ATI Questions

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the celling. Instilling a drop onto the center of conjunctival sac an applying gentle pressure to the lower lid with facial tissue. Which actions should nurse take?

1. Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse is applying an ice bag to the ankle of a client following a sport injury which action should nurse take?

1. Fill the bag 2/3 full of ice

A nurse is changing the dressings for client recovering form appendectomy following ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to provider?

1. Halo of erythema surrounding skin

A nurse in a same day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo MRI?

1. Hearing aids

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?---

1. Hold the breath for 5 sec after goal volume is reached

a nurse is preparing to remove an ng tube for a client who had a partial colectomy. Which action should the nurse take?

1. Pinch the ng tube while removing the tube

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

1. Ventrogluteal

A nurse is teaching a client who has asthma the proper use of an albuterol inhaler. Which of the statements indicates an understanding of the teaching?

- I will shake inhaler well before I use it

nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which actions should the nurse take first?

- check the clients perineum

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing or care for client?

- test the presence of gag reflex

A nurse is collecting a halth history data from a client who is deaf and uses American sign language to communicate, The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter?---

--- Pace speech to allow time for the interpreter when explaining the procedure.

1 L of dextrose in 0.45% sodium chloride infusing at 125 mK/her. How many hours will it take for the littler to infuse?

---8

A nurse on a mental health unit is preparing to terminate the nurse client relationship with a client who no longer needs care. Which concepts should nurse, and client discuss in termination phase of relationship?

-Loss

A nurse is assessing client who has sudden onset of severe back pain of unknown origin. Which of the questions should nurse ask to encourage discussion with the client?

1. What do you think cause the onset of your pain?

A nurse document the presence of clubbing of fingernails for client with emphysema. Which is underlying cause of this finding?

1. chronic hypoxemia

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require blood transfusion. The client expresses concern about the risk of acquiring infection form the blood transfusion. Which statements should the nurse share with client?

1. donate autologous blood before the surgery"

A nurse is teaching AP how to obtain capillary finger stick blood sample. Which actions by the AP requires the nurse to intervene?

1. elevating the finger above heart level

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders?

1. glaucoma

A nurse caring for a toddler at well child visit when mother calls HELP my baby is choking on food. Which finding indicates the toddler has airway obstruction?

1. inability to cry or speak

A nurse is presenting an in-service training session about nutrition. Which simple sugars should the nurse identify as the carb found in milk?

1. lactose

A nurse is caring for a client who has chronic kidney disease. The kidney regulates body fluid as well as assisting with which function?

1. regulation of acid base balance.

A nurse is assessing a client's nutrition status. The nurse determines the client is consuming 500 Cal more per day than his energy level requires. If his dietary habits do not change how long will it take the client to gain 4.5 kg?

10 weeks

A nurse is caring for client who has prescription acetaminophen 325 mg PO for oral temp of 38.4. above what Fahrenheit temp should the nurse administer to client?

101.1

A nurse is preparing to administer sotalol to client with prescription for 320 mg/day divided equally every 12 hr. the med is available in 80 mg tab. How many tabs should the nurse administer per dose?

2 tabs

A nurse is calculating a client's intake for a 12 hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/r, gentamicin 150 mg in 100 mL at 1400, ranitidine 50 mg in 50 ML at 1000 and 16000, 259 mL of blood over 2 hr. What is the total intake in ML that the nurse should document over this 12 hr period? ---

2130

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which actions should nurse take while client is in restraints?

Remove the restraints one at a time

A nurse is performing a neurological assessment of client. to promote safety during exam the nurse stand nearby as the client follows instruction of which of flowing tests?

Romberg

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a from of secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations.

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 ml occurs each day through which of the following organs?

Skin

A nurse is caring for client who is hospitalized and has a new tracheostomy. Which actions should the nurse take when performing tracheostomy care for client?

