ATI Exam PN1

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? A. Oral temperature 37.8° C (100° F) B. Respirations 30/min C. BP 148/88 mm Hg D. Radial pulse rate 45 beats/30 seconds

B. Respiration 30/min

A nurse is preparing to obtain a client's BP. Which of the following actions should the nurse take to measure the BP accurately? A. Obtain the reading in the early morning. B. Use a cuff of the appropriate size for the client. C. Assist the client to the bathroom to void. D. Apply the cuff loosely around the client's arm.

B. Use cuff appropriate size for client

A nurse is about to irrigate a client's open wound. Besides gloves which of the following PPE should nurse wear? A.A sterile gown B.Goggles C.A face shield D. An N95 respirator

C. face shield

Which of the following is an advantage of using alcohol-based gel? A. It takes less time to use than washing with soap and water. B. It removes gross contamination better than soap and water does. C. Its protective nature reduces the need for frequent handwashing. D. It provides adequate protection before surgical applications.

A. takes less time than washing with soap and water

A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes? A. Moisture from excessive diaphoresis can cause skin breakdown. B. Moisture on the sheets can cause discomfort to the client. C. It provides an opportunity to frequently evaluate the skin on the client's back side. D. It provides an opportunity to turn the client from side to side to facilitate clearing potential fluid from the lungs.

A. moisture from excessive diaphoresis can cause skin breakdown

Steps to assist a client with a tub bath.

1. gather supplies 2. place rubber matt 3.assist client to bathroom 4.instruct to use bars before getting in/out 5. instruct to remain in tub no longer than 20 min.

A nurse is obtaining a client's vital signs. the client has a new onset of a temp of 39C(102 F). Which of the following other vital signs should the nurse expect? A. An elevated pulse rate B. A decreased blood pressure C. An elevated blood pressure D. A decreased pulse rate

A. elevated pulse rate

A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I'll swab the client's mouth with lemon-glycerin swabs." B. "I'll swab the client's mouth with mouthwash." C. "I'll swab the client's mouth with chlorhexidine." D. "I'll swab the client's lips with a very small amount of mineral oil."

C. Ill swab with chlorhexidine

A nurse is preparing to use a tympanic thermometer to acquire a client's temp. which of the following actions should the nurse take to ensure an accurate reading? A. Attach the disposable probe cover. B. Assess the external ear for redness. C. Pull the pinna back and upward gently. D. Replace the thermometer in its charger.

C. pull the pinna back and upward gently

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? A. It corresponds to the client's systolic pressure. B. It is the second diastolic pressure to record. C. It is the loudest of the Korotkoff sounds. D. It might not follow with a fifth Korotkoff sound.

D. It might not follow with a fifth korotkoff sound

A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection? A. Massage reddened areas of the client's skin. B. Wash eyes from the outer canthus to the inner canthus. C. Wash the client from the shoulder down to the fingertips with smooth, short strokes. D. Clean the least-soiled areas prior to cleaning the most-soiled areas.

D. clean least soiled areas prior to cleaning most soiled areas

A nurse is taking an adult client's temp rectally/ What action should the nurse take? A.Rotate the probe if any resistance is met as the thermometer is inserted. B.Insert the probe to aim at the client's pelvic area. C.Dip the probe about 0.58 cm (2 in) into a tube of lubricant. D.Insert the probe about 1.27 cm (0.5 in) into the client's anus.

Insert the probe about 1.27cm into the client's anus

A nurse stand facing a client to demonstrate active range-pf-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? A. Move their leg behind their body. B. Move their leg forward and up. C. Move their leg medially toward their other leg. D. Turn their foot and leg away from their other leg.

A. move their leg behind their body

A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take? A. Raise the room temperature. B. Completely remove the linens. C. Add soap to the water in the basin before beginning the bath. D. Bathe one side of the body at a time.

A. raise room temp.

A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions, Which of the following actions should the nurse take when caring for the client? A. Wear a respirator. B. Protect their eyes. C. Put on clean gloves. D. Wear shoe covers.

B. protect eyes

A nurse is caring for a client who has a prescription for knee-length antiembolic stocking. Which of the following actions should the nurse take? A. Place the stockings on the client after the client ambulates to the restroom. B. Ensure the client's toes are visible after placing the stockings on the client. C. After applying the stockings, place two fingers between the client's leg and stocking to check the fit. D. Measure the client's calf circumference and leg length from heel to knee.

D. measure the client's calf circumference and leg length from heel to knee

A nurse is preparing to record the difference btw a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? A. Auscultatory gap B. Pulse pressure C. Orthostatic hypotension D. Pulse deficit

B. Pulse pressure

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration? A. Observe the degree of chest-wall movement during inspiration and expiration. B. Count how many breathing cycles are observed per minute. C. Notice whether or not expiration takes longer than inspiration. D. Measure the precise amount of air the client takes in and breathes out.

A. Observe the degree of chest-wall movement during inspiration and expiration

A nurse is measuring a client's temp, orally. Which of the following actions should the nurse take? A. Place the probe in the posterior lingual pocket lateral to the midline. B. Rest the probe on the lower lingual frenulum. C. Place the probe centrally on top of the client's tongue. D. Rest the probe under the tongue just beyond the client's teeth.

A. Place the probe in the posterior lingual pocket lateral to the midline

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? Select all that apply A. The client who has a BMI of 35. B. The client has had nausea for 2 days. C. The client is reporting a "stuffy" nose. D. The client has been fasting for blood tests. E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.

