ATI Practice Assessment Questions b

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? A. Incident report completed B. Client climbed over the side rails C. Client found lying on floor D. Client was trying to get out of bed

C. A nurse should always be objective

Which diseases have protective environment?

Clients who have compromised immune system

What 3 signs indicate infiltration at an IV site?

Skin blanching, edema, and coolness

T/F For a 24 hour urine collection, the client should discard the first voiding and save all subsequent voidings

T

Describe the ethical principle of veracity

The nurse must tell the truth at all times and never deceive others

Which diseases have contact precautions?

Vancomyicin- resistant enterococci, methicillin resistant staphylococcus aureus, and scabies

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. 1. Inject 10 units of air into the bottle of NPH insulin 2. Inject 5 units of air into bottle of regular insulin 3. Wthdraw the correct dose of regular insulin 4. Withdraw the correct dose of NPH insulin from the bottle

1, 2, 3, 4

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the container of medication prior to administration B. Transfer the medication to medicine cup C. Place the client in a semi-fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administering it

A

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? A. Droplet B. Airborne C. Contact D. Protective environment

A.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. Auscultate lung sounds B. Measure urine output C. Monitor blood pressure readings D. Monitor electrolyte levels

A. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy

A nurse is teaching an older adult client who is at risk for osteoporosis about the beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobic

A. Weight bearing exercises are essential for maintaining bone mass, which helps prevent osteoporosis

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Ensure sterilization of non-disposable items with ethylene oxide B. Wrap monitoring cords with stockinette and tape them in place. C. Cleanse latex ports on IV tubing with chlorhexadine before injecting medication D. Wear hypoallergenic latex gloves that contain powder

B.

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? A. Rinse the feeding bad with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30 degrees. C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol

B.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? A. "Drink a cup of hot cocoa before bedtime" B. "Maintain a consistent time to wake up each day" C. "Exercise 1 hour before going to bed" D. Watch a television program in bed before going to sleep."

B.

A nurse is giving change-of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? A. Admitting diagnosis B. Breath sounds C. Body temperature D. Diagnostic test results

B.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? A. Activate the emergency fire alarm B. Extinguish the fire C. Evacuate the client D. Confine the fire

C.

A nurse in a clinic is caring for a middle adult client who states, "The doctors say 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? A. I'll get a blood sample from you and send it for a screening test B. Beginning at age 60, you should have a colonscopy C. You should have a fecal occult blood test every year D. The recommendation is to have a sigmoidoscopy every 10 years

C.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? A. Client flow sheet B. Acuity ratings C. Current medications D. Incident reports

C.

A nurse is 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? A. 2 cups of soup B. 1 quart of water C. 8 oz. of ice chips D. 6 oz of tea

C.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. Neck vein distension B. Urine specific gravity 1.010 C. Rapid heart rate D. Blood pressure 144/82 mm Hg

C.

A charge nurse is discussing the responsibility of nurses caring for clients who have C diff. infection. Which of the following info should the nurse include in the teaching? A. Assign the client to a room with a negative airflow system B. Use alcohol-based hand sanitizer when leaving the client's room C. Clean contaminated surfaces in the client's room with a phenol solution D. Have family member wear a gown and gloves when visiting

D.

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? A. "This type of hearing aid does not allow for fine tuning of volume" B. "I shouldn't have trouble keeping the hearing aid in place during exercise" C. "I expect to hear a whistling sound when I first insert the hearing aid" D. "I will be sure to remove my hearing aid before taking a shower"

D.

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? A. Role play B. Group discussions C. Question-Answer meetings D. Practice sessions

D.

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? A. Dissolve each medication in 5 mL of sterile water B. Draw up medications together in the syringe C. Push the syringe plunger gently when feeling resistance D. Flush the tube with 15 mL of sterile water

D.

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. A client who has a history of physical abuse B. A client who has a permanent pacemaker C. A client who has ulcerative colitis D. A client who has asthma

D. Some essential oils can cause bronchospasm

Which diseases have droplet precautions?

Influenza, rubella, meningoccal, pneumonia, streptococcal pharyngitis.

Which diseases have airborne precautions?

Varicella, TB, and measles