Soak the inner canula of the tracheostomy tube in normal saline

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower intensity activities of daily living. Which of the following is recommended?---

Washing dishes

A nurse is initiating seizure precaution for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at client's bedside? -

oxygen equipment

A nurse is admitting a client who has measles. Which of the following types of transmission precaution should the nurse initiate?

airborne

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which actions should nurse take first?

ask the client to identify the specific food allergies

a nurse is supervising a new nurse who is administering a controlled substance. Which action by the new nurse indicates an understanding of procedure?

asking another nurse to observe the disposal of an unused portion of medication

A nurse is preparing to insert an indwelling urinary catheter for female. Which action should the nurse have the client perform just before inserting?

bear down gently

A nurse is caring for a client who requires peripheral iv insertion. When choosing the site which sites should the nurse select?

choose a vein that is soft on palpation

A nurse is performing a physical assessment of client. the nurse should recognize that which of the following findings places the client at risk for impaired skin integrity?

faint pedal pulses

A nurse is called away for an emergency while conversing with client who is concerned about his medical diagnosis. The nurse returns to client promptly as promised. Which ethical principle is the nurse demonstrating?

fidelity

Nurse is preparing client who is scheduled for a hysterectomy for transport to the OR. The client states she no longer wants surgery. Which action should nurse take?

notify provider of the client's decision

A nurse caring for client who has injuries resulting form motor vehicle crash. Which client statement should nurse address first?

"I can't sleep well because whenever I move in my sleep the pain wakes me up"

A nurse is caring for a client who has a terminal illness. The family wants to care for client at home. Which of the following statements indicates that the nurse understands family centered care?

"let's set up a meeting time with the doctor to discuss your options for home care

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?---

Potassium 3.0

Nurse in planning to insert ng tube for client after explaining procedure client state you are no putting that hose down my throat. Which of the following statements should the nurse make? -

1. "I can see this is upsetting you"

A nurse is assisting a client who has dysphagia at mealtime. Which action should the nurse take?

Advise the client to tuck his chin downward

A nurse is preparing to anchor the catheter tube with tape for a male client who has a newly inserted indwelling catheter. At which of the following locations should nurse tape catheter? -

lower abdomen

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following location should the nurse palpate the posterior tibial pulse?

Below the medial malleolus

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury the nurse should suspect injury to which of the following areas of the brain? -

Cerebellum

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene. Which action should nurse take?

Circle the injection area with a pen

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are age 65 or older are reluctant to report pain

A nurse is caring for client who had a mastectomy and has a self-suction drainage evacuator in place. Which actions should nurse take to ensure proper operation of device?Collapse the device to remove air after emptying

Collapse the device to remove air after emptying

A nurse is teaching a client who is postoperative how to use a flow oriented incentive spirometer. Which of the following instructions should the nurse include?---

Cough deeply after each use

A nurse is assessing a client. Which findings should the nurse identify as an indication of protein calorie malnourishment?

Dry brittle hair, EDEMA, poor wound healing

While admitting client to medical unit the nurse asks if he has advance directive. Client states "I have a document with me that name someone who can make health care decision for me if not able" the nurse should identify that the client is referring to which document?

Durable power of attorney document.

A nurse is teaching middle aged female about disease prevention and health maintenance. Which diagnostic test should the nurse recommend as part of the client's routine heath screening?

Eye exam every 2 years

A nurse is communicating with a group pf clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?---

Feedback is provided

A nurse is caring for client with gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

Hyperglycemia

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which interventions should the nurse include?

Limit drinking liquids with food

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which adhering devices is the best choice for nurse to use to decrease skin irritation?

Montgomery straps

A nurse on med surg unit is caring for a client. which actions should the nurse prioritize when using nursing process?

Obtain client information

A nurse is preparing to irrigate client wound. Which actions should nurse take?

warm irrigation solution 37 c or 98.6 F

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse see first?

1. -A client who has HF and receiving 100% o2 via partial rebreather mask.

A nurse is teaching a client who is postoperative following knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement of knee joint?

