ATI exam

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 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 had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

DVT

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 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 degree angle

Which of the following uses of technology would constitute a violation of HIPAA?

texting a picture

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?

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 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 preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client

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 working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching?

"I will have my husband wear a condom during intercourse."

Which of the following legislative acts stupulate that clients be allowed to see and make corrections to their health care records?

Health Information Porability and Accountability Act (HIPPA)

The 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 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 withdrawn the catheter

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 reviewing professional communication skills with a newly licensed nurse. Which of the following is a form of effective communication?

assertive

A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

atrophy

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following?

facial edema

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

foot drop

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 irritant used from the client's urine output

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

tendons connect muscle to bone

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

the client has the crutches resting 5 cm (2 in) below their axilla

A nurse is caring for a client who has a terminal illness and 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 client every 2 hours

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 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 a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take?

Determine respiratory status.

And informatics nurse specialist may engage in numerous roles. Which of the following Roles specific to her qualifications?

Liaison between healthcare professionals, information technology department, and administration

A charge nurse is reviewing organizational structure with a group of newly licensed nurses. Which of the following should she include in her discussion?

Lines of authority, organizational size, formal structures, and informal structures

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 AP?

assist the client with a partial bed bath, measure the client's BP after the nurse administers an antihypertensive medication, use a communication board to ask what the client wants for lunch

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

fowlers

Which of the following types of communication is informal, distorted, and typically involved three or four individuals?

grapevine

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 preparing to apply a dressing for a client who has a stage 2 pressure injury. Which type of dressing should the nurse use?

hydrocolloid

The purpose of using critical pathways to help manage the care of clients who have specific clinical problems is to

improve client outcomes by providing timely interventions

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse manager is reviewing concepts related to organizational communication with a group of charge nurses. Which of the following statements made by a charge nurse requires additional teaching?

"Information should be informally distributed"

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching?

"It is the responsibility of the provider to obtain express consent."

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?

"Let's discuss some strategies you can use when this happens again."

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

mechanical lift

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 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 6 L/min

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

role overload

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 neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?

Hypoglycemia

The primary goal of nursing informatics is to do which of the following?

Improve health by optimizing information management and communication

A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse manager is discussing formal and informal structures or processes with a newly licensed nurse. Which of the following statements made by the newly licensed nurse requires further teaching?

Informal structures are visible

A nurse manager is discussing aggressive communication with a nurse who is having conflicts with peers due to her ineffective communication patterns. Which of the following should the nurse manager identify as a characteristic of aggressive communication?

Infringes on the rights of others

which of the following illustrates the integration of informatics into a health care system to support cost containment?which of the following illustrates the integration of informatics into a health care system to support cost containment?

Installing bar cades on medications with alerts for low supplies

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward

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 teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?

toileting

When administering a clients medication and nurse uses which of the following actions is the best way to reduce preventable medication errors?

Visually verify the medication and asked the client to state her name and date of birth

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 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"

Which of the following support the integration of informatics into nursing practice to support safety in client care?

Embedded medication alerts Immediate Access to digital x-rays Use of phones that connect directly Integration of telehealth

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

Remind the client to use incentive spirometer

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

prone

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 caring for a client who is postoperative. When the nurse prepares to change her dressing, she says "every time you change my badge, 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 reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching?

"I can have 1 to 2 alcoholic beverages each week."

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients 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 understand 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 client who is contemplating retirement. The client states, " I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse take?

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

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and lower the back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat 5. Push up from the knees when lifting the object

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

1. A stable center of gravity increases stability and balance 2. A wide base lowers the center of gravity 3. Proper body alignment involves tightening the abdomen

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 (divide ml by hr)

Which of the following electronic resources should a nurse use to obtain clinical practice guidelines.

Agency for Healthcare Research and Quality

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin?

Allow the child to manipulate the medical equipment.

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign?

An adolescent who is 2 days postoperative following an appendectomy

A new staff member asks the nurse what the abbreviation CDSS means. The correct response is

Clinical decision support system

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching?

Cue the client by providing picture cards that portray common needs.

The Centers for Medicare and Medicaid Services electronically reports specific quality outcomes.

Have a higher percentage of hospital-acquired infections

Risks associated with the use of information technologies include which of the following?

Loss of electronic information due to glitches and external threats to security

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

Which of the following should be included in an interpersonal or interdisciplinary team?Which of the following should be included in an interpersonal or interdisciplinary team?

Respiratory therapist, Provider, Nurses, Dietitian

A nurse should recognize that to be a meaningful user of electronic health record's he should do which of the following?

Respond appropriately to our clinical decision-making support systems and alerts.

A nurse manager is discussing organizational concepts in a charge nurse meeting. Which of the following statements by a charge nurse indicates a need for further teaching?

Smaller organizations find communication more difficult due to size and complex processes

A nurse is caring for a client who is receiving parenteral nutrition through a non tunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first?

Stop the infusion

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions?

Supine with head of the bed elevated to 30°

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first?

Take an ABG specimen to the laboratory

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

The contraction of a muscle results in flexion of a joint

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfactions

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 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 has herpes zoster and asks the nurse about the use of complimentary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which therapy?

acupuncture

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

Which of the following is a standardized tool used to outline daily nursing care to clients who have common needs or a medical conditions?

critical pathways

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

damage into the skin layer

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 HR

A nurse off duty receives a photo on her cell phone from a fellow nurse who is at work.

delete the photo

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 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 nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis?

elevated temperature

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?

lethargy

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 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 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 caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

occupational therapist

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile?

outcome audit

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 caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infections?

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

a nurse is planning to insert a pheripheral 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 completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

sit on the edge of the bed for 1 min

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, & recommendation (SBAR)

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

slide board

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 follow-up visit for a client who has a gastrostomy 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 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.

1.obtain the pronouncement of death from the provider 2.Remove tubes and indwelling lines 3.Wash the client's body 4.Ask the client's family members if they would like to view the body 5.Place name tag on the body

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting?

Dietician, Physical therapist, Social worker

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice?

Discuss the risks associated with leaving with the client.

A health care facility recently opened a research department to collect and analyze data related to improved client outcomes. Which of the following examples represents integration of technology to support creation of scholarly knowledge?

Electronic collection of healing times

Confidential information in a secure network is most often breached by

On authorized access to the disclosure of information by authorize users

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 manager is conducting an in-service on ineffective communication patterns. Which of the following should she include when discussing components of passive communication?

Puts others' needs and wants ahead of self, Avoids conflict, difficult time saying no

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion?

Reduced bleeding time

Which of the following illustrates the use of technology to improve communication with a client who is cognitively impaired?

Use an electronic drawing screen a client to create pictures during an assessment

A newly licensed nurse is expected to do which of the following?

Use technology to obtain information about unfamiliar procedures

A nurse needs to determine the use of technology as an assistive device to facilitate discharge for a client.

Using translation Supplying the link Explaining the use Accessing an iPad

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

the top of the walker should be at the level of your wrist

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

check the IV tubing for obstruction

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 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 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 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 clients arm

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.

examine personal values about the issue

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication?

excessive vomiting

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

muscles

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