ATI pre-question (EXAM 1)

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? A. Gait B. Hearing C. Vision D. Balance

D. Balance

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39° C (102° F). Which of the following other vital signs should the nurse expect? A. An elevated pulse rate B. A decreased blood pressure C. An elevated blood pressure D. A decreased pulse rate

A. An elevated pulse rate

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include? A. "Insert the earpieces at a downward angle toward your nose." B. "Use the diaphragm to listen to low-pitched sounds." C. "Drape the stethoscope over your neck when not in use." D. "Clean the stethoscope by immersing it in soapy water."

A. "Insert the earpieces at a downward angle toward your nose."

A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI? A. A Salmonella infection that occurs after eating contaminated food from the cafeteria B. An infection that occurs during a therapeutic procedure C. A yeast infection that occurs while receiving broad spectrum antibiotics D. A urinary tract infection that occurs after a sterile catheter insertion

A. A Salmonella infection that occurs after eating contaminated food from the cafeteria

Which of the following actions should a nurse take after witnessing a breach of a client's confidentiality in a provider's office? A. Complete a health information privacy complaint form. B. Anonymously notify the proper governmental agency. C. Notify the client and ask them to complete a health information privacy complaint form. D. Inform the provider that a formal complaint will be submitted if another breach is committed.

A. Complete a health information privacy complaint form.

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings? A. Crackles B. Stridor C. Wheezes D. Friction rub

A. Crackles

To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? A. Drying provides the full antiseptic effect. B. Residual alcohol can easily stain clothing. C. Excess gel could transfer to the client. D. Slippery gel can make the nurse drop supplies.

A. Drying provides the full antiseptic effect.

Which of the following is an advantage of using alcohol-based gel? A. It takes less time to use than washing with soap and water. B. It removes gross contamination better than soap and water does. C. Its protective nature reduces the need for frequent handwashing. D. It provides adequate protection before surgical applications.

A. It takes less time to use than washing with soap and water.

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration? A. Observe the degree of chest-wall movement during inspiration and expiration. B. Count how many breathing cycles are observed per minute. C. Notice whether or not expiration takes longer than inspiration. D. Measure the precise amount of air the client takes in and breathes out.

A. Observe the degree of chest-wall movement during inspiration and expiration.

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take? A. Place the probe in the posterior lingual pocket lateral to the midline. B. Rest the probe on the lower lingual frenulum. C. Place the probe centrally on top of the client's tongue. D. Rest the probe under the tongue just beyond the client's teeth.

A. Place the probe in the posterior lingual pocket lateral to the midline.

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (Select all that apply.) A. The client who has a BMI of 35. B. The client has had nausea for 2 days. C. The client is reporting a "stuffy" nose. D. The client has been fasting for blood tests. E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.

A. The client who has a BMI of 35. C. The client is reporting a "stuffy" nose. E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.

After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? A. The gloves B. The gown C. The face shield D. The N95 respirator

A. The gloves

Which of the following methods of information exchange can occur without client authorization? A. Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room B. Recording shift report on a device for all oncoming staff to access information about all clients on the unit C. Talking about a client's information during a staff in-service with all levels of unit staff present D. Providing an employer with confirmation that their employee is currently being treated in the facility

A. Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room

A nurse is teaching a newly licensed nurse about using a computer to document in a client's health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I should share my computer password with the nurse orienting me." B. "I should remain aware of my surroundings when documenting in the computer." C. "I can step away from the computer for a short time if I am logged on and no one is around." D. "I can review the health records of other clients on the unit not assigned to me."

B. "I should remain aware of my surroundings when documenting in the computer."

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? A. Document accurate data B. Develop a plan of care C. Validate previous data D. Evaluate outcomes of care

B. Develop a plan of care

A nurse is assessing a client's respiration. Which of the following actions should the nurse take? A. Have the client lie flat in bed with their head on a pillow. B. Elevate the head of the client's bed 45° to 60°. C. Encourage the client to breathe shallowly. D. Ask the client to take several deep breaths prior to the assessment.

B. Elevate the head of the client's bed 45° to 60°.

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? A. Auscultation B. Inspection C. Percussion D. Palpation

B. Inspection

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? A. Lordosis B. Kyphosis C. Ankylosis D. Scoliosis

B. Kyphosis

A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? A. Wear a respirator. B. Protect their eyes. C. Put on clean gloves. D. Wear shoe covers.

B. Protect their eyes.

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? A. Auscultatory gap B. Pulse pressure C. Orthostatic hypotension D. Pulse deficit

B. Pulse pressure

A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? A. Borborygmi B. Rebound tenderness C. Tympany D. Abdominal guarding

B. Rebound tenderness

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? A. Oral temperature 37.8° C (100° F) B. Respirations 30/min C. BP 148/88 mm Hg D. Radial pulse rate 45 beats/30 seconds

B. Respirations 30/min

A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurses take to ensure the study complies with the HIPAA Privacy Rule? A. Contact the medical record department to obtain permission to access clients' charts. B. Submit their proposal to the institutional review board for review and describe how they will de-identify client information. C. Notify the clients who will be included in the study to submit a written request if they choose not to participate. D. Obtain permission from the risk management department to gain access to incident reports that were filed due to client falls.

B. Submit their proposal to the institutional review board for review and describe how they will de-identify client information.

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately? A. Obtain the reading in the early morning. B. Use a cuff of the appropriate size for the client. C. Assist the client to the bathroom to void. D. Apply the cuff loosely around the client's arm.

