ATI Practice A Post Quiz

A nurse is completing dietary teaching with a client who has heart failure and has a prescription for a 2 g sodium diet. Which of the following statements made by the client indicates an understanding of the teaching?

"I can have nonfat yogurt as a dessert." Rationale: The nurse should identify that yogurt is a recommended dessert for a client on a 2 g sodium diet who has heart failure because it is low in sodium and fat.

A nurse is teaching a client who has a new hearing aid. Which of the following statements by the client indicates to the nurse an understanding of the teaching?

"I will reinsert the hearing aid if I hear a whistling sound." Rationale: A whistling sound can indicate incorrect insertion of the hearing aid, improper fit, or ear wax build-up.

A nurse is planning care for four clients. Which of the following clients should the nurse see first?

A client who has pneumonia and expiratory wheezing Rationale: he first action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's airway and breathing, which could be impaired as a as a result of the pneumonia, When using the airway, breathing, circulation approach to client care, the nurse should plan to see the client who has pneumonia and expiratory wheezing first. The nurse should auscultate the client's lungs and measure their oxygen saturation.

A nurse is performing a preoperative assessment on four clients. The nurse should identify that which of the following clients is at risk for a latex allergy?

A client who has spina bifida Rationale: A client who has spina bifida is at risk for a latex allergy because of their history of frequent contact with latex products, such as urinary catheters. The nurse should use latex-free products to reduce the risk for a hypersensitivity reaction.

A nurse is completing an informed consent document for a 16-year-old adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take?

Ask the client if they understand the provider's plan for the appendectomy. Rationale: To ensure informed consent, the nurse should ask the client if they understand the planned procedure. In most states, a married adolescent is considered emancipated, and has the legal authority to provide their own consent.

A nurse in a community health center is teaching a group of clients about the use of aromatherapy. The nurse should include in the teaching that which of the following essential oils is used to alleviate swollen joints?

Chamomile Rationale: Chamomile is an essential oil that has anti-inflammatory properties that can be used to alleviate swollen joints and muscle aches.

A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Check the pH of the client's stomach contents. Rationale: According to evidence-based practice, the nurse should first check the pH of the aspirate by drawing up 5 mL of gastric fluid. The pH should be less than 5 to confirm gastric placement.

A nurse is performing guaiac testing for a client to screen for colon cancer. The nurse should identify that ingestion of which of the following foods can cause a false negative result?

Citrus fruits Rationale: Clients should not consume citrus fruits or juices for 3 days prior to guaiac stool testing because vitamin C can produce a false negative result.

A nurse is teaching a client how to perform active range-of-motion exercises of the lower extremities to improve mobility. Which of the following instructions should the nurse include in the teaching?

Complete each session two times per day. Rationale: The nurse should instruct the client to complete each session two times per day to reduce the risk for injury.

A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following findings should the nurse report to the provider?

Gastric aspirate pH of 7 Rationale: The nurse should identify that a gastric pH of 7 is an indication the nasogastric tube is not in the stomach. Gastric pH is usually between 1 and 4 but can be up to 6, if the client receives a medication that alters gastric pH. The client is at risk for aspiration and the nurse should report this finding to the provider.

A nurse is teaching a client about health promotion and secondary prevention strategies. Which of the following recommendations should the nurse include?

Hypertension screening Rationale: A hypertension screening is an example of secondary prevention and focuses on early detection of a disease and interventions to provide prompt treatment of disease.

A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to decrease the client's risk for venous stasis?

Instruct the client to elevate her legs when sitting in a chair. Rationale: The nurse should instruct the client to elevate her legs when sitting in a chair to prevent pooling and clotting of the blood in the lower extremities.

A charge nurse is teaching a newly hired nurse about the facility's computerized documentation system. Which of the following actions should the nurse take?

Instruct the newly hired nurse to use direct quotes when recording client statements. Rationale: The newly hired nurse should include both subjective data, what the client says, and objective data, what the nurse observes, when entering computer documentation. It is important to directly quote what the client says rather than summarizing to provide factual information.

A nurse in a provider's office is reviewing the laboratory reports for a client who is at risk for heart disease. Which of the following results should the nurse report to the provider?

LDL 170 mg/dL Rationale: An LDL level of 170 mg/dL is above the expected reference range and places the client at increased risk for heart disease; therefore, the nurse should report this result to the provider.

A nurse is preparing the room for a client who is transferring from the emergency department and is on seizure precautions. Which of the following items should the nurse place in the client's room?

Oral-nasal suction Rationale: The nurse should place oral-nasal suction equipment in the client's room to clear the client's airway, which reduces the risk for aspiration.

A nurse is reviewing a client's ABG laboratory results. Which of the following ABG results should the nurse report to the provider?

PaCO2 32 mm Hg Rationale: A PaCO, of 32 mm Hg is below the expected reference range of 35 to 45 mm Hg and should be reported to the provider.

A nurse is preparing to perform a sterile procedure for a client. Which of the following actions should the nurse include in the plan?

Position a bedside table so the sterile field can be seen continuously throughout the procedure. Rationale: The nurse should keep the sterile field in view at all times to ensure that accidental contamination does not occur.

A charge nurse is delegating tasks for four clients. Which of the following tasks should the nurse delegate to the assistive personnel (AP)?

Prepare the room for a client who requires seizure precautions. Rationale: An AP can set up a room with the equipment a client requires for seizure precautions because the necessary equipment is the same for each client.

A nurse is admitting a client to an acute care facility. Which of the following actions by the nurse promotes client self-determination?

Providing the client with information about end-of-life decision-making Rationale: By promoting the client's autonomy, the nurse ensures the client's ability to self-determine care. Under the Patient Self-Determination Act, facilities must ensure a client is aware of their rights to make choices about their care, including completing advance directives to predetermine end-of- life treatment options.

A nurse is evaluating the developmental motor skills of a 4-month-old infant. Which of the following findings should the nurse expect?

Sits up with support Rationale: The nurse should expect a 4-month-old infant to be able to sit up with support. By this age, the infant should have no head lag when sitting.

A nurse is caring for a client who is recovering from a stroke and tells the nurse he is concerned about paying his medical bills. The nurse should refer the client to which of the following members of the interprofessional health care team?

Social worker Rationale: The nurse should refer the client to a social worker to assist the client with finding available financial resources.

A nurse is repositioning a client in bed. Which of the following actions should the nurse take when using ergonomic principles to move the client?

Tighten the abdominal muscles Rationale: The nurse should tighten their abdominal muscles when repositioning a client to prevent muscle injury.

A nurse is planning to perform postmortem care for a client. Which of the following actions should the nurse plan to take?

Verify whether the client requires an autopsy. Rationale: The nurse should verify whether the client requires an autopsy before completing postmortem care or removing any indwelling lines, tubes, or catheters.

A nurse is caring for a client who has a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse take?

Wear a cover gown when caring for the client. Rationale: The nurse should wear a cover gown and gloves when caring for a client who requires contact isolation, such as C. difficile infection, to reduce the risk of spreading the infection.