ATI Test Taking Strats Pretest and Posttest

A nurse at a long-term care facility discovers a wastebasket fire in the room of two residents. Identify the sequence of actions the nurse should follow.

1. Assist the residents out of the room to the end of the hallway 2. Activate the fire alarm 3. Close the door to the client's room 4. Activate an appropriate fire extinguisher 5. Put out the base of the fire using a side-to-side motion

A nurse is caring for a client immediately following lumbar puncture. Which of the following actions should the nurse plan to take first? 1. Remind the client analgesia may be prescribed for headache 2. Place the bed flat with a pillow under the client's head 3. Offer the client a choice of beverages to drink 4. Review the purpose of spinal fluid testing with the client

Place the bed flat with a pillow under the client's head The time elapsed default strategy can be useful in determining the priority action for the nurse to take. Immediately following lumbar puncture, there is increased risk of leakage of spinal fluid from the puncture site. Therefore, the nurse should place the bed flat and place a pillow under the clients head. The client should remain flat for the amount of time prescribed by the physician.

A nurse is caring for a client who has orthopnea and is confused. The nurse is preparing to apply restraints to prevent the client from removing the oxygen device. Which of the following images indicates an action the nurse should plan to take?

The nurse should secure the client's restraints that will prevent harm to the client. The nurse should be able to place two fingers between restraint and the client's wrist. This ensures the restraint is secure enough to stay in place and loose enough to stay in place and loose enough to maintain adequate tissue circulation.

A nurse is preparing to collect physical assessment data from an older adult client who has acute confusion. Which of the following assessments should the nurse perform first? 1. Auscultate lung sounds 2. Check skin turgor 3. Measure body temperature 4. Obtain blood pressure

1. Auscultate lung sounds Using the ABC priority-setting framework, maintaining patent airway and effective breathing are the nurse's top priorities. For older adult client, cognitive changes are often the first indications of a respiratory problem.

A nurse is contributing to the plan of care for a client who has left-sided weakness due to a stroke. Which of the following interventions should the nurse identify as the priority? 1. Determining whether the client is able to feed himself 2. Supporting role changes among the client's family members 3. Encouraging the client's efforts to begin a new hobby 4. Providing the client with information about a stroke support group

1. Determining whether the client is able to feed himself According to Maslow's Hierarchy of Needs priority-setting framework, physiological needs, such as food and water, receive the highest priority. Determining whether the client is able to feed himself is the priority intervention to help ensure the client's physiological needs are met.

A nurse is preparing to collect physical assessment data from clients following a natural diaster in the community. The nurse should first collect data from clients in which of the following triage categories? 1. Emergent 2. Minor 3. Expectant 4. Urgent

1. Emergent The highest priority is assigned to clients in the emergent category. Clients assigned to hte emrgent triage category in a mass casualty event have life-threatening but survivable injuries if immediate care is received based on the survival potential priority-setting framework, the nurse should first collect data from clients in this category.

A nurse is reinforcing teaching with a client who reports having leg cramps due to hypokalemia. The nurse should recommend 1 cup servings of which of the following foods for this client? 1. Fresh avocado 2. Air-popped popcorn 3. Canned apricots 4. Raw green lettuce 5. Brazil nuts

1. Fresh avocado 3. Canned apricots 5. Brazil nuts

A nurse is collecting data from a client who is 4 days postoperative following abdominal surgery. The client reports feeling his incision "pop", and the nurse sees the client's organs protruding through the abdominal wall. Which of the following actions should the nurse take? Select all that apply. 1. Monitor the client for manifestations of shock 2. Have an assistive personnel hold dry towels over the wound 3. Assist the client to lie down 4. Retrieve the sterile hydrogen peroxide from the supply room 5. Instruct the client to bend his knees

1. Monitor the client for manifestations of shock 5. Instruct the client to bend his knees 1. Wound evisceration can cause shock. The nurse should stay with the client and monitor blood pressure and heart rate, and for indications of shock. 5. Wound evisceration can cause decreased perfusion of the intestines. The nurse should remain in the room and instruct the client to bend his knees to help support the abdominal tissue and promote return of blood flow to the intestines.