B. Use a cuff of the appropriate size for the client.

A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which of the following actions? A. Make sure that the water is hot. B. Wash for at least 20 seconds. C. Use a liquid soap preparation. D. Remove rings and watches first.

B. Wash for at least 20 seconds.

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take? A. Cleanse their hands with an alcohol-based gel. B. Wash their hands with soap and water. C. Brush off the soil against a cloth surface. D. Use a wet paper towel to remove the soil.

B. Wash their hands with soap and water.

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A. A continuous sensation of vibration felt over the second and third left intercostal spaces. B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum. C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. D. A whooshing or swishing sound over the second intercostal space along the left sternal border.

C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line.

A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear? A. A sterile gown B. Goggles C. A face shield D. An N95 respirator

C. A face shield

A nurse in a pediatrician's office is speaking on the telephone with the guardian of a school-age child who will become a new client at the office. The nurse should instruct the guardian to call the child's previous provider's office to request which of the following? A. The guardian be allowed to take the child's medical records and make photocopies for the new pediatrician's office B. The child's original medical records be given to the new pediatrician's office C. A form authorizing release of copies of the child's medical records to be signed by the guardian D. A form authorizing release of the child's medical records to be signed by the new pediatrician and sent back to the previous provider

C. A form authorizing release of copies of the child's medical records to be signed by the guardian

What should the nurse do to maintain standard precautions? A. Rinse gloves that become visibly soiled during use. B. Use an antimicrobial soap for routine handwashing. C. Disinfect hands immediately after removing gloves. D. Keep gloves on when touching environmental surfaces.

C. Disinfect hands immediately after removing gloves.

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses? A. Posterior tibial B. Popliteal C. Dorsalis pedis D. Femoral

C. Dorsalis pedis

A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instruct the client to file the complaint? A. Occupational Safety and Health Administration (OSHA) B. The Joint Commission C. Office for Civil Rights (OCR) D. Privacy and Civil Liberties Office

C. Office for Civil Rights (OCR)

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope? A. Over the right midclavicular line B. Over the angle of Louis C. Overt the fifth intercostal space at the left midclavicular line D. Over the suprasternal notch

C. Overt the fifth intercostal space at the left midclavicular line

Which of the following products can affect the permeability of latex gloves? A. Antimicrobial soap and water B. Alcohol-based antiseptic gel C. Petroleum-based hand lotion D. Water-based hand lotion

C. Petroleum-based hand lotion

A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading? A. Attach the disposable probe cover. B. Assess the external ear for redness. C. Pull the pinna back and upward gently. D. Replace the thermometer in its charger.

C. Pull the pinna back and upward gently.

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? A. Right upper quadrant B. Left upper quadrant C. Right lower quadrant D. Left lower quadrant

C. Right lower quadrant

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? A. When the atria contracts vigorously B. As the ventricular walls contract C. When the semilunar valves close D. As the mitral valve snaps open

C. When the semilunar valves close

A newly hired nurse is reviewing information about the HIPAA Privacy Rule during facility orientation. Which of the following statements by the nurse indicates an understanding of the Privacy Rule? A. "Clients do not have the right to read their charts." B. "I can read the charts of other clients on my floor." C. "I will expect a list of clients and their admitting diagnoses to be posted on my unit." D. "I can give information about a client over the phone if the client gives permission."

D. "I can give information about a client over the phone if the client gives permission."

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? A. Hepatitis B B. Measles C. Meningitis D. Infectious diarrhea

D. Infectious diarrhea

A nurse in the emergency department is caring for a client following a motor-vehicle crash. The client is unresponsive and the client's spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client's surgery? A. Ask the facility's Privacy Officer to witness the informed consent document. B. Inform the client's friends that are present about the surgery and obtain group consent. C. Ask the nursing supervisor to provide implied emergency consent. D. Inform the provider of the spouse's contact information so consent can be obtained over the telephone.

D. Inform the provider of the spouse's contact information so consent can be obtained over the telephone.

A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take? A. Rotate the probe if any resistance is met as the thermometer is inserted. B. Insert the probe to aim at the client's pelvic area. C. Dip the probe about 0.58 cm (2 in) into a tube of lubricant. D. Insert the probe about 2.5 cm (1 in) into the client's anus.

D. Insert the probe about 2.5 cm (1 in) into the client's anus.

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? A. It corresponds to the client's systolic pressure. B. It is the second diastolic pressure to record. C. It is the loudest of the Korotkoff sounds. D. It might not follow with a fifth Korotkoff sound.

D. It might not follow with a fifth Korotkoff sound.

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? A. Instruct the client to breathe in and to exhale out as they normally do. B. Count the client's respirations for 15 seconds then multiply by 4. C. Determine if the client has a history of any chronic respiratory problems. D. Observe the client's chest movements while appearing to assess their pulse.

D. Observe the client's chest movements while appearing to assess their pulse.

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact? A. The client can stick their tongue out. B. The client can smile symmetrically. C. The client can hear whispered words. D. The client can identify a minty scent.

D. The client can identify a minty scent.

A nurse is performing a general client survey and finds that the client has a body mass index (BMI) of 23. Which of the following should the nurse document? A. The client has no nutritional issues or deficits. B. The client is at high risk for obesity-related health problems. C. The client will need a referral to a dietitian. D. The client has a BMI within the expected reference range.

D. The client has a BMI within the expected reference range.