ATI Study Questions

A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take?

Remove all equipment from the client's bedside.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session

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?

Establish client outcomes.

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older."

A nurse is reviewing instructions with a client who has a new prescription for hearing aids.Which of the following client statements

"I will take the batteries out of my hearing aids when I take them off at night."

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include?

"Try to block the urge to urinate until the next scheduled time."

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings.When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make?

"Water helps clear the tube so it doesn't get clogged."

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure?

2 mm

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?

Accompany the client back to his room

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Face the client when speaking

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear.

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

Albumin

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment

A nurse is caring for a client who is postoperative.Which of the following interventions should the nurse take to reduce the risk of thrombus development?

Assist the client to change positions often.

A nurse is caring for a client who has hearing loss. The nurse should plan which of the following interventions when communicating with the client?

Attract the client's attention before speaking

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy?

Carbohydrates

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene.

A nurse is caring for a client who is two days postoperative and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first?

Check the client to determine the reason for inadequate pain relief.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4 hr

A nurse is caring for a client who has a stage Ill pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?

Chronic hypoxemia

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

Clean the drain site from the center outward

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take?

Cover the area with saline-soaked sterile dressings. and lay patient supine with hip and knees bent

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

Determine the client's ability to help with the transfer.

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family?

Difficulty swallowing

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning?

During the admission process

1. The nurse is preparing to insert an NG tube on a client for stomach decompression. When determining the length of the tube to be inserted, what anatomical location should the nurse use second for measurement?

Earlobe

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

Encourage the client to perform antiembolic exercises every 2 hr.

A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include?

Ensure the specimen does not include urine.

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?

Fowler's

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowler's

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility?

Give a verbal transfer report via telephone.

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups?

Grains

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

Granulation tissue fills the wound during healing.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

Halo of erythema on the surrounding skin

A nurse is caring for a client who has a stage ll pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process?

Instruct clients who are able to ambulate to leave.

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?

Instructing the client to tuck their chin when swallowing

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Keep the head of the bed elevated 30°.

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?

Limit drinking liquids with food

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching?

Medication error

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate?

Obtain the provider's signature on the prescription within 24 hr.

A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention?

Open burn area & Stage 3 pressure injury

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?

Orient the client to their room.

A nurse is caring for a client who is expected to die within 24 hr. The client's family asks the nurse what physical changes to expect. Which manifestations should the nurse include?

Periods of apnea

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?

Pressure injury

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent exudate

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record?

Put the date and time on all entries.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

Semi-Fowler's

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

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 interprofessional team to evaluate the client for dysphagia?

Speech-language pathologist

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

Stop the feeding.

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?

Vanilla custard

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure?

Verify the placement of the NG tube.

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection?

WBC 15,000 mm 13

A nurse is preparing to administer a cleansing enema to a client. what should the nurse do first?

Warm the enema solution.