A nurse is assisting with the admission of a client who is postoperative following laparoscopic abdominal surgery. Which of the following assessments should the nurse identify as the priority? 1. Observe the client's breathing pattern 2. Auscultate bowel sounds 3. Determine the client's ability to void 4. Check incision site for indications of infection

1. Observe the client's breathing pattern The time elapsed default strategy can be useful in determining the priority assessment for this client. Airway edema, weakness of airway muscles from anesthesia or the buildup of lung secretions can cause postoperative airway obstruction. Considering the time elapsed since anesthesia administration, the priority action the nurse should take is to observe the client's breathing pattern and other data regarding airway patency.

A nurse is caring for a client who is receiving enteral nutrition. The nurse should plan to monitor the client for which of the following early indications of aspriation? 1. Restlessness 2. Behavioral changes 3. Peripheral cyanosis 4. Tachypnea 5. Pulmonary abscess formation

1. Restlessness 2. Behavioral changes 4. Tachypnea

A nurse is preparing to administer medications to a client who begins having a seizure. Which of the following actions should the nurse take first? 1. Turn the client on her side 2. Administer an anticonvulsant medication 3. Document the time the seizure began 4. Provide verbal reassurance for the client

1. Turn the client on her side Using the ABC priority-setting framework, maintaining a patent airway is the nurse's priority concern for a client who is having a seizure. An airway obstruction is a potential complication for clients during a seizure secondary to production of secretions. Placing the client in a lateral position promotes drainage of the secretions. Based on the knowledge and using the ABC priority-setting framework, the nurse's first action is to place the client in a lateral position to maintain a patent airway.

A nurse is providing instructions for a client who has urinary frequency and is scheduled for a bladder ultrasound the following day. Which of the following information should the nurse include? 1. "You will receive a cleansing enema early tomorrow morning." 2. "You may be asked to drink water before the test." 3. "You will be given intravenous contrast by the radiologist." 4. "You may experience a short-term dysuria following the procedure."

2. "You may be asked to drink water before the test." Fluids are often given prior to an ultrasound of the bladder is full, and structures can be visualized appropriately; therefore the nurse should include this information in the teaching.

A nurse is collecting data from clients following a mass casualty event. Which of the following clients should the nurse recommend for priority treatment? 1. A client who is in cardiac arrest 2. A client who has an open femur fracture 3. A client who has a large penetrating foot wound 4. A client who has multiple abrasions

2. A client who has an open femur fracture Clients who have an open fracture of a long bone have a life-threatening, but survivable condition if immediate care is received. The highest priority is assigned to the client who has injuries that are severe but has the potential to survive with treatment.

A nurse in a provider's office has completed preliminary screening of four clients. Which of the following clients should the nurse recommend first treatment? 1. A client who has a 5 cm long laceration on the arm 2. A client who has audible inspiratory stridor 3. A client who reports dysuria 4. A client who reports a headache of 5 on a 0 to 10 scale

2. A client who has audible inspiratory stridor A client who has audible respiratory stridor has airway impairment and is unstable. Based on the stable vs. unstable priority-setting framework, the nurse should identify this client as the priority and recommend immediate treatment by the provider.

