ATI Seminar Post-Test

A nurse is talking with an older adult client during a home visit. Which of the following statements by the client should the nurse identify as the priority?

"I don't know if my smoke alarms work." The client is at risk for injury from a home fire if smoke alarms are not functional. Using the safety and risk reduction priority-setting framework, the nurse should identify this statement by the client as the priority. The nurse should ensure the client's smoke alarms are in working order and help the client make arrangements to have the alarms tested on a routine basis.

A nurse is providing instructions for a client who has urinary frequency and is scheduled for a bladder ultrasound the following day. Which of the following information should the nurse include?

"You may be asked to drink water before the test." Fluids are often given prior to an ultrasound of the bladder so the bladder is full, and structures can be visualized appropriately; therefore, the nurse should include this information in the teaching. note: "You will be given intravenous contrast by the radiologist." The nurse should instruct a client scheduled for abdominal CT with contrast or intravenous pyelogram about intravenous contrast, and identify client allergy to shellfish or iodine.

A nurse is reinforcing teaching with a client who reports having leg cramps due to hypokalemia. The nurse should recommend 1 cup servings of which of the following foods for this client? (Select all that apply.)

- Avocado - Canned Apricots - Brazil nuts Fresh avocado is correct. Using the direction and magnitude default strategy, the nurse should focus on the diagnosis of hypokalemia. To treat low potassium, the nurse should recommend food sources high in potassium. Fresh avocado contains at least 728 mg of potassium per 1-cup serving. Air-popped popcorn is incorrect. The nurse should select a food source that is higher in potassium to help treat hypokalemia. Air-popped popcorn only contains a maximum 26 mg of potassium per 1-cup serving. Canned apricots is correct. Using the direction and magnitude default strategy, the nurse should focus on the diagnosis of hypokalemia. To treat low potassium, the nurse should recommend food sources high in potassium. Canned apricots contain at least 310 mg of potassium per 1-cup serving. Raw green lettuce is incorrect. The nurse should select a food source that is higher in potassium to help treat hypokalemia. Raw green lettuce contains a maximum 70 mg of potassium per 1-cup serving. Brazil nuts is correct. Using the direction and magnitude default strategy, the nurse should focus on the diagnosis of hypokalemia. To treat low potassium, the nurse should recommend food sources high in potassium. Brazil nuts contain at least 876 mg of potassium per 1-cup serving.

A nurse is performing blood pressure screenings. For one client, the nurse last palpates the radial pulse at 120 mm Hg. How many mm Hg should the nurse inflate the cuff in order to auscultate the client's blood pressure? (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

150 mm Hg. Applying the use what you know default strategy, the nurse should recall that that a client can have an auscultatory gap, or break in the systolic blood pressure, of about 40 mm Hg. To avoid a false low systolic blood pressure reading, the nurse should inflate the cuff 30 mm Hg higher than the point where the pulse can no longer be palpated. Systolic blood pressure can then be measured allowing the sphygmomanometer to decrease 2 mm Hg/sec, and noting the point the where the pulse is palpated again or auscultated.

A nurse is collecting data from clients following a mass casualty event. Which of the following clients should the nurse recommend for priority treatment?

A client who has an open femur fracture Clients who have an open fracture of a long bone, such as the femur, have a life-threatening, but survivable condition if immediate care is received. The highest priority is assigned to the client who has injuries that are severe but has the potential to survive with treatment. Based on the survival potential priority-setting framework, the nurse should recommend priority care to this client. note: A client who is in cardiac arrest--> Clients who are in cardiac arrest are considered to be dead or expected to die. Clients assigned to the expectant triage category in a mass casualty situation are not expected to survive and are provided comfort measures only. The nurse should not recommend priority care for this client. A client who has a large penetrating foot wound--> Clients who have large wounds or major injuries are included in the urgent triage category. Clients assigned to the urgent triage category in a mass casualty event have significant injuries but can wait up to 2 hr before receiving care. The nurse should not recommend priority care for this client.

A nurse in a provider's office has completed preliminary screening of four clients. Which of the following clients should the nurse recommend first for treatment?

A client who has audible inspiratory stridor A client who has audible respiratory stridor has airway impairment and is unstable. Based on the stable vs. unstable priority-setting framework, the nurse should identify this client as the priority and recommend immediate treatment by the provider.

A nurse is assigned to provide care for a group of clients. Which of the following actions should the nurse plan to complete first?

Administer an antidiarrheal medication for a client who has had multiple watery stools. Diarrhea is an acute infectious condition that places the client at risk for fluid and electrolyte imbalance. Based on the acute versus chronic priority-setting framework, the nurse should identify this information as priority. The nurse should administer an antidiarrheal medication and collect data to determine the cause of diarrhea.

