ATI Practice Quiz
A nurse is ready to insert an indwelling catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? A. Contract the pelvis muscles. B. Take a sip of water. C. Exhale slowly. D. Bear down.
D. Bear down.
A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? Use a sterile swab to obtain the specimen. Place the specimen in a sterile container. Label the paper bag in which specimen container is placed. Send specimen container immediately to the lab.
Send specimen container immediately to the lab.
A nurse in a clinic is caring for a client who reports pain crepitus and popping sound in his temporomandibular joint. Based on these findings to which of the following providers should the nurse request a referral to this client? A. Occupational therapist. B. Oral surgeon. C. Physical therapist. D. Otorhinolaryngologist.,
B. Oral surgeon.
A charge nurse is planning a room assignment for a client who has a productive cough a questionable chest X ray and a positive Mantoux test. Room 208 is a private negative pressure airflow room. Room 212 is a semi-private positive pressure airflow room; 214 is a negative pressure semi-private room; And Room 216 is a private positive pressure airflow room. Which of the following rooms should the nurse assign the patient? A. 208. B. 212. C. 214. D. 216.
A. 208.
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses station? A. A client who sustained a head injury and is having periods of confusion. B. A client who reports a severe migraine headache. C. A client who has a suspected diagnosis of tuberculosis (TB). D. A client who has a history of atrial fibrillation and is on continuous ECG monitoring.
A. A client who sustained a head injury and is having periods of confusion.
A nurse is caring for a client who requires isolation for active pulmonary Tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? Select all that apply. A. A protective mask. B. A closed door. C. A gown. D. A puncture proof sharps container. E. Hand hygiene.
A. A protective mask. B. A closed door. D. A puncture proof sharps container. E. Hand hygiene.
A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client decisions? A. Advocate. B. Caregiver. C. Manager. D. Educator.
A. Advocate.
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury which of the following actions should the nurse take? A. Apply the bag for 30 mins at a time. B. Reapply the bag 30 min after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin.
A. Apply the bag for 30 mins at a time.
An AP reports client's vital signs as tympanic temp 37.1oC (98.8oF) HR 92 bpm RR 18 rpm and BP of 98/58 mmHg. Which of the following vital signs should the nurse remeasure? A. BP. B. Respiratory rate. C. Pulse. D. Temperature.
A. BP.
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes poles of 100 beats per minute respiratory rate of 24 respirations a minute blood pressure of 132/76 mmHg And a temperature of 36.8 degrees Celsius (Or 98.2oF.) Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administered to prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the clients evening dose of digoxin.
A. Complete a neurological check.
A nurse is orienting a newly license nurse about documentation of a client's information in the electronic health record. What are the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A. Documentation is a communication tool for the interprofessional health care team. B. Documentation provides information to the client about financial charges for care provided. C. Documentation provides information for a client audit. D. Documentation allows providers to monitor the nurses activities.
A. Documentation is a communication tool for the interprofessional health care team.
A nurse is assisting an older client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? A. Gait belt. B. Jacket harness. C. Four wheel Walker. D. Cane.
A. Gait belt.
And nurses receiving a providers prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? Select all that apply A. Repeat the order back to the provider. B. Question any part of the order that is unclear or inappropriate. C. Transcribe order into the client's health record. D. Obtain the provider signature within 8 hours. E. Implement a recorded order message if the nurse can hear and understand it clearly.
A. Repeat the order back to the provider. B. Question any part of the order that is unclear or inappropriate. C. Transcribe order into the client's health record.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? Select all that you buy? A. Report of feeling pressure. B. Tenderness over the symphysis pubis. C. Distended bladder. D. Voiding 30 milliliters frequently. E. Dysuria.
A. Report of feeling pressure. B. Tenderness over the symphysis pubis. C. Distended bladder. D. Voiding 30 milliliters frequently.
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure their restraints using a quick release tie. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure their strengths to the lowest bar of the side rail. D. Anticipate removing the restraints every four hours.
A. Secure their restraints using a quick release tie.
A nurse is administrating nasal congestion drops for a client. Which of the following actions should the nurse take? A. Tell the patient to blow her nose gently before the installation. B. Assist the client to a sidelying position. C. Hold the dropper 2 centimeters (or one inch) above the naris. D. Instruct the client to stay in the same position for two minutes.
A. Tell the patient to blow her nose gently before the installation.
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage skin over the clients bony prominences. D. Elevate the head of the bed no more than 45 degrees.
A. Use a transfer device to lift the client up in bed.
A nurse at an extended care facility is instructing a class of assistive personnel about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the client's use of a cane? A. When the client moves he should move the cane forward first. B. The client should hold the cane on the weak side of the body. C. The grip should be level with the client's waist. D. The client should first move the strong leg, then the weak one.
A. When the client moves, he should move the cane forward first.
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? Adjust the water temperature to feel hot. Apply 4 to 5 milliliters of liquid soap to hands. Hold the hands higher than the elbows. Rub hands and arms to dry.
Apply 4 to 5 milliliters of liquid soap to hands.
