluteal
A nurse is obtaining a capillary blood sample to determine a clients blood glucose level. The nurse prepares and punctures the clients finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? A) Smear the small amount of blood onto the testing strip B) Hold the finger above heart level C) Massage the clients fingertip D) Wrap the clients finger in a warm washcloth
D) Wrap the clients finger in a warm washcloth