first half of ATI questions

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? A. Reassess the client to determine the reasons for unsatisfactory pain relief. B. See whether the pain lessens during the next 24 hr. C. Change the plan to ensure that the client achieves adequate pain relief. D. Teach the client about the plan of care for managing his pain.

A

a nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. which of the following actions should the nurse plan to perform first? A. implement airborne precautions B. obtain a sputum culture C. administer antituberculosis medications D. recommend a screening test for family members

A

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP), which of the following instructions should the nurse include when discussing handwashing? (select all that apply.) A. apply 3 to 5 ml of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds C. Rinse the hands with hot water D. Use clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing

B,C,D

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscular atrophy C. Pressure injury D. Fecal impaction

C

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? Select all that apply A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles

A, B, D

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (SATA) A. fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A, B, E

a nurse in a residential care facility is assessing an older adult client. which of the following findings should the nurse identify as atypical indications of infection in this client? (select all that apply) A. urinary incontinece B. malaise C. acute confusion D. fever E. agitation

A, C, E

which of the following actions should the nurse take when demonstrating an empathic presence to a client? (select all that apply) a. use of open posture b. write down what the client says to avoid forgetting details c. establish and maintain eye contact d. nod in agreement with the client throughout the conversation e. sit facing the client

A, C, E

A charge nurse is reviewing steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data (select all that apply)? a. respiratory rate is 22/min with even, unlabored respirations b. the client's partner states, "they said they hurt after walking about 10 minutes" c. the client's pain rating is 3 on a scale of 0 to 10 d. client's skin is pink, warm, and dry e. the assistive personnel reports that the client walked with a limp

A, D, E

A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. which of the following incidents should the nurse include as examples of the direct mode of transmission? (select all that apply) A. blood spurting from an arterial wound splashes into a nurses eye B. a nurse has a needle stick injury C. a mosquito bites a hiker in the woods D. a nurse finds a hole in their glove while handling a soiled dressing E. a person fails to wash their hands after using the bathroom and touches a client

A, E

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrates the rationale for reporting? (select all that apply) A. Planning and evaluating control and preventing strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. D.Identifying endemic disease. E. Monitoring common source outbreaks.

A,B, C, E

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of the cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Please the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

A,B,D

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address" b. "I will review past medical history on the client's record to get more information" c. "I will carry out the new prescription from the provider." d. I will ask the client if their nausea has resolved"

A

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr prn for pain. The nurse administered the medication and checked with the client 40 mins later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. evaluation

A

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. complete a fall risk assessment' B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession

A

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breath every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

A

A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. Supine B. Semi-fowler's C. Semi-prone D. Trendelenburg

B

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating

B

A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This device will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

B

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway."

B

a nurse is caring for a school-aged child who is sitting in a chair. to facilitate effective communication, which of the following actions should the nurse take? a. touch the child's arm b. sit at eye level with the child c. stand facing the child d. stand with a relaxed posture

B

which of the following strategies should a nurse use to establish a helping relationship with a client? a. make sure the communication is equally distributed between the nurse's and client's desires b. encourage the client to communicate their thoughts and feelings c. give the nurse-client communication no time limits d. allow communication to occur spontaneously throughout the nurse-client relationship

B

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Please pillows under the client's knees and lower extremities. E. Assist the client to change position often.

B, E

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (select all that apply) A. Open doors to client rooms B. Place blankets over clients who are confined to beds. C. Move beds away from the windows. D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms.

B,C,D

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? Select all that apply A. "My line of gravity should fall outside my base of support" B. "The lower my center of gravity, the more stability I have" C. "To broaden my base of support, I should spread my feet apart" D. "When I lift an object, I should hold it as close to my body as possible" E. "When pulling an object, I should move my front foot forward"

B,C,D

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (select all that apply) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B,C,D

A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant-Staphylococcus aureus (MRSA). which of the following statements should the newly licensed nurse understands the teaching? A." I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed. C. " i will protect others from exposure when I transport the client outside the room." D. " to decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."

C

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority? A. A client who received crush injuries to the chest and abdomen and is expected to die. B. A client who has a 4-inch laceration to the head C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia

C

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with our head and shoulders supported by a pillow." B. "Have your head turned to the side while you lie on your stomach." C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D. "Lie on your side with your top arm resting on the bed and your weight on your hip."

C

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit

C

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical,resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area w/ running water B. Wash the affected area w/ antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive

C

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. keep the sterile field at least 6 ft away from the client's bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. keep a box of facial tissues nearby for the client to use during the dressing change.

C

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? A. A client who is dehydrated and receiving IV fluid and electrolytes. B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg E. A client who has acute appendicitis and is scheduled for an appendectomy

C, D

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include?(select all that apply) a. writing a prescription for morphine sulfate as needed for pain b. inserting a nasogastric (NG) tube to relieve gastric distension c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every 2 hours to reduce pressure injury risk

C, D, E

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (select all that apply) A. Place a best restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment

C, D, E

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (select all that apply.) A. a bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C, D, E

a nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. which of the following statements should the nurse make? (select all that apply) a. "you will do great! you just have to get used to it." b. "why are you worried about going home?" c. "your daily routines will be different when you get home" d. "tell me about the support system you'll have after you leave the hospital" e. "it sounds like you are not sure how having a colostomy will affect swimming."

C,D,E

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? a. open the windows in the client's room to allow smoke to escape b. obtain a class C fire extinguisher to extinguish the fire c. remove all electrical equipment from the client's room d. place wet towels along the base of the door to the client's room

D

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. tuberculosis

D

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse' priority at this time? A. Obtain a walker for the client to use to transfer back to bed B. Call for additional staff to assist w/ the transfer. C. use a transfer belt and assist the client back into bed. D. Determine the client's ability to help with the transfer

D

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."

D

a nurse in a primary care clinic assessing a client who has a history of herpes zoster. which of the following findings suggest that the client has postherpetic neuralgia? A. linear clusters of vesicles on the right shoulder B. purulent drainage from both eyes C. decreased white blood cell count D. report of continued pain following resolution of the rash

D