A nurse is assigned to provide care for a group of clients. Which of the following actions should the nurse plan to complete first? 1. Reinforce teaching about a low-sodium diet with a client who has hypertension 2. Administer an antidiarrheal medication for a client who has had multiple watery stools 3. Record the meal intake for a client who has dementia 4. Observe a client who has rheumatoid arthritis perform active range-of-motion exercises

2. Administer an antidiarrheal medication for a client who has had multiple watery stools Diarrhea is an acute infectious condition that places the client at risk for fluid and electrolyte imbalance. Based on the acute versus chronic priority-setting framework, the nurse should identify this information as priority. The nurse should administer an antidiarrheal medication

A nurse is reviewing the plan of care for several clients at the beginning of the shift. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)? Select all that apply. 1. Reviewing pre-printed instructions with a client regarding diet 2. Feeding a client who had a stroke 2 years ago 3. Performing a bed bath for a client who is paraplegic 4. Comparing a client's peripheral pulses 5. Determining whether a client has rebound tenderness

2. Feeding a client who had a stroke 2 years ago 3. Performing a bed bath for a client who is paraplegic

A nurse is caring for an older client who is agitated and attempting to pull out of the peripheral IV catheter. Which of the following actions should the nurse take first? 1. Put a thumbless mitten device on the hand opposite of the IV site 2. Place a stockinette dressing over the client's IV site 3. Apply bilateral restraints on the client's wrists 4. Request an antianxiety medication from the provider

2. Place a stockinette dressing over the client's IV site Applying a stockinette dressing over the client's IV line camouflages the site and decreases the client's focus on the area. Using the least restrictive, least invasive priority-setting framework, this action is less invasive than physical or chemical restraints, and should be the nurse's first action.

A nurse is taking with an older adult client during a home visit. Which of the following statements by the client should the nurse identify as the priority? 1. "I can't sleep as well at night as during the day." 2. "I can't afford to buy many fresh fruits and vegetables." 3. "I don't know if my smoke alarms work." 4. "I don't get along well with most of my family."

3. "I don't know if my smoke alarms work." The client is at risk for injury from a home fire if smoke alarms are not functional. Using the safety and risk reduction priority-setting framework, the nurse should identify this statement by the client as the priority. The nurse should ensure the client's smoke alarms are in working order and help the client make arrangements to have the alarms tested on a routine basis.

A nurse is contributing to the plan of care for an older adult client who has impaired vision and lower extremity weakness due to diabetes mellitus. Which of the following interventions is the nurse's priority? 1. Reinforce teaching about diabetes mellitus management 2. Recommend a referral for physical therapy 3. Ensure the client's call light is within reach 4. Identify the location of food on a plate using clock numbers as a reference

3. Ensure the client's call light is within reach Clients who have impaired vision and weakness are at risk for falls, and ensuring the client's call light is within reach reduces this risk. Based on the safety and risk reduction priority-setting framework, this should be the nurse's priority action.

A nurse is caring for an older adult client who is receiving hospice care. Which of the following actions should be the nurse's priority? 1. Encourage the family to give the client permission to die 2. Contact the client's spiritual care provider 3. Ensure the client's pain is controlled 4. Support the client's family during the grieving process

3. Ensure the client's pain is controlled The first level of Maslow's Hierarchy of Needs includes physiological needs. Pain control and physical comfort at the end of life are physiological needs and are included in the first level of Maslow's Hierarchy of Needs. Based on it, controlling the client's pain is the priority action.

A nurse at a long-term care facility is talking with a group of clients at breakfast. One client reports not having a bowel movement the previous day. Which of the following actions should the nurse take first? 1. Administer a laxative medication 2. Request a prescription to check for impaction 3. Offer to help the client to the toilet after meal time 4. Provide the client with a glycerin suppository

3. Offer to help the client to the toilet after meal time Offering to help the client to the toilet after breakfast can promote bowel movement. Eating causes increased peristalsis of the colon and should be the strongest after breakfast. Based on the least restrictive, least invasive priority-setting framework, this is the first action the nurse should take.

A nurse collects nutritional data from a client and determines that the client is underweight and needs to increase daily caloric intake. Which of the following actions should the nurse take first? 1. Recommend a referral for a dietary consult 2. Create a menu plan based on the client's preferences 3. Set a goal with the client for weight gain 4. Instruct the client to record daily caloric intake

3. Set a goal with the client for weight gain Using the nursing process, the nurse should complete the planning phase prior to implementing interventions. Setting client-focused goals is part of the planning phase of the nursing process. The nurse should collaborate with the client to set a realistic and measurable goal for weight gain and then implement appropriate interventions to assist the client in meeting this goal.