1. -Antagonistic

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and puncture clients finger for procedure but does not obtain adequate amount of blood. Which actions should the nurse take next?

wrap the client's finger in a warm's washcloth

The nurse is assessing a client's respiratory system. Which breath sounds should the nurse expect to hear over the periphery of the major lung fields?

1. - vesicular

A nurse caring for client who is well hydrated and has no visible evidence of nutritional deficiencies. A lab result within expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

-albumin

A nurse is conducting an admission interview with client. Which pieces of assessment info should nurse collect during introductory phase of interview?

-clients level of comfort and ability to participate in interview

a nurse is reviewing a client's 24 hr. dietary recall. The client reports eating slice of toasted bread with butter and banana glass of milk and cup coffee. Grilled chicken baked potatoes and mil for lunch apple chees for snack 2 serving of chicken two broccoli and glass of milk for dinner. The client's diets are deficient in which of the following food groups?

-grains

A nurse is teaching AP about proper hand hygiene. Which of the following statements by the AP indicates an understanding of teaching?

1. "there are times I should use soap and water rather than an alcohol-based rub to clean my hands"

A nurse is teaching client how to use albuterol metered dose inhaler. After removing cap from inhaler and shaking what sequence of instructions should the nurse give?

1. ****Hold the mouthpiece 1 to 2 inches from mouth. ***** 2. Tilt you head back slightly and open your mouth wide 3. Depress the canister while taking a slow deep breath 4. Hold your breath for 10 sec

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assess the nurse notes the clients wound eviscerated. Which actions should the nurse take?

1. ****Place client in a supine position with hips and knees flexed.*** 2. cover the wound and intestine with sterile moistened dressing. 3. Monitor client of shock

a nurse is providing teaching to a newly nurse about removing sutures from the client laceration. Which of the following statements by the nurse indicates an understanding of teaching?

1. - "I will clip each suture close to the skin and pull it through from the other side"

A nurse is caring for client who is scheduled to receive transcutaneous electrical nerve stimulation for pain. The client asks how tens unit helps relieve pain which response should nurse make?

1. - "it modulates the transmission of pain impulse"

A nurse is an oncology clinic is assessing client who undergoes treatment for ovarian cancer. Which statement by client indicates she is in psychological distress?

1. - I keep having nightmares about my upcoming surgery

A nurse is administering a med to client who ask the nurse to leave the medication at the bedside to be taken later. Which response should nurse make?

1. - call me when you are ready, and I will return with medication

A nurse is discussing fire safety with newly hired nurses. Which actions is priority if a fire occurs in health facility? -

1. - evacuate clients from the unit

A nurse is preparing to administer a partial dose of prefilled opioid analgesic parenterally to a client. Which actions should nurse take?

1. - record the amount of medication wasted on the controlled substance inventory record

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which sites should the nurse select for the injection?

1. - side hip between the iliac crest and anterior iliac crest spine

A nurse is providing teaching to client about surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which actions should the nurse take?

1. - stop the teaching and check with the surgeon about informed consent

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give client before inspecting and palpating this gland?

1. - tilt your head back and swallow

A nurse in an urgent care center is caring for 15-year-old client whose symptoms suggest sexually transmitted infection. The client's parent is unavailable, but the client's grandmother accompanies the clients. which action should the nurse take?

1. -ask the adolescent to sign the consent form

A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at bedside. Which actions should nurse take first?

1. -lower the client to the floor

A nurse is caring for group of clients. Which of the tasks should the nurse assign to an assistive personnel?

1. -provide oral care to a client who cannot take oral fluids

A nurse is caring for client with breast cancer. The client has been receiving radiation therapy for several months and refuses to undergo further treatment. Which action should the nurse take? -

1. -support the client's decision

A nurse is preparing to insert an ng tube for a client. Which actions will help facilitate the insertion of the tube?

1. 1. Coat the tip of the tube with water soluble lubricant 2. Ask client to swallow water while the tube enters throat 3. ****Tell the client to tilt her head backward as insertion begins. ****

A nurse is preparing to change dressing on client who is receiving negative pressure wound therapy what is sequence of action?

