ATI Questions

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A) Abnormally prominent U wave B) Elevated ST segment C) Wide QRS D) Inverted P wave

A) Abnormally prominent U wave

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? A) "The client should be seen by a neurologist" B) "The client was found unconscious on the floor in her home" C) "There are no providers prescriptions available" D) "The client is disoriented. Pupils are slow to respond to light"

B) "The client was found unconscious on the floor in her home"

A nurse is caring for a client who has a postoperative ileum and an NG tube that has drained 2,500 mL in the past 6 hours. Which of the following electrolyte imbalances should the nurse monitor the client for? A) Elevated Sodium level B) Decreased potassium level C) Elevated magnesium level D) Decreased calcium level

B) Decreased Potassium level

A nurse is preparing to measure a clients level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A) Finger B) Earlobe C) Toe D) Skin fold

B) Earlobe

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? A) Hypernatremia B) Hyperuricemia C) Hypercalcemia D) Hyperchloremia

B) Hyperuricemia

A charge nurse is observing a nurse auscultating a clients bowel sounds. Which of the following actions requires intervention by the charge nurse? A) Clamps the NG tube during auscultation B) Performs auscultation between meals C) Auscultates bowel sounds for 3 to 5 min D) Palpates the abdomen prior to performing auscultation

D) Palpates the abdomen prior to performing auscultation

A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to describe one physical effect. The nurse is focusing on which of the following elements of the communication process? A) Feedback B) Channel C) Environment D) Message

A) Feedback

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A) "Information about a client can be disclosed to family members at any time" B) "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form" C) "A clients address would be an example of personally identifiable information" D) "HIPAA is a federal law, not a state law"

A) "Information about a client can be disclosed to family members at any time"

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection? A) "You seem upset about taking your blood pressure medication" B) "Why do you feel afraid to take your medication?" C) "You won't get better until you take your medication?" D) "Did your symptoms occur before or after you took the medication?"

A) "You seem upset about taking your blood pressure medication"

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy 5 L/min via nasal cannula. Which of the following actions should the nurse take? A) Attach a humidifier bottle to the base of the flow meter B) Remove the nasal cannula while the client eats C) Secure the oxygen tubing to the bed sheet near the client's head D) Apply petroleum jelly to the nares as needed to soothe mucous membranes

A) Attach a humidifier bottle to the base of the flow meter

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching? A) "Do not adjust the oxygen flow fate" B) "Check your oxygen equipment once each week" C) "Store unused oxygen tanks horizontally" D) "Use wool blankets on your bed"

A) "Do not adjust the oxygen flow rate"

A nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? A) "I will be able to eat solid food when I wake up from anesthesia" B) "I will have a glass of juice the morning of my surgery" C) "I understand what risks I can expect with this surgery" D) "I will take time to relax if I get nervous the night before surgery"

A) "I will be able to eat solid food when I wake up from anesthesia"

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? A) Elicit information from the client B) Encourage the client to use self-exploration C) Review the clients progress toward personal objectives D) Talk with others who have information about the client

A) Elicit information from the client

A nurse is reviewing the lab results from a client who has pre renal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect? A) Hyperkalemia B) Hypernatremia C) Hypercalcemia D) Hypophosphatemia

A) Hyperkalemia

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (select all that apply) a) Check the tops of the ears for skin breakdown b) Post "no smoking" signs in a prominent location in the house c) Verify the oxygen flow rate every other day d) Check the cannula position on a regular basis e) Apply petroleum ointment to nares if they become dry and irritated

A, B, D,

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply) A) Education B) Feedback C) Perception D) Gender E) Time

A, C, D

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentrations? A. 28% B. 36% C. 50% D. 70%

A. 28%

A nurse is assessing a clients bowel sounds. At which of the following points in the assessment should the nurse auscultate the clients abdomen? A) After palpating the abdomen B) Prior to percussing the abdomen C) After assessing for kidney tenderness D) Prior to inspecting the abdomen

B) Prior to percussing the abdomen

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take in maintain privacy for the client? A) Close the door to the clients room B) Pull the curtain around the clients bed C) Ask family members to leave the room D) Use sterile drapes to cover the client

B) Pull the curtain around the clients bed

A nurse is preparing a teaching plan for a client who has a chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching? A) The client should drink two to three 8 oz glasses of water each day B) The client should follow a high-fiber diet to establish bowel regularity C) The client should try to take in all of the required dietary fiber with the morning meal D) The client should be taught that the goal of therapy is to have a bowel movement daily

B) The client should follow a high-fiber diet to establish bowel regularity

A nurse is providing instructions to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications put clients at risk for both hyperkalemia and hypnatremia? A) Furosemide B) Hydrochlorothiazide C) Metolazone D) Spironolactone

B)Hydrochlorothiazide

A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include? A) "To prevent dehydration, drink an additional liter of fluid during preparation time" B) "Expect bowel movements to begin 3 hrs following completion of solution" C) "Abdominal bloating might occur" D) "Drink 400 mL every hour until bowel movements are clear"

C) "Abdominal bloating might occur"

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A) Lactated Ringer's B) Dextrose 5% in 0.9% sodium chloride C) 0.45% sodium chloride D) Dextrose 10% in water

C) 0.45% sodium chloride

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop bowel through an opening in the surgical incision. Which of the following actions should the nurse take? A) Place the head of the client's bed in the flat position B) Gently reinsert the bowel back into the clients wound C) Apply moistened sterile gauze to the site D) Position the client on his left side

C) Apply moistened sterile gauze to the site

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client 6 hrs postoperative from a total hysterectomy. The nurse notes the clients oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the clients oxygen level and HR in which component of SBAR? A) Situation B) Background C) Assessment D) Recommendation

C) Assessment

A client who has a femur fracture states "I can't stay in this bed any longer. I need to get home so I can take care of my family." The nurse responds, "You have talked about your family several times. Can you tell me more about your specific concerns?" Which type of therapeutic communication response is the nurse using? A) Summarizing B) Empathizing C) Focusing D) Clarifying

C) Focusing

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? A) Transpersonal B) Intrapersonal C) Interpersonal D) Public

C) Interpersonal

A nurse is caring for the client who states "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent? A) Providing a passive response B) Showering disapproval C) Offering false reassurance D) Offering sympathy

C) Offering false reassurance

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A) Hyperactive reflexes B) Extreme thirst C) Weak, irregular pulse D) Hyperactive bowel sounds

C) Weak, irregular pulse

A nurse is caring for a client who has returned to the unit following a surgical procedure. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first? A) Administer oxygen at 2 L/min B) Administer prescribed analgesic medications C) Encourage coughing and deep breathing D) Raise the head of the bed

D) Raise the head of the bed

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take? A) Focus on the clients present circumstances instead of his personal stories B) Verbalize understanding of how the client feels C) Offer the client personal thought and beliefs D) Use attentive listening with the client

D) Use attentive listening with the client