A nurse is caring for a client who has active pulmonary tuberculosis. The client requires airborne precautions and is receiving multi drug therapy. Which of the following should the nurse take to transport the client safely to the radiology department for a chest X ray? A. Ask the X ray technician to come to the clients room to obtain a portable X ray. B. Have the client wear a mask. C. Notify the X ray department that the client requires airborne precautions. D. Wear a filtration mask in glove during transport.
B. Have the client wear a mask.
A nurse is preparing to administer a cleansing enema. Which of the following action should the nurse take? A. Keep the container of solution at a level to maintain client comfort. B. Hold the container of solution 30 centimeters or 12 inches above the anus. C. Hold container of solution level with the clients upper hip. D. Hold the container of solution 15 cm (6 in.) above anus then lower it 15 cm below the anus.
B. Hold the container of solution 30 centimeters or 12 inches above the anus.
A nurse is caring for a client who has an Ng tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0
B. 4.0
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? A. Steatorrhea B. Blood. C. Bacteria. D. Parasites.
B. Blood.
A nurse is receiving change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process. A. Critically analyze client data to determine priorities. B. Collect and organize client data. C. Set client centered measurable and realistic goals. D. Determine effectiveness of interventions.
B. Collect and organize client data.
A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? Select all that Apply. A. Self-confessor. B. Coordinator. C. Evaluator. D. Energizer. E. Dominator.
B. Coordinator. C. Evaluator. D. Energizer.
A nurse is planning care for a client who has a decreased Level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe clients respiratory status. B. Elevate the head of the clients bed 30 degrees to 45 degrees. C. Monitor intake and output every eight hours. D. Check residual volume every four to six hours.
B. Elevate the head of the clients bed 30 degrees to 45 degrees.
A nurse is caring for a client who has experienced a lacerated spleen and has been on bed rest for several days. The nurse auscultates decrease breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which the following conditions. A. An upper respiratory infection. B. Pulmonary edema. C. Atelectasis. D. Delayed gastric emptying.
C. Atelectasis.
A nurse is providing teaching to an assistive personnel about caring for a client with restraints. Which of the following statements by the AP indicates an understanding of teaching? A. I will tie restraints in double knots. B. I will tie restraint to the portion of the bed that moves when the head of the bed is moved. C. I will ensure that restraints fit tightly against the client. D. I will put four side rails up if client is confused.
B. I will tie restraint to the portion of the bed that moves when the head of the bed is moved.
A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse indicate in the demonstration? A. Place her hands on the sides of her rib cage. B. Inhale slowly and evenly through her nose. C. Hold her breath for at least 10 seconds. D. Exhale forcefully through the nose.
B. Inhale slowly and evenly through her nose.
A nurse is assisting with transferring a client from a bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90 degree angle to the bed. B. Lock the wheels of the bed and the wheelchair. C. Acquire the help of several people to lift the client. D. Elevate the bed to a position of comfort for the nurse.
B. Lock the wheels of the bed and the wheelchair.
A nurse has completed an informed consent form with a client. The client then states "I have changed my mind and I do not want to have a procedure done." Which of the following actions should the nurse take? A. Remind the client that a signed informed consent form is legally binding document. B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. C. Inform the surgical team to cancel the client surgery. D. Proceed with preparation of the client for the surgical procedure.
B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure.
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent? A. Obtain the client's consent. B. Witness the client signature. C. Explain the risk and benefits of the procedure. D. Explain the procedure to the client if they do not understand.
B. Witness the client signature.
A nurse is caring for a client who has fallen while getting out of the bed and states "I'm OK! I guess I should have called for help to the bathroom." After assessing the client the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? There were no injuries sustained. An incident report was completed. An incident report was forwarded to risk management. The provider was notified. A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? Pernicious anemia. Dehydration. Prostate enlargement. Bladder infection.
Bladder infection.
A nurse in clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about client's potential allergies during which phase of the nursing process. A. Planning. B. Evaluation. C. Assessment. D. Implementation.
C. Assessment.
The family of an older adult client brings him to the emergency room after finding him wandering outside. During the initial assessment the nurse notes that the patient flinches when she palpates abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as likely explanation for the client's behavior? A. He is hard of hearing. B. Pain. C. Confusion. D. Language barrier.
C. Confusion.
A nurse is assessing cyanosis and a client has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand. C. Conjunctivae. D. Dorsal surface of the foot.
C. Conjunctivae.
A nurse is discussing the norming stage of the group development process with the nurse student. Which of the following statements by the student indicates understanding of the discussion? A. This stage involves constructive efforts on the part of the group members. B. This stage is when testing occurs to identify boundaries of interpersonal behaviors. C. Consensus evolves in this stage. D. Resistance is evident as subgroups form in this stage.
C. Consensus evolves in this stage.
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings the nurse recognizes that these findings are consistent with which of the following condition? Sodium equals 152. Potassium equals 3.6. Chloride equals 105. Glucose equals 102. BUN = 18. Creatinine in equals 0.7. A. Renal failure. B. Low protein diet. C. Dehydration. D. Syndrome of inappropriate antidiuretic hormone (SIADH).