A nurse is preparing to collect data from an adult client after receiving change-of-shift report. Which of the following client issues should the nurse address first? 1. The client requests pain medication for joint pain due to arthritis 2. The client has obesity and refuses the prescribed diet 3. The client has orthostatic hypotension 4. The client has repeated episodes of stress incontinence

3. The client has orthostatic hypotension Orthostatic hypotension is a result of peripheral vasodilation and is associated with acute disorders, such as dehydration and bleeding. Based on the acute vs. chronic priority-setting framework, the nurse should collect further data about this client need first.

A nurse is collecting data from a client who is having repeated episodes of emesis. Which of the following findings is the priority for the nurse to report to the provider? 1. Urine output 40 mL/hr 2. Rapid capillary refill 3. Pulse rate 68/min 4. Decreased level of consciousness

4. Decreased level of consciousness A client who is repeated episodes of emesis is at risk for fluid volume deficit. A decreased level of consciousness indicates extracellular fluid volume deficit. Based on the stable vs. unstable priority-setting framework, this finding is the priority and should be immediately reported to the provider.

A nurse is caring for a female client who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take first? 1. Perform a routine cleansing of the perineal area 2. Place the client in a dorsal recumbent position 3. Set up a sterile field with catherization supplies 4. Determine if the client has any physical limitations

4. Determine if the client has any physical limitations Using the nursing process, the nurse should first assess or collect data so a plan of care can be developed. If the client has physical limitations, the nurse may need to plan an alternative method of client positioning during the procedure and obtain assistance from nursing staff. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? 1. Assist the client into the right Sims' position 2. Lubricate 1.3 to 2.5 cm of the enema tubing 3. Hold the enema bag 45 cm above the client to initiate fluid flow 4. Insert the tubing into the client's rectum toward the umbilicus 5. Fill the enema bag with 750 mL of warmed solution

4. Insert the tubing into the client's rectum toward the umbilicus 5. Fill the enema bag with 750 mL of warmed solution 4. The nurse should insert the tubing toward the client's umbilicus's to prevent damaging the client's rectal mucosa and to ensure enema fluid is able to flow freely into the bowel. 5. The nurse should warm the prescribed enema solution to prevent abdominal cramping. The appropriate volume of enema solution for an adult client is 500 to 1,000 mL.

A nurse enters a client's room and finds the client lying on the floor at the bedside. The client states, "I fell because no one would help me to the bathroom, but I think I can get up okay." Which of the following actions by the nurse is appropriate? 1. Report the client's fall to the facility administer 2. Place an incident report in the client's medical record 3. Obtain a wheelchair and assist the client back to bed 4. Push the client's call button and request assistance

4. Push the client's call button and request assistance When a client falls, the nurse's primary responsibility is to help the client. Based on the keep the client with the nurse default strategy, the nurse should stay with the client and wait for additional help to arrive. While waiting for help, the nurse can check the client for injuries and observe surroundings for factors contributing to the fall. If there are no contraindications, the nurse may transfer the client back to bed once additional nursing personnel arrives.

A nurse is caring for a client who reports a latex allergy and is scheduled for surgery the following day. When implementing latex allergy precautions. Which of the following tasks should the nurse assign to an assistive personnel (AP)? 1. Reviewing a pamphlet about latex exposure with the client's family 2. Documenting the presence of a latex allergy on the preoperative checklist 3. Replacing the client's IV site dressing with non-latex tape 4. Placing a latex-free cart outside the client's door

Placing a latex-free cart outside the client's door The task does not require decision-making or analysis by the AP. It is a routine task and there is little of harm to the client. It is appropriate for the nurse to delegate this task to the AP.