ATI Practice Test A Rationales
A nurse is caring for a patient who reports pain. When documenting the quality of the patients pain which statement made by the patient should the nurse record?
"The pain is like a dull ache in my stomach" (Client is describing the quality of pain, which is how the pain feels in her own words)
A nurse is caring for a client who is terminally ill. Which statement should the nurse identify as an indication that the client's family member is coping effectively with the situation? 1. "We are not worried. We still have hope that everything will be okay." 2. "This is a difficult time, but we are helping each other through this." 3. "After he comes home, we can plan the family reunion" 4. "We don't need to discuss funeral arrangements at this time"
"This is a difficult time, but we are helping each other through this." (using social supports to assist throughout the grief process)
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? 1. Lacrimal Apparatus 2. Pupil clarity 3. Appearance on bulbar conjuctivae 4. Visual fields 5. Visual acuity
*Pupil clarity (cloudy pupils indicate cataracts, which can increase risk of falling *Visual fields (Use a finger to test client's peripheral vision by moving it out of range and then back. Visual impairment can increase fall risk *Visual acuity (assess distance, can increase fall risk -Bulbar conjuctivae will not impede client safety
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which therapy? 1. Biofeedback 2. Aloe 3. Feverfew 4. Acupuncture
Acupuncture (prevent an open portal on the skins surface which could increase risk for further infection)
A nurse is admitting a client who has varicella. Which type of transmission precautions should the nurse initiate? 1. Airborne 2. Droplet 3. Contact 4. Protective environment
Airborne
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2mL vial. Which action should the nurse take? 1. Ask another nurse to observe the medication wastage 2. Notify the pharmacy when wasting the medication 3. Lock the remaining medication in the controlled substances cabinet 4. Dispose of the vial with the remaining medication in a sharps container
Ask another nurse to observe the medication wastage (a second nurse must witness the disposal of any portion of a dose of a controlled substance)
A nurse is caring for a patient with a prescription for wound irrigation. Which action should the nurse take?
Cleanse the wound from the center outward (prevent introduction of micro-organisms from the outer skin surface)
A nurse is evaluating a client's use of a cane. Which action should the nurse identify as as an indication of correct use? 1. The top of the cane is parallel with clients waist 2. When walking, client moves the cane 18 inches forward 3. Client holds the cane on the stronger side of the body 4. Client moves her stronger limb forward with the cane
Client holds the cane on the stronger side of the body (to increase support and maintain alignment)
The nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which type of transmission precautions should the nurse initiate?
Contact precautions (Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with patient)
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which action should the nurse take?
Flush the tube with 15 mL of sterile water (The nurse should flush the tube with 15-30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication)
A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which food item should the nurse remove from the client's breakfast tray? 1. Tomato juice 2. Bananas 3. Pancakes 4. Fried egg
Fried egg (are evidence-based not part of a mechanical soft diet. Eggs that are poached or scrambled are acceptable for a mechanical soft diet.)
A nurse is performing a romberg's test during the physical assessment of a client. Which technique should the nurse use first?
Have the client stand with her arms at her side and her feet together (Romberg's test helps to identify alterations in balance. The nurse should have the client stand with arms at the side and feet together to observe for swaying and loss of balance)
A nurse is caring for a client who requires an NG tube for stomach decompression. Which action should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed 30 degrees prior to insertion of tube 2. Remove the NG tube if patient starts to gag or choke 3. Apply suction to the NG tube prior to insertion 4. Have the client take sips of water to promote insertion of the NG into the esophagus
Have the client take sips of water to promote insertion of the NG into the esophagus (prevents passage of tube into trachea)
A charge nurse is discussing the responsibilities of nurses caring for patients with c-diff infection. Which information should the nurse include in the teaching?
Having family members wear a gown and gloves (to prevent the transmission of c-diff. Caregivers must also wear gown and gloves)
A nurse is reviewing a client's fluid and electrolyte status. Which finding should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L
Potassium 5.4 mEq/L (value is lower than expected reference range and the nurse should report on it. Client is at risk for dysrythmias)
A nurse is administering an otic medication to an older adult client. Which action should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the tragus of of the ear (helps medication reach inner ear)
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which action should the nurse take?
