ATI exam

a nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

a nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many ml/hr?

107ml/hr

a nurse calculating a client's fluid intake over the past 8 hr. which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips

a nurse is caring for a group of clients on a med-surge unit. in which of the following situations does the nurse demonstrate the ethical principal of veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

a community health is checking blood pressure for a group ofd clients at a community health screening. which of the following clients at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

a nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take?

Cleanse the wound from the center outward.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

Evacuate the client.

a nurse is preparing to administer 0.5 mL of oral single disease liquid medication to a client. which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30°.

a nurse is caring for a client who has diarrhea due to shigella. which of the precautions should the nurse implement for this client?

Wear a gown when caring for the client.

a nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

calf swelling

a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?

"Maintain a consistent time to wake up each day."

a nurse in a clinical is caring for a middle adult client who states, "the dr says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."

a nurse has accepted a verbal prescription "for 3/10s of a mg of levothyroxine IV state" for a client who has myxedema coma. how should the nurse transcribe the dosage od this medication int he client's medical record?

0.3mg

a nurse is preparing to delegate client care tasks to an assistive personnel (AP). which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

a nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension.

a nurse is caring for a client who has an indwelling urinary catheter. which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine.

a nurse is giving a change of shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide?

Breath sounds

a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family? select all that apply.

Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia

a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long term facility. which of the followup documentation should the nurse include?

Current medications

a nurse is administering 1L of 0.9% NaCl to a client who is postoperative and has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take?

Examine personal values about the issue.

a nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. which if the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

is nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

a nurse ,imager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client.

a nurse is preparing to administer enoxaparin subcut to a client. which of the following actions should the nurse take?

Administer the medication with the needle at a 45° angle.

a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include?

Advocacy ensures clients' safety, health, and rights.

a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the client's plate.

a nurse is preparing to administer an injection of an opioid medication to a client. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage.

a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Select all that apply.

Assist the client with a partial bed bath is correct. Measure the client's BP after the nurse administers an antihypertensive medication is correct Use a communication board to ask what the client wants for lunch is correct

a nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and leaves the client's room. when the nurse asks if the client would like to discuss any concerns, the client declines. which of the following statements should the nurse make?

"I am available to talk if you should change your mind."

a nurse is caring for a client who has a terminal illness and is at the end of life. the nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time."

a nurse is assessing a client's readiness to learn about insulin self administration. which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

the nurse discussing the use of herbal supplements for health promotion with a client. which of the client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system."

nurse is caring for a client who requires a 24hr urine collection. which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

a client who is postoperative is verbalizing pain as a 2 on the pain scale of 0 to 10; which of the following statements should the nurse identify as an indication that the client understands the postoperative teaching she received about pain management?

"It might help me to listen to music while I'm lying in bed."

a nurse is talking with an older adult client who is contemplating retirement. the client states, "I keep thinking about how much I enjoy my job. im not sure I want to retire." which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you."

a middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people"

a nurse is caring for who asks about the purpose of advance directives. which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness."

a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

a nurse is admitting a client who has rubella. which of the following types of transmission based precautions should the nurse initiate?

Droplet

a nurse is caring for a client who has pharyngeal diphtheria. which of the following types of transmission precautions should the nurse initiate?

Droplet

a nurse is admitting a client who is having an exacerbation of heart failure. in planning this client's care, when should the

During the admission process

a nurse is assessing 4 adults. which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

a nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene?

Erythema on pressure points

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water.

a charge nurse is discussing the responsibility of nurses caring for clients who have C. Diff. which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together.

a nurse caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to ,ensure the client's vital signs every 15 min and to report back in 1hr. which of the following actions should the nurse take next?

Notify the nursing manager.

a nurse is caring for a client who has TB. which of the following actions should the nurse take? (select all that apply)

Place the client in a room with negative-pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

a nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions

A nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to ensure that the medication reachers the inner ear?

Press gently on the tragus of the client's ear.

a nurse is completing an admission for a client who reports committing and diarrhea for the past 3 days. which of the following findings should the nurse expect?

Rapid heart rate

a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

a nurse is reviewing evidence-based practice about administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

a nurse is reviewing protocol in prep for suctioning secretions from a. client who has a new tracheostomy. which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen.

a nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR)

a nurse is caring for a client who is receiving fluid through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration?