A nurse at a long-term care facility discovers a wastebasket fire in the room of two residents. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Applying the use what you know default strategy, the nurse should recall the RACE and PASS pneumonic, which are used to help manage fire. Following RACE: 1. The first step the nurse should take is to rescue, or assist the residents out of the room to safety. 2. Next, the nurse should activate the alarm system. 3. Third, the nurse should confine the fire by closing the room door, and fire doors, if present. 4. The last letter stands for extinguish. The PASS pneumonic describes fire extinguisher use. The nurse should pull the pin to activate the extinguisher. Finally, the nurse should put out the fire by aiming at the base, squeezing the trigger, and sweeping from side to side.

A nurse is preparing to collect physical assessment data from an older adult client who has acute confusion. Which of the following assessments should the nurse perform first?

Auscultate lung sounds. Using the ABC priority-setting framework, maintaining a patent airway and effective breathing are the nurse's top priorities. For the older adult client, cognitive changes are often the first indications of a respiratory problem. Based on this knowledge and using the ABC priority-setting framework, the nurse's priority concern is to auscultate lung sounds to gain information about the client's breathing pattern.

A nurse is collecting data from a client who is having repeated episodes of emesis. Which of the following findings is the priority for the nurse to report to the provider?

Decreased level of consciousness A client who has repeated episodes of emesis is at risk for fluid volume deficit. A decreased level of consciousness indicates extracellular fluid volume deficit. Based on the stable vs. unstable priority-setting framework, this finding is the priority and should be immediately reported to the provider.

A nurse is caring for a female client who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take first?

Determine if the client has any physical limitations. Using the nursing process, the nurse should first assess or collect data so a plan of care can be developed. If the client has physical limitations, the nurse may need to plan an alternate method of client positioning during the procedure and obtain assistance from nursing staff. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is contributing to the plan of care for a client who has left-sided weakness due to a stroke. Which of the following interventions should the nurse identify as the priority?

Determining whether the client is able to feed himself According to Maslow's Hierarchy of Needs priority-setting framework, physiological needs, such as food and water, receive the highest priority. Determining whether the client is able to feed himself is the priority intervention to help ensure the client's physiological needs are met. note: While supporting role changes among the client's family members will meet the client's need for love and belonging, this is not the intervention the nurse should identify as the priority over physiological needs.

A nurse is reviewing the medical record of a client on an acute care unit. Which of the following actions by the nurse is appropriate? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Elevate the client's lower extremities on a pillow. Dependent edema is a manifestation of heart failure resulting from fluid retention. Using the prevent harm to the client default strategy, the nurse should elevate the client's lower extremities to promote venous return.

A nurse is preparing to collect physical assessment data from clients following a natural disaster in the community. The nurse should first collect data from clients in which of the following triage categories?

Emergent The highest priority is assigned to clients in the emergent category. Clients assigned to the emergent triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received. Based on the survival potential priority-setting framework, the nurse should first collect data from clients in this category. note: Urgent: Clients assigned to the urgent triage category in a mass casualty event have significant injuries but can wait up to 2 hr before receiving care. The nurse should not place priority on collecting data from clients in this category.

A nurse is contributing to the plan of care for an older adult client who has impaired vision and lower extremity weakness due to diabetes mellitus. Which of the following interventions is the nurse's priority?

Ensure the client's call light is within reach. Clients who have impaired vision and weakness are at risk for falls, and ensuring the client's call light is within reach reduces this risk. Based on the safety and risk reduction priority-setting framework, this should be the nurse's priority action. note: Identify the location of food on a plate using clock numbers as a reference. Identifying the location of food on a plate using clock numbers as a reference is appropriate to promote independence during meals for the client who has impaired vision. However, another action increases client safety and should be the nurse's priority action.

A nurse is caring for an older adult client who is receiving hospice care. Which of the following actions should be the nurse's priority?

Ensure the client's pain is controlled. The first level of Maslow's Hierarchy of Needs includes physiological needs. Pain control and physical comfort at the end of life are physiological needs and are included in the first level of Maslow's Hierarchy of Needs. Based on Maslow's Hierarchy of Needs, controlling the client's pain is the priority action.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

Insert the tubing into the client's rectum toward the umbilicus is correct. The nurse should insert the tubing toward the client's umbilicus to prevent damaging the client's rectal mucosa, and to ensure enema fluid is able to flow freely into the bowel. Fill the enema bag with 750 mL of warmed solution is correct. The nurse should warm the prescribed enema solution to prevent abdominal cramping. The appropriate volume of enema solution for an adult client is 500 to 1,000 mL. incorrect: Assist the client into the right Sims' position is incorrect. The nurse should assist the client into left Sims' position with the knees flexed to aid the flow of fluid into the bowel .Lubricate 1.3 to 2.5 cm (0.5 to 1 in) of the enema tubing is incorrect. The nurse should lubricate 56 to 8 cm (2.5 to 3 in) of the enema tubing with a water-soluble lubricant to prevent trauma to the rectal mucosa. Hold the enema bag 45 cm (18 in) above the client to initiate fluid flow is incorrect. The nurse should hold the enema bag at the level of the client's hips during initial fluid flow, then raise it to the appropriate height according to the provider's prescription for a high, regular, or low enema [7.5 to 45 cm (3 to 18 in)].