C. Dehydration.
A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? A. I will begin 40 hour before the clients discharge. B. I will begin once the client's discharge order is written. C. I will begin upon the client's admission to the facility. D. I will begin once the clients insurance company approves to discharge coverage.
C. I will begin upon the client's admission to the facility.
A nurse is caring for an older client who states "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the clients fluid intake in the evening. B. Obtain a bedside commode for the clients use. C. Leave a night light on in the patients room. D. Put the side rails up and tell the client to call the nurse before voiding.
C. Leave a night light on in the patients room.
A client smoking in his bathroom has dropped a cigarette butt in a wastepaper basket which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.
C. Move any clients in the immediate vicinity.
A nurse is caring for a client who has a methicillin-resistant Staphylococcus Aureus (MRSA) in an abdominal wound. The nurse enters the room to check the patient's pulse. Which of the following actions should the nurse take? A. Wear a gown. B. Wear sterile gloves. C. Wear clean gloves. D. Wear protective eyewear.
C. Wear clean gloves.
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine Kinase B. Troponin C. Total bilirubin. D. Albumin.
D. Albumin.
A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? A. An adolescent who has a cervical fracture and is in a halo brace. B. A young adult who has a femur fracture and is in skeletal suspension traction. C. A middle adult who has a fractured radius and an arm cast. D. An older adult who has a hip fracture and is in Buck's traction.
D. An older adult who has a hip fracture and is in Buck's traction.
A nurse is assessing a client's cranial nerves as part of a neuro examination. Which of the following actions should the nurse take to assess cranial nerve III? A. Testing visual acuity. B. Observing for facial symmetry. C. Eliciting the gag reflex. D. Checking the pupillary response to light.
D. Checking the pupillary response to light.
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing planter flexion contractures? A. Trochanter roll. B. Sheepskin heel pad. C. Abduction pillow. D. Footboard.
D. Footboard.
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? A. I will wear gloves when removing food from the freezer. B. I will try to anticipate and avoid stressful situations when possible. C. I will complete this smoking cessation program I started. D. I will take my medications at the first sign of an attack.
D. I will take my medications at the first sign of an attack.
A nurse is preparing to administer an intramuscular injection of Meperidine to a client. Which of the following is the priority assessment the nurse should complete? A. Apical Pulse rate. B. Blood pressure. C. Level of consciousness. D. Respiratory rate.
D. Respiratory rate.
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? A. A client who has a tracheostomy tube attached to humidified oxygen. B. The client who has an indwelling urinary catheter to gravity drainage. C. The client who has a chest tube to water seal. D. The client who has a nasogastric tube to suction.
D. The client who has a nasogastric tube to suction.
A nurse enters an older adult clients room to insert a saline lock. The client asked the nurse "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide? A. It is quicker to administer medications intravenously in the hospital. B. Clients over the age of 65 must have a saline lock according to facility policy. C. We administer all medications intravenously to clients in this unit. D. Your provider has prescribed antibiotic therapy to be administered intravenously every six hours.
D. Your provider has prescribed antibiotic therapy to be administered intravenously every six hours.
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? Select all that apply. More difficulty seeing due to a greater sensitivity to glare. Decrease cough reflex. Decrease bladder capacity. Decrease systolic blood pressure. Dehydration of intervertebral discs.
Decrease cough reflex. Decrease bladder capacity. Dehydration of intervertebral discs.
A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?
Femoral, patella, shin, toes
A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed? Battery. Negligence. Malpractice. Assault.
Negligence.
A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Occupational therapist. Social worker. Registered dietitian. Speech pathologist.
Occupational therapist.
A nurse is documenting information in a computerized health record. Which of the following nurse's actions jeopardizes clients confidentiality? Logging out of the computer before leaving a terminal. Sharing computer passwords with coworkers. Using a computer terminal in a non public area. Preventing an unidentified health care worker from viewing a health record on the computer screen.
Sharing computer passwords with coworkers.
A nurse providing oral care for a client who is immobile. Which of the following actions should the nurse take? Use a stiff toothbrush to clean the client's teeth. Use the thumb and index finger to keep the clients mouth open. Turn the client on his side before starting oral care. Apply petroleum Jelly to the client's upper lip after oral care.
Turn the client on his side before starting oral care.
A nurse is providing discharge teaching about the clean intermittent self-catheterization to our client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? Perform catheterization when you recognize the urge to void. Hold the penis at a 30 degree to 45 degree angle when inserting the catheter. Inflate the balloon when the urine flow stops. Use soap and water to wash the catheter after each use.
Use soap and water to wash the catheter after each use.
A nurse is performing a cardiac assessment. Identify where the nurse should place Stethoscope to auscultate the clients apical pulse?
aortic valve pulmonary valve 2nd pulmonary/ erb's point tricuspid valve mitral valve
A nurse is reviewing information about the health insurance portability and Accountability Act (HIPAA) With a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. Information about a client can be disclosed to family members at anytime. B. HIPAA established regulations of individually identifiable health information is verbal
electronic, or written form. C. Hey client address would be an example of personal identifiable information. D. HIPAA is a federal law, not a state law., A. Information about a client can be disclosed to family members at anytime.
