ATI Testing and Remediation Beginning Test

12) A nurse in caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The clients states, I will quit smoking if the results don't come back positive for cancer. Anger Acceptance Bargaining Denial

Bargaining. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.

Palpation

Palpation should be the fourth technique used during examination of the abdomen to identify abdominal tenderness, masses, or distention. Both light and deep palpation techniques should be performed to identify unexpected masses or organ size outside the expected parameters.

8) A nurse on a pediatric unit is caring for an infant who is diagnosed with larynotrachebronchitis. While performing a respiratory examination the nurse hears which sound?

STRIDOR Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchiti

5) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? Lithotomy Dorsal recumbent Prone Sims'

Sims left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution.

Lithotomy position

facilitates insertion of a vaginal speculum to examine the female genitalia and genital tract. The client should not be placed in this position to administer an enema.

5 percussion sounds

five percussion sounds: flatness, dullness, resonance, hyper-resonance, and tympany

17) A nurse is caring for a client who is receiving vancomycin for a beta hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? Respiratory depression Hearing loss Hypertension Bradycardia

hearing loss THIS drug might cause hearing loss. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss.

Ginkgo biloba

is sometimes taken to increase cognitive functions in older adults and to delay the progression of Alzheimer's disease

Percussion

is the third technique used while conducting an abdominal assessment on a client to discern the presence of tympany and dullness. It is performed to evaluate for the presence of gas in the intestines or fluid and masses in the abdominal cavity.

15) A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?

lying on side This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.

7) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?

partial thickness skin loss Characteristics for a stage II ulcer include partial thickness skin loss. The nurse would know this because she is familiar with the stages of pressure ulcers.

Prone position

places the client on the abdomen and is only used to determine extension of the hip joint, and examining skin and the buttocks.

14) A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the vetrogluteal muscle?

1 ½ A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.

2)A nurse in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose?

2 tsp

Auscultation

Auscultation should be the second technique used while conducting an abdominal assessment on a client to determine the frequency and intensity of bowel sounds. Normal bowel sounds occur 5 to 35 times per min. Auscultation also detects vascular sounds or bruits.

19) A nurse is reinforcing a teaching to a client who has fractured ankle and is learning to walk up the stairs. Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait.

Bear weight on unaffected leg, transfer weight to crutches, advance unaffected leg, shift weight from crutches to unaffected leg, and go up stairs. go up stairs is to stand and bear weight on the unaffected leg. The second action the client should be taught when using a 3-point crutch gait to go up stairs is to transfer body weight to the crutches. The third action the client should be taught when using a 3-point crutch gait to go up stairs is to advance the unaffected leg between the crutches. The fourth action the client should be taught when using a 3-point crutch gait to go up stairs is to shift weight from the crutches to the unaffected leg. The fifth action the client should be taught when using a 3-point crutch gait to go up stairs is to align crutches on the stair.

9) A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion? Dullness Hyper-resonance Resonance Tympany

Dullness The nurse would know that a client with pneumonia likely would have a dullness sound in his lungs. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation Percussion over emphysematous lungs produces a booming sound, which is described as hyper-resonance. This is not the sound that will be elicited during percussion over areas of consolidation. Percussion over healthy lung tissue produces a hollow sound, which is described as resonance. This is not the sound that will be elicited during percussion over areas of consolidation. Percussion over healthy lung tissue produces a hollow sound, which is described as resonance. This is not the sound that will be elicited during percussion over areas of consolidation.

3) A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the clients diet? a. cooked oatmeal b. grape juice c. applesauce d. ice cream e. smooth peanut butter

Grape Juice, Ice Cream Cooked oatmeal is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Cooked oatmeal is appropriate for a soft diet, but should not be included in a full liquid diet.Grape juice is correct. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Grape juice is appropriate to include in both a clear liquid and a full liquid diet.Applesauce is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Applesauce is appropriate for a soft diet, but should not be included in a full liquid diet.Ice cream is correct. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Ice cream is appropriate to include in a full liquid diet.Smooth peanut butter is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at room temperature and some foods at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Smooth peanut butter does not turn liquid at room temperature, therefore is not a part of a full liquid diet.

18) A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed a dose of lorazepam preoperatively. Which of the following statement by the client indicates the medication has been effective? "I am wide awake now." "My mouth is very dry." "I feel very relaxed." "My heart is racing."

I feel very relaxed now Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety and to promote relaxation. With this response the nurse would know that the drug has done its job effectively

20) A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? Percussion Palpation Auscultation Inspection

Inspection Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.

Inspection of abdomen

Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.

6) A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following? Mood Immunity Memory Vitality

Mood St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.

16) A nurse is preparing to transfer a client from a bed to a chair. The nurse should take which of the following actions to prevent a lift injury? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.

Stand close to the client To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back. prevent a lift injury when transferring the client from the bed to a chair, the nurse should flex the knees instead of locking them. Flexing the knees increases the stability of the nurse. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand with the feet wide apart instead of close together. Standing with the feet wide apart provides a wide base of support, which improves stability. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should keep the back, neck, pelvis, and feet in alignment instead of twisting at the waist. Maintaining proper body alignment reduces risk of injury to the lumbar vertebrae.

4)A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes.

Toward the back of the neck while facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.

10) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading? Wrapping the cuff loosely around the arm Using a cuff that is too wide Leaving client's arm unsupported Taking client's blood pressure immediately after client sits down

Using a cuff that is too wide. Using a cuff that is too wide can result in a false low blood pressure reading.

13) A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways? Vector Airborne Vehicle Bloodborne

Vector The nurse would know that the way Lyme disease is typically transmitted is through a tick, therefore it would fall in the vector category. Airborne illnesses are transmitted through residue or evaporated particles that are suspended in the air. Examples of airborne illnesses include varicella zoster, measles, and mycobacterium tuberculosis. Lyme disease is not transmitted in this manner. Vehicles include inanimate objects, such as contaminated items, water, and food. Illnesses that can be transmitted by a vehicle include MRSA, pseudomonas, salmonella, E. coli, and syphilis. Lyme disease is not transmitted in this manner. Bloodborne illnesses are transmitted through contact with infected blood. Examples of bloodborne illnesses include HIV, hepatitis B, and hepatitis C. Lyme disease is not transmitted in this manner.

Dorsal recumbent position

places the client prone with knees flexed. This position allows for relaxation of the abdominal muscles and facilitates assessment of the abdomen. The client should not be placed in this position to administer an enema.

11) A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take?

restrict fluid intake Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.

Ginseng,

taken to improve overall energy and vitality, particularly during times of fatigue or stress.

Echinacea

taken to reduce the manifestations and duration of colds and flu-like illnesses. improve immunity

1) A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?

¾ cup of canned tomato juice The nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it.