A nurse is collecting data from a client who is 4 days postoperative following abdominal surgery. The client reports feeling his incision "pop," and the nurse sees the client's organs protruding through the abdominal wall. Which of the following actions should the nurse take? (Select all that apply.)

Monitor the client for manifestations of shock is correct. Wound evisceration can cause shock. The nurse should stay with the client and monitor blood pressure and heart rate, and for indications of shock. Assist the client to lie down is correct. Wound evisceration can cause hypotension. The nurse should remain with the client and assist the client to lie down in bed. This position promotes adequate tissue perfusion of the client's vital organs. Instruct the client to bend his knees is correct. Wound evisceration can cause decreased perfusion of the intestines. The nurse should remain in the room and instruct the client to bend his knees to help support the abdominal tissue and promote return of blood flow to the intestines. Have an assistive personnel hold dry towels over the wound is incorrect. Wound evisceration is an emergency. The nurse should keep the client's organs moist to promote circulation and should plan to remain directly by the client's bedside until the client returns to surgery. .Retrieve sterile hydrogen peroxide from the supply room is incorrect. The nurse should use sterile normal saline irrigation solution to keep the client's organs moist. Wound evisceration is an emergency. The nurse should plan to remain directly by the client's bedside until the client returns to surgery

A nurse is assisting with the admission of a client who is postoperative following laparoscopic abdominal surgery. Which of the following assessments should the nurse identify as the priority?

Observe the client's breathing pattern. The time elapsed default strategy can be useful in determining the priority assessment for this client. Airway edema, weakness of airway muscles from anesthesia, or the buildup of lung secretions can cause postoperative airway obstruction. Considering the time elapsed since anesthesia administration, the priority action the nurse should take is to observe the client's breathing pattern and other data regarding airway patency. note: Check incision sites for indications of infection. Although it is important for the nurse to check the client's surgical incisions, manifestations of postoperative infection usually appear 3 to 6 days postoperatively. The nurse should identify another assessment as the priority at this time.

A nurse at a long-term care facility is talking with a group of clients at breakfast. One client reports not having a bowel movement the previous day. Which of the following actions should the nurse take first?

Offer to help the client to the toilet after meal time. Offering to help the client to the toilet after breakfast can promote bowel movement. Eating causes increased peristalsis of the colon and should be strongest after breakfast. Based on the least restrictive, least invasive priority-setting framework, this is the first action the nurse should take.

A nurse is caring for an older adult client who is agitated and attempting to pull out the peripheral IV catheter. Which of the following actions should the nurse take first?

Place a stockinette dressing over the client's IV site. Applying a stockinette dressing over the client's IV line camouflages the site and decreases the client's focus on the area. Using the least restrictive, least invasive priority-setting framework, this action is less invasive than physical or chemical restraints, and should be the nurse's first action.

A nurse is caring for a client immediately following lumbar puncture. Which of the following actions should the nurse plan to take first?

Place the bed flat with a pillow under the client's head. The time elapsed default strategy can be useful in determining the priority action for the nurse to take. Immediately following lumbar puncture, there is increased risk of leakage of spinal fluid from the puncture site. Therefore, the nurse should place the bed flat and place a pillow under the clients head. The client should remain flat for the amount of time prescribed by the physician. note: Review the purpose of spinal fluid testing with the client. Although it is important for the nurse to review the purpose of spinal fluid testing with the client, this information can be provided later when there is decreased risk of post-procedure complications. Therefore, there is another action the nurse should plan to take first.

A nurse is caring for a client who reports a latex allergy and is scheduled for surgery the following day. When implementing latex allergy precautions, which of the following tasks should the nurse assign to an assistive personnel (AP)?

Placing a latex-free cart outside the client's door This task does not require decision-making or analysis by the AP. It is a routine task and there is little risk of harm to the client. It is appropriate for the nurse to delegate this task to the AP. note: A nurse should deliver or reinforce client teaching. APs do not have the knowledge, skills, or ability to reinforce the information or answer client questions.

A nurse enters a client's room and finds the client lying on the floor at the bedside. The client states, "I fell because no one would help me to the bathroom, but I think I can get up okay." Which of the following actions by the nurse is appropriate?

Push the client's call button and request assistance. When a client falls, the nurse's primary responsibility is to help the client. Based on the keep the client with the nurse default strategy, the nurse should stay with the client and wait for additional help to arrive. While waiting for help, the nurse can check the client for injuries and observe surroundings for factors contributing to the fall. If there are no contraindications, the nurse may transfer the client back to bed once additional nursing personnel arrives.