Remove the stockings at least once per shift
A nurse is assisting a client who is post-operative with the use of an incentive spirometer. Into which of the positions should the nurse place to client? 1. Side lying 2. Supine 3. Semi-fowlers 4. Trendelenburg
Semi-fowlers (allows for maximum expansion of the lungs)
A nurse is caring for a patient who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer SUBQ. Determine the correct order of steps
The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the regular the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH solution and withdraw the correct amount of NPH insulin.
A nurse is caring for a patient who reports experiencing difficulty falling asleep. Which measure should the nurse recommend?
Use progressive relaxation techniques at bedtime (promotes sleep by decreasing stress and reducing muscle tension)
A nurse is teaching an older adult client at risk for osteoporosis about beginning a program of regular physical activity. Which type of activity should the nurse recommend?
Walking briskly (weight bearing exercises are essential for maintaining bone mass, which prevents osteoporosis. Walking engages older adult client in this preventative and therapeutic strategy)
A nurse is caring for a client who requires a 24 hour urine collection. Which statement made by the client indicates an understanding of the teaching? 1. "I had a bowel movement, but I was able to save the urine" 2. "I have a specimen in the bathroom from about 30 minutes ago" 3. "I flushed what I urinated at 7:00 am and have saved all urine since" 4."I drink a lot, so I will fill up the bottle and complete the test quickly"
"I flushed what I urinated at 7:00 am and have saved all urine since" (client should discard the first voiding and save all subsequent voiding)
A nurse is caring for a client who asks about the purpose of advance directives. Which statement should the nurse make? 1. "They allow the court to overrule an adult client's refusal of medical treatment" 2. "They indicate the form of treatment a client is willing to accept in the event of a serious illness" 3. "They permit a client to withhold medical information from health care personnel" 4. "They allow health care personnel in the emergency department to stabilize a patients condition"
"They indicate the form of treatment a client is willing to accept in the event of a serious illness" (Advance directives include a living will, which permits the client to direct treatment in the case of a terminal illness)
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which response should the nurse give? 1. "I'll get a blood sample from you and send it for a screening test" 2. "Beginning at age 60 you should have a colonoscopy." 3. "You should have a fecal occult blood test every year" 4. "The recommendation is to have a sigmoidoscopy every ten years"
"You should have a fecal occult blood test every year" (colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually)
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take actions to assist the client? -Have the client sit and dangle his feet at the bedside -Use the stand-and-pivot technique to move the patient to the chair -Ask the client if he can bear weight -Position the chair at the left side of the bed
1. Assess the client and determine if he can bear weight to assist with his transfer 2. Position the chair on the side of the bed closest to the patient's stronger side 3. Have client sit and dangle his feet at the bedside 4. Use stand-and-pivot technique to move the client to the chair
A nurse is providing care to four clients. Which situation requires the nurse to complete an incident report? 1. A nurse tied a patient's restraint straps to the moveable part of the bed frame 2. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology 3. A nurse administers a medication 30 minutes before the dose is due 4. A client who has an IV infusion pump receives an additional 250 mL of IV fluid
A client who has an IV infusion pump receives an additional 250 mL of IV fluid (report IV malfunction to assist in compiling information for risk management to determine actions to take to further prevent similar incidents)
Transmission precautions: Droplet precautions used for?
A requirement for clients who have infections spread via droplet nuclei that are larger than 5 microns in diameter including: *Rubella *Meningococcal pneumonia *Streptococcal pharyngitis
Transmission precautions: Contact precautions used for?
A requirement for clients who have infections that spread via direct contact or contact with the environment including: *Vancomysin-resistant enterococci *Methicillin-resistant staphylococcus aureus *Scabies
Transmission precautions: Airborne precautions used for?
Airborne precautions are a requirements for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter including: *Varicella *Tuberculosis *Measles
A nurse is administering IV fluid to an older adult. The nurse should perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds (the PRIORITY assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating the lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles, heard in lung fields, dyspnea, & shortness of breath)
A nurse is assessing a client who has been on bed rest for the past month. Which finding should the nurse identify as an indication that the client has developed thrombophlebitis? 1. Bladder distention 2. Decreased blood pressure 3. Calf swelling 4. Diminished bowel sounds
Calf swelling (swelling, tenderness and redness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility)
Transmission precautions: Protective environment used for?