Skin blanching

a nurse receives report about a client who has 0.9% NaCL infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has only received 80 mL over the last 2 hours. which of the following actions should the nurse take first?

The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.

a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system.

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place.

a nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that this condition is a contraindication for which of the following therapies.

acupuncture

a nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first?

check the client for injuries

a nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

a nurse is reviewing a client's fluid and electolyte status. Which of the following findings should the nurse report to the provider?

potassium 5.4 mEq/L

a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply)

pupil clarity visual fields visual acuity

A nurse is talking with the partner of an older adult client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

role overload

a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse?

the caregiver insists on remaining in the room.

a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol?

the client uses non acetone nail polish remover

a home health nurse is performing a followup up cities for a client who has a gastronomy tube through which they receive intermittent feedings and medications. the client has recently developed diarrhea. which of the following findings should the nurse identify as a possible cause of the diarrhea?

the client's caregiver washes out the feeding bag with warm water once every 24 hr.

a nurse is caring for a client who has recently started using a behind the ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

"I will be sure to remove my hearing aid before taking a shower."

a nurse is caring for a client who has a sodium level of 125 mEq/L. which of the following findings should the nurse expect?

Abdominal cramping

a nurse is caring for a client who is postoperative. when the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing.

a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion?

Apply an ankle-foot orthotic device to the client's feet.

a nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of the following types of transmission precautions should the nurse initiate?

Contact precautions

a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins

a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse taker to precent skin breakdown?

Have the client use a trapeze bar when changing position.

a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area

a nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position

a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

a nurse is providing discharge instructions to a client who will be using a walk. which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch."

a nurse is educating a client who has a terminal illness about declining resuscitation in a living will. the client asks, "what would happen if I arrived at the emergency department and I had difficulty breathing?" which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose."

a nurse is caring for a client who has terminal liver cancer. which of the following stamements should the nurse identify as an indication that they client is experiencing spiritual distress?

"What could I have done to deserve this illness?"

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance

a nurse is providing discharge teaching to a client about self-administering heparin. which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen.

a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus.

a nurse is caring for a client who has a respiratory infection. which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter.

a nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

a nurse is caring for a client who is receiving pain medication through a pt-controlled analgesia (PCA) pump. which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

a nurse is evaluating a client's use of a can. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

a nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors.

a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions should the nurse as when assessing the quality of the client's pain?

"Is your pain sharp or dull?"

a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves.

a nurse in a long term care facility is caring for a client who dies during the nurse's shift. identify the sequence in which the nurse should perform the following steps.

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

a nurse is caring for a client who has a terminal illness and is approaching death. the client is short of break and has noisy respirations from the secretions in the airway. which of the following actions should the nurse take?

Turn the client every 2 hr.

a nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which of the following types of dressing should the nurse use?

Hydrocolloid

a nurse is reviewing a client's medication prescription that reads, :digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with provider?

Medication dose

a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take?

Withhold the blood transfusion.

a nurse is caring for a client who requires an informed consent for a surgical procedure. which of the following actions is the nurse's responsibility?

Witness the client's signature on the consent form.

a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed.

a nurse is planning an educational program, for a group of older adults at a senior living center. which of the following recommendations should the nurse include?

You should receive a pneumococcal vaccine when you are 65 years old."

a nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident?

"Client found lying on floor."

a nurse is teaching a client whose left leg is in a cast about using crutches, which of the following statements should the nurse identify as an indication that the client understands the teaching?

"When descending stairs, I will first shift my weight to my right leg."

a nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

the nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as a priority?

Auscultate lung sounds.

a nurse is planning care for a client who has TB. the nurse should use which of the following pieces of PPE when caring the client?

N95 respirator

a nurse is caring for a group of clients. which of the following actions should the nurse take to prevent the spread of infection?

Place a client who has tuberculosis in a room with negative-pressure airflow.

a nurse on a medical unit is preparing to discharge a client to home. which of the following actions should the nurse take as part of the medication reconciliation process?

Tell the client to keep the head of the bed elevated at least 30°.

a nurse is caring for a client who reports pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following?

The pain is like a dull ache in my stomach."

a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend?

Walking briskly