A nurse is caring for a client who is receiving enteral nutrition. The nurse should plan to monitor the client for which of the following early indications of aspiration? (Select all that apply.)

Restlessness is correct. The nurse should monitor the client for early indications of hypoxia resulting from aspiration. Using the early vs. late signs and symptoms default strategy, the nurse should expect early findings to be generalized and nonspecific. Restlessness results from inadequate perfusion of oxygenated blood to the brain and is an early indication of hypoxia due to aspiration. Behavioral changes is correct. The nurse should monitor the client for early indications of hypoxia resulting from aspiration. Using the early vs. late signs and symptoms default strategy, the nurse should expect early findings to be generalized and nonspecific. Behavioral changes result from inadequate perfusion of oxygenated blood to the brain and are an early indication of hypoxia due to aspiration. Peripheral cyanosis is incorrect. Peripheral cyanosis is a late indication of hypoxia due to aspiration. Clients develop a bluish discoloration of the extremities as a result of desaturated hemoglobin in the capillaries. Tachypnea is correct. The nurse should monitor the client for early indications of hypoxia resulting from aspiration. Using the early vs. late signs and symptoms default strategy, the nurse should expect early findings to be generalized and nonspecific. Tachypnea results from inadequate oxygenation from the alveoli to the bloodstream and is an early indication of hypoxia due to aspiration. Pulmonary abscess formation is incorrect. Pulmonary abscess formation is a late manifestation aspiration that results from localized infection of the area.

A nurse is reviewing the plan of care for several clients at the beginning of the shift. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)? (Select all that apply.)

Reviewing pre-printed instructions with a client regarding diet is incorrect. A registered nurse should develop the teaching plan for a client, and licensed personnel should deliver or reinforce client teaching. It is outside the AP's scope of practice to reinforce the information or answer client questions.Feeding a client who had a stroke 2 years ago is correct. It is appropriate for the nurse to delegate feeding a client to an AP if there is no indication of acute impairment in swallowing.Performing a bed bath for a client who is paraplegic is correct. It is appropriate for the nurse to delegate bathing to an AP. The AP should seek supportive assistance if lifting is required and notify the nurse if IV lines need to be manipulated.Comparing a client's peripheral pulses is incorrect. Comparing a client's pulses requires knowledge of physical assessment technique and pathophysiology. The nurse should not delegate this task to an AP.Determining whether a client has rebound tenderness is incorrect. Determining whether a client has rebound tenderness requires knowledge of physical assessment technique and pathophysiology. The nurse should not delegate this task to an AP.

A nurse collects nutritional data from a client and determines that the client is underweight and needs to increase daily caloric intake. Which of the following actions should the nurse take first?

Set a goal with the client for weight gain. Using the nursing process, the nurse should complete the planning phase prior to implementing interventions. Setting client-focused goals is part of the planning phase of the nursing process. The nurse should collaborate with the client to set a realistic and measurable goal for weight gain and then implement appropriate interventions to assist the client in meeting this goal.

A nurse is preparing to collect data from an adult client after receiving change-of-shift report. Which of the following client issues should the nurse address first?

The client has orthostatic hypotension. Orthostatic hypotension is a result of peripheral vasodilation and is associated with acute disorders, such as dehydration and bleeding. Based on the acute vs. chronic priority-setting framework, the nurse should collect further data about this client need first. note: The client has repeated episodes of stress incontinence. Stress incontinence is a chronic disorder associated with weakened pelvic floor muscles. The nurse should instruct the client with techniques for strengthening pelvic floor muscles; however, there is a more acute need the nurse should collect further data on first.

A nurse is caring for a client who has orthopnea and is confused. The nurse is preparing to apply restraints to prevent the client from removing the oxygen device. Which of the following images indicates an action the nurse should plan to take?

The nurse should secure the client's restraints in a manner that will prevent harm to the client. The nurse should be able to place two fingers between the restraint and the client's wrist. This ensures the restraint is secure enough to stay in place and loose enough to maintain adequate tissue circulation.

A nurse is preparing to administer medications to a client who begins having a seizure. Which of the following actions should the nurse take first?

Turn the client on her side. Using the ABC priority-setting framework, maintaining a patent airway is the nurse's priority concern for a client who is having a seizure. An airway obstruction is a potential complication for clients during a seizure secondary to production of secretions. Placing the client in a lateral position promotes drainage of the secretions. Based on this knowledge and using the ABC priority-setting framework, the nurse's first action is to place the client in a lateral position to maintain a patent airway. note: The nurse should document data about the seizure in the client's medical record including start and end time, seizure manifestations, nursing interventions, and client responses. However, this is not the action the nurse should perform first.