Clients who have an immune-system compromise, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which action should the nurse take first? 1. Gently shake the container of medication prior to administration 2. Transfer the medication to a medicine cup 3. Place the client in a semi-fowlers position prior to medication administration 4. Verify the dosage by measuring the liquid before administering it
Gently shake the container of medication prior to administration (ensure that it is mixed)
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions is within the RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube (It is within the RN scope of practice to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tube)
A nurse is caring for a patient with tuberculosis. Which of the following actions should the nurse take? (Select all that apply)
Place the client in a room with a negative pressure airflow (Meets requirements of airbone precautions) Wear gloves when assisting the client with oral care (Wear gloves whenever hands make contact with bodily fluids, meets requirements of standard precautions) The nurse should wear an N95 respirator during client care (to meet requirements of airborne precautions) Use antimicrobial hand sanitizer for routine hand hygiene (nurse should also wash her hands with soap and water when hands have visible soiling)
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take? 1. Insert the catheter at a 45 degree angle 2. Place the client's arm in a dependent position 3. Shave excess hair from the insertion site 4. Initiate IV therapy in the veins of the hand
Place the client's arm in a dependent position (Because the veins will dilate due to gravity)
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following should the nurse expect?
Rapid heart rate (tachycardia indicates fluid-volume deficit, which is an expected finding for this case)
Types of role-performance stress
Role Ambiguity: Occurs when a person is unclear about the expectations of a role of his given situation Sick Role: Refers to a person experiencing an alteration in health, not the caregiver Role Overload: Having more responsibilities within a role that one person can perform Role Conflict: A person must assume opposing roles with incompatible expectations
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which action should the nurse plan to take? 1. Use a resuscitation bag with 80 percent oxygen prior to procedure 2. Select a suction catheter that is half the size of the lumen 3. Place the end of the suction catheter in water soluable lubricant 4. Adjust the wall suction apparatus to a pressure of 170 mmHg
Select a suction catheter that is half the size of the lumen (Prevents hypoxemia (low concentration of oxygen in the blood) and trauma to the mucosa) (nurse should adjust pressure to 120 mmHg and no higher than 150)
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which finding at the IV site should the nurse identify as infiltration? 1. Purulent exudate 2.Warmth 3. Skin blanching 4. Bleeding
Skin blanching (Skin blanching, edema, and coolness at IV site indicate infiltration)
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which action should the nurse take? 1. Place patient in side-lying position 2. Instill 15 mL of irrigation fluid into the catheter with each flush 3. Subtract the amount of irrigant used from the client's urinary output 4. Perform the irrigation using 20 mL syringe
Subtract the amount of irrigant used from the client's urinary output (open irrigation requires instilling 30-40 mL of irrigation fluid)
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which action should the nurse take first? 1. Rinse the feeding bad with water between feedings 2. Tell the client to keep the head of the bed elevated at least 30 degrees 3. Make sure the enteral feeding formula is at room temp 4. Wipe the top of the formula can with alcohol
Tell the client to keep the head of the bed elevated at least 30 degrees (prevent aspiration of enteral formula, keep head of bed elevated to prevent reflux of the formula backward into the esophagus)
A nurse is caring for a patient who is refusing a blood transfusion due to religious reasons. The client's partner wants them to receive the transfusion. Which action should the nurse take? 1. Ask the client to consider a direct donation 2. Withhold the blood transfusion 3. Request a consultation with the ethics committee 4. Ask the family to intervene
Withhold the blood transfusion (The principle of autonomy ensures that the client who is competent has the right to refuse treatment)
A nurse in a surgical suite notes documentation on a client's medical record that he as a latex allergy. In preparation for the client's procedure, which precaution should the nurse take? 1. Ensure sterilization of non-disposable items with ethylene oxide 2. Wrap monitoring cords with stockinette and tape them in place 3. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication 4. Wear hypoallergenic latex gloves that contain powder
Wrap monitoring cords with stockinette and tape them in place (many monitoring devices and cords contain latex. Nurse should prevent contact with these cords with client's skin by covering them with a nonlatex barrier material, such as stockinette, and using non latex tape to secure them)