A. a client with BMI 35 C. Client with stuffy nose E. Digoxin F. Mastectomy

A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following would describe and exogenous HAI? A. A Salmonella infection that occurs after eating contaminated food from the cafeteria B. An infection that occurs during a therapeutic procedure C. A yeast infection that occurs while receiving broad spectrum antibiotics D. A urinary tract infection that occurs after a sterile catheter insertion

A. a salmonella infection that occurs after eating contaminated food from cafeteria

To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? A. Drying provides the full antiseptic effect. B. Residual alcohol can easily stain clothing. C. Excess gel could transfer to the client. D. Slippery gel can make the nurse drop supplies.

A. drying provides the full antiseptic effect

After completing a procedure that required donning PPE consisting of gown, N95, face shield and gloves which should be taken off first? A.The gloves B.The gown C.The face shield D.The N95 respirator

A. gloves

A nurse is assessing a client's respiration. Which of the following actions should the nurse take? A. Have the client lie flat in bed with their head on a pillow. B. Elevate the head of the client's bed 45° to 60°. C. Encourage the client to breathe shallowly. D. Ask the client to take several deep breaths prior to the assessment.B. elec

B. Elevate the head of the client's bed 45-60degrees

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side position to a 180° angle C. Abducting the arm to a 90° angle from the side of the body D. Circumducting the shoulder in a 180° half circle

B. Flexing the shoulder by raising the arm from aside position to 180 degree angle

A nurse is observing assistive personnel who is using a mechanical life with a hammock sling to transfer from the bed to a chair. For which of the following actions by the AP should the nurse intervene? A. Places a removable cover over the sling B. Leaves the bed in the lowest position throughout the procedure C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before the transfer

B. leaves the bed in the lowest position throughout the procedure

A nurse is preparing to provide oral care for a client who is NPO. The Client tells the nurse "I do not need oral care because I haven't eaten anything," which of the following responses should the nurse make? A. "Since you are not eating, we can wait and do it before bedtime." B. "Oral care is still important even though you are not eating." C. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out." D. "We will wait until your family gets here to help."

B. oral care is still important even though you are not eating

A nurse is washing their hands with soap and water prior to reposition a client in bed during the handwasing procedure, it is important to take which of the following action? A. Make sure that the water is hot. B. Wash for at least 15 seconds. C. Use a liquid soap preparation. D. Remove rings and watches first.

B. wash hands for 15 seconds

After assisting a newly admitted client with removing their shoes and outwear, the nurse notices what appears to be soil or grime on their hands, which of the following actions should the nurse take? A. Cleanse their hands with an alcohol-based gel. B. Wash their hands with soap and water. C. Brush off the soil against a cloth surface. D. Use a wet paper towel to remove the soil.

B. wash hands with soap and water

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed B. Placing the client's left leg in front of the right leg just prior to the transfer C. Aligning the nurse's knees with the client's knees just before the transfer D. Grasping the client under the axillae to assist them to their feet

C. Aligning the nurse's knees with the client's knees just before the transfer

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. which of the following instructions should the nurse include? A. "Lean on the crutches to support your body weight when standing." B. "Fully extend your arms when holding onto the hand grips." C. "Hold the crutches on your unaffected side when preparing to sit in a chair." D. "Hold the crutches 9 inches in front of and to the side of each foot."

C. Hold crutches on your unaffected side when preparing to sit in chair

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse(PMI). In which of the following locations should the nurse position the stethoscope? A. Over the right midclavicular line B. Over the angle of Louis C. Overt the fifth intercostal space at the left midclavicular line D. Over the suprasternal notch

C. over the 5th intercostal space at the left midclavicular line

Which of the following products can affect the permeability of latex gloves? A. Antimicrobial soap and water B. Alcohol-based antiseptic gel C. Petroleum-based hand lotion D. Water-based hand lotion

C. petroleum-based hand lotion

A nurse is establishing baseline for a client's respiration. Which of the following actions should the nurse take? A. Instruct the client to breathe in and to exhale out as they normally do. B. Count the client's respirations for 15 seconds then multiply by 4. C. Determine if the client has a history of any chronic respiratory problems. D. Observe the client's chest movements while appearing to assess their pulse.

D. observe the client's chest movement while appearing to assess their pulse

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? A. Hepatitis B B. Measles C. Meningitis D. Infectious diarrhea

D. infectious diarrhea

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? A.When the atria contracts vigorously B.As the ventricular walls contract C.When the semilunar valves close D.As the mitral valve snaps open

C. When the Semilunar valves close

A nurse is planning morning hygiene care for a postoperative client. Which of the following actions should the nurse take? A. Inform the client when morning hygiene care is provided at the hospital. B. Schedule the client's morning hygiene care at the same time as their roommate. C. Ask the client in what order they typically perform their morning routine. D. Plan to provide care before the next scheduled dose of pain medication.

C. ask the client in what order they typically perform their morning routine

What should the nurse do to maintain standard precautions? A. Rinse gloves that become visibly soiled during use. B. Use an antimicrobial soap for routine handwashing. C. Disinfect hands immediately after removing gloves. D. Keep gloves on when touching environmental surfaces.

C. disinfect hands immediately after removing gloves

A nurse is observing an AP make a client's bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure? A. The AP records the task when it is completed. B. The AP wears sterile gloves while making the bed. C. The AP changes the client's pillowcase. D. The AP reuses the client's clean blanket and spread.

D. AP reuses client's clean blanket and spread

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A. Wrap both arms around the client's arms and shoulders. B. Move both feet together when the client begins to fall. C. Protect the client's extremities while lowering them to the floor. D. Extend one leg and allow the client to slide down the leg to the floor.

D. extend one leg and allow the client to slide down the leg to the floor