CORE-ATI PRACTICE EXAMS

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 a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward

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 medication reconciliation process?

Compare prescriptions with medications the client received while at the facility

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. 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 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 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 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 indicated effective coping?

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

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

SBAR

A nurse is educating a client who has terminal illness about declining resuscitation in a living well. 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 preparing a heparin infusion for a client who has been admitted to the facility with deep-vein thrombosis. The prescription reads 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/her. At what rate should the nurse set the infusion pump? want: mL/hr

8 mL/hr

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle 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 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 ca contraindication for which of the following therapies?

Acupuncture

A nurse is caring for a client who is postoperative. When the nurse prepares the change her dressings, 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 giving 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 admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the clients home medications with the providers prescriptions

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

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?

Evacuate the client

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

Potassium 5.4 mEq/L

A nurse is reviewing evidence-based practice principles 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 6L/min

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

Wear a gown when caring for the client

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 recently used 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 providing discharge instructions to a client who will be using a walker. 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 caring for a client 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 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 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 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 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 is preparing to administer enoxaparin subcutaneously 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 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 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 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 caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

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 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 the provider?

Medication dose

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 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 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 degrees.

A nurse is evaluating a client's use of a cane. 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 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 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 receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

check the IV tubing for obstruction

A nurse is administering 1 L of 0.9% sodium chloride 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 assessing four adult clients. 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 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 administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

press gently on the tragus of the client's ear

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

turn the client every 2 hr.

A nurse is assessing an older clients risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

visual fields + visual acuity; pupil clarity

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"

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 assessing a client who reports pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?"

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative 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 whi is contemplating retirement. The client states, "I keep thinking abou thow much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"Lets talk about how the change in your job status will affect you"

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 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 client statements?

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

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

-assist the client with a partial bed bath -Measure the clients BP after the nurse administers an antihypertensive medication. -Use of communication board to ask what the client wants for lunch.

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

0.3 mg

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?

Gently shake the container of medication prior to administration

A nurse is 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 measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager

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?

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 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 identifies the location of a fire extinguisher

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

Use a bed exit alarm system

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

Advocacy ensures client's safety, health, and rights

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.

Obtain pronouncement of death remove tubes and indwelling lines Wash the client's body Ask the family members for a view Name tag on body

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

Pad the client's wrist before applying the restraints

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload

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

Auscultation lung sounds

A nurse is planning care for a client who has tuberculosis? The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

N95 Respirator

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the hollowing sound. This sound indicates which of the following?

Narrowed arterial lumen

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 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 home health nurse is performing a follow-up visit for a client who has a gastrostomy tube though 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 diarrhea?

The clients caregiver washes out the feeding bag with warm water once every 24 hr.

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