ATI Testing and Remediation Beginning Test

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief?

Bargaining To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is scheduled for a biopsy of a tumor located in her left lower lobe. The client states, "I will quit smoking if the results don't come back positive for cancer." Question: This statement indicates the client is in which of the following stages of grief? Person of Focus: The client scheduled for the biopsy of a lung tumor Key Words: tumor, left lower lobe of lung, "I will quit if" So, the question is asking which of the stages of grief is client is in. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.

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?

"I feel very relaxed."

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 ventrogluteal muscle.

1 1/2 inch

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?

3/4 cup of canned tomato soup

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?

2 tsp

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.

Client stands, bearing weight on unaffected leg. Client transfers body weight to the crutches. Client advances the unaffected leg between the crutches. Client shifts weight from crutches to the unaffected leg. Client aligns crutches on the stair.

A nurse is preforming a respiratory examination in a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion?

Dullness the question is asking which of the sounds heard during percussion should be elicited over areas of consolidation. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.

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?

Grape juice, ice cream

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes.

Hot spot A (behind neck)

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 next?

Inspection

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following?

Mood

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?

Partial thickness skin loss Scenario: A nurse is caring for a client who is immobile and has developed a pressure ulcer. Question: Which of the following characteristics is associated with a stage II pressure ulcer? Person of Focus: The client who has developed a pressure ulcer Key Words: pressure ulcer, characteristics, stage II So, the question is asking which of the characteristics is associated with a stage II pressure ulcer. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 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.

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? 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

Restrict fluid intake

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?

Sims'

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to precent a lift injury?

Stand close to the client

a nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While preforming a respiratory examination, the nurse hears the sound on the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds?

Stridor

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low-pitched diastolic murmur?

The guy lying on his side "this image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.

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?

Using a cuff that is too wide. So, the question is asking which of the actions can cause an inaccurately low reading. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Leaving client's arm unsupported is incorrect. Leaving the arm unsupported can result in a false high blood pressure reading. If you missed this item, your remediation should include an overview of factors that influence blood pressure readings.

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. Th nurse should include that the disease is transmitted in which of the following ways?

Vector Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. Question: The nurse should include that the disease is transmitted in which of the following ways? Person of Focus: The nurse who is reinforcing the teaching Key Words: Lyme disease, transmitted So, the question is asking which of the modes is how Lyme disease is transmitted. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 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.

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?

Hearing loss To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is receiving vancomycin for a beta-hemolytic streptococci infection. Question: For which of the following adverse effects should the nurse monitor? Person of Focus: The client who is receiving vancomycin Key Words: laboratory values, indicates, nephrotoxicity So, the question is asking which finding the nurse should monitor for in a client who is receiving vancomycin. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next, you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Hearing loss is correct. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect.