ATI - Testing and Remediation Beginning Test
14) A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the vetrogluteal muscle?
Answer: 1 ½ Rationale: The nurse would now that the larger needle is needed to administer the injection to insure that it medicine reached where is suppose to go. 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30. 1/2 inch is incorrect. A 1/2 inch needle is used for subcutaneous injections in adults; it is inappropriate to use for an IM injection. 5/8 inch is incorrect. A 5/8 inch needle is used for subcutaneous injections in adults; it is inappropriate to use for an IM injection. 1 inch is incorrect. A 1 inch needle is used for IM injections in adults who have a low BMI; it would be inappropriate to use a needle of this length for an adult with a BMI of 30.
2)A nurse in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine (Benadryl) 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose?
Answer: 2 tsp Rationale: 12.5 x 2 = 25mg every 6 hours
12) A nurse in caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The clients states, I will quit smoking if the results don't come back positive for cancer.
Answer: Bargaining. Rationale: The client is making a decision based on the results of another action. This is called bargaining.
19) A nurse is reinforcing a teaching to a client who has fractured ankle and is learning to walk up the stairs. Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait.
Answer: Bear weight on unaffected leg transfer body weight to crutches, advance unaffected leg between the crutches shift weight from crutches to unaffected leg, aligns crutuches on the stairs Rationale the nurse would know that this is correct sequence of events for her client.
9) A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion?
Answer: Dullness Rationale: The nurse would know that a client with pneumonia likely would have a dullness sound in his lungs.
3) A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the clients diet?
Answer: Grape Juice, Ice Cream Rationale: Both of these items have a liquid consistency. Therefore it is safe enough for a client with a liquid diet to enjoy.
18) A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed a dose of lorazepam (Ativan) preoperatively. Which of the following statement by the client indicates the medication has been effective?
Answer: I feel very relaxed now Rationale: The nurse would know that the purpose of this drug is to promote relaxation. With this response the nurse would know that the drug has done its job effectively
20) A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first?
Answer: Inspection Rationale: The nurse should know that this is proper thing to do first so she can assess any other problems IAPPa 1st Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen. 2nd Auscultation is incorrect. Auscultation should be the second technique used while conducting an abdominal assessment on a client to determine the frequency and intensity of bowel sounds. Normal bowel sounds occur 5 to 35 times per min. Auscultation also detects vascular sounds or bruits. 3rd Percussion is incorrect. Percussion is the third technique used while conducting an abdominal assessment on a client to discern the presence of tympany and dullness. It is performed to evaluate for the presence of gas in the intestines or fluid and masses in the abdominal cavity. 4th Palpation is incorrect. Palpation should be the fourth technique used during examination of the abdomen to identify abdominal tenderness, masses, or distention. Both light and deep palpation techniques should be performed to identify unexpected masses or organ size outside the expected parameters.
6) A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following?
Answer: Mood Rationale: The nurse would know that the client is depressed and that taking a supplement that might improve mood might help him with his issues.
5) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
Answer: Sims Rationale: The proper position for a client who needs an enema is Sims. It allows for the most comfort and easy administration for the nurse.
16) A nurse is preparing to transfer a client from a bed to a chair. The nurse should take which of the following actions to prevent a lift injury?
Answer: Stand close to the client Rationale: The nurse would know that this could provide adequate leverage in order to move the client smoothly.
8) A nurse on a pediatric unit is caring for an infant who is diagnosed with larynotrachebronchitis. While performing a respiratory examination the nurse hears which sound?
Answer: Stridor Rationale: The nurse would know that the sound she is hearing is Stridor. This would mean she was familiar with her breath sounds. Stridor is correct. Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. Wheezes is incorrect. Wheezes are abnormal breath sounds that are produced because of a narrowing passageway. It is commonly seen in clients with asthma. Rhonchi is incorrect. Rhonchi are course rattling sounds that are similar to snoring. Crackles is incorrect. Crackles are abnormal breath sounds that result from air passing through fluid.
4)A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes.
Answer: Toward the back of the neck Rationale: With proper understanding of the lymphatic system the nurse would know that this would be the correct place to check for a problem.
10) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading?
Answer: Using a cuff that is too wide. Rationale: By using a cuff that is too wide the nurse would know that the time may not be recorded accurately and may result in a low reading,
13) A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways?
Answer: Vector Rationale: The nurse would know that the way Lyme disease is typically transmitted is through a tick, which is a life living thing. Therefore it would fall in the vector category. Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector Airborne is incorrect. Airborne illnesses are transmitted through residue or evaporated particles that are suspended in the air. Examples of airborne illnesses include varicella zoster, measles, and mycobacterium tuberculosis. Lyme disease is not transmitted in this manner. Vehicle is incorrect. Vehicles include inanimate objects, such as contaminated items, water, and food. Illnesses that can be transmitted by a vehicle include MRSA, pseudomonas, salmonella, E. coli, and syphilis. Lyme disease is not transmitted in this manner. Bloodborne is incorrect. Bloodborne illnesses are transmitted through contact with infected blood. Examples of bloodborne illnesses include HIV, hepatitis B, and hepatitis C. Lyme disease is not transmitted in this manner.
17) A nurse is caring for a client who is receiving vancomycin for a beta hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?
Answer: hearing loss Rationale: the nurse would know that the drug might cause hearing loss. Therefore she would monitor the possibilities of this adverse reaction.
15) A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?
Answer: lying on side Rationale: The nurse would know that this is the easiest way for the client to lie in order to have the most accurate reading on the test.
7) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?
Answer: partial thickness skin loss Rationale: Characteristics for a stage II ulcer include partial thickness skin loss. The nurse would know this because she is familiar with the stages of pressure ulcers. Nonblanchable redness is incorrect. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage I pressure ulcer involves intact skin with a localized area of nonblanching redness. Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister. Visible subcutaneous fat is incorrect. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage III pressure ulcer involves full-thickness skin loss and can have visible subcutaneous fat. Exposed muscle is incorrect. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage IV pressure ulcer involves full-thickness tissue loss and exposed bone, tendon, or muscle. Slough or eschar can also be present.
A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Exhibit 1 Serum Laboratory Results: Hemoglobin 15.4 g/dL Protein 7.2 g/dL BUN 8mg/dL Glucose 72mg/dL Exhibit 2 Physical Assessment: 2+ peripheral edema Blood pressure 144/96 mm Hg Increased urinary output Respiratory crackles bilaterally Exhibit 3 Health History: Total hip arthroplasty 10 days ago 15-year history of diabetes mellitus 32-year history of heart failure
Answer: restrict fluid intake Rationale: The nurse would know that by restricting fluid intake the client might become more active and want to go home. Restrict fluid intake is correct. Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.
1) A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?
Answer: ¾ cup of canned tomato juice Rationale: The nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it.
