ATI - Testing and Remediation Beginning Test
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.
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: 1.5" needle is used for IM injection in adults in ventrogluteal muscle (common site), esp. W/30 BMI
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: 1. Bear weight on unaffected leg. 2. Transfer weight to crutches. 3. Advance unaffected leg. 4. Shift weight from crutches to unaffected leg, 5. Align crutches on stairs and go up stairs. Rationale the nurse would know that this is correct sequence of events for her client.
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: 25 mg x 5 ml ÷ 12.5 mg = x ml; (125 ÷ 12.5 = 10 ml) 1 tsp = 5ml. 10 ml = 2 tsp. per dose.
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. "I will do... if ..."
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: A client with PNA likely would have a dullness sound in his lungs. (thumping watermelon sound)
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: Liquids & food that turns to liquid @ room temp. (Unable to tolerate solid/semi-solid) Full liquid is low in iron (d/t constipation), protein (work on liver & kidneys), & calories. It is contra for long-term. Therefore it is safe enough for a client with a liquid diet to enjoy.
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: Lorazepam (Ativan) = benzodiazepine (lams, pams, vans) antianxiolytic ("Get in the van, pam, we're goin on the lam")
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 to 1. Inspect (look) 2. Auscultate (listen) 3. Percuss (tap) 4. Palpate (feel)
A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?
Answer: L lateral, side-lying Rationale: This is the easiest way for the client to lie in order to have the most accurate reading on the test.
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 anticipate issues w/depression and that this supplement might improve 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?
Answer: Partial thickness skin loss Rationale: Characteristics for a stage II ulcer include partial thickness skin loss. (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? (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: FVE: 2+ peripheral edema. ^BP, Respiratory crackles bilat., 8 BUN (10-20)
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: This provides adequate leverage.
A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination the nurse hears which sound?
Answer: Stridor Rationale: You need to know breath sounds... ("musical" usually c/b blockage in the larynx)
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: Posterior = back Cervical = cervical spine
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,
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: Lyme disease is typically transmitted via a deer tick (arthropods) carry & transmit. (Mosquitoes = malaria, ticks = Rocky Mountain Fever)
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.
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: Tomato juice= 820 mg of Na+