1. 1. Turn off the vacuum on the npwt device and administer prescribed analgesic 2. Remove the solid dressing and perform hand hygiene 3. Apply sterile or clean gloves to irrigate. **** 4. Appling skin protectant or barrier film to skin around wound 5. Place foam in the wound bed and cover with transparent dressing. 6. Connect the tubing to transparent film and turn on new unit.

A nurse is caring for a client who has tracheostomy and requires suctioning. Which of the following actions should nurse take first?

1. ? Hyperoxygenate the client before suctioning.

A nurse is helping a client change his hospital gown. The client has an iv infusion via an infusion pump. Which of the following actions should the nurse take first?

1. ? Remove the sleeve of the gown from the arm without the iv line

A nurse is caring a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?---

1. ?--- Cover the incision with a moist sterile dressing

A nurse asks "a bird in the hand is worth two in the nest" through this question the nurse is evaluating the client's ability in which of the intellectual functions?

1. Abstract reasoning

A nurse on a telemetry unit is caring for a client who had a mypcardial infarction. The client states, "all of this equipment is making me nervous." Which of the following responses should the nurse offer?

1. All of this equipment can be frightening

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?---

1. Bounding pulse

A nurse is talking with client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of diagnosis. The nurse should identify the client is in which stages of dying?

1. Depression

A nurse is performing a mental status exam on a client who has manifestation of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?

1. Discuss the meaning of a common proverb

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

1. Insert the tip of the tubing 8 cm or 3.1 in

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use assess for a pulse deficit?---

1. Obtain the apical and radial rates simultaneously

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements indicates an understanding of the teaching?---

1. People who are practicing Judaism stay with the body of the deceased until burial

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which actions should the nurse plan to take?

1. Place the client in the Trendelenburg position

A nurse at screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

1. Second intercostal space to the right of the sternum

Nurse is assessing client who is unconscious. Family members are present and answer the nurse's questions about medical history. Nurse should document the information as which of the following types of data? -

1. Secondary-source data

A nurse is caring for a client who has a bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?—

1. Sit at the bedside while feeding the client

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

1. Sit on the toilet 30 min after eating meal

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltrations of the IV infusion site?---

1. Taut skin around the IV catheter site that is cool to the touch

A nurse on med surg unit is washing her hands prior to assisting with a surgical procedure. Which actions by the nurse demonstrates proper surgical handwashing technique?

1. The nurse holds her hands higher than her elbows while washing

A nurse is caring for a child who has metchiliin resistant staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?

1. Wear a gown when in the client's room

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral med. How many ML of water should the nurse document as intake for 3 separate meds the client receives during 12-hour shift?

90

A nurse is obtaining the blood pressure in client lower extremity. Which actions should nurse take?

? Place the bladder of the cuff over the posterior aspect of the thigh.

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red bloody drainage

A nurse is employing a thorough systematic method while obtaining objective date about a client. Through which method should the nurse collect information?

Physical examination

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the functional classifications? -

Plasms volume expander

A nurse on med surg unit is caring for client who has been coughing intermittently during meals. Attempting to clear her throat repeatedly and eating only small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

Speech language pathologist

As part of a neurological exam, a nurse instructs a client to keep his eyes closed, placed object in hand. And asks to identify. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis

A nurse is applying antiembolitic stockings for a client who has history of dep vein thrombosis. Which actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying.

A nurse is teaching middle aged client about health promotion and disease prevention. The nurse should inform the client that which changes should occur?

decreased estrogen and testosterone production

A nurse is caring for client who's unstable and vital signs measured every 15 min by electronic blood pressure machine. Nurse notices the machine begins to measure BP at varied intervals and reading are inconsistent. Which action should nurse take?

disconnect the machine and measure the BP manually every 15 min

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? - elevate

elevate the head of the client's bed

a nurse is caring for a client who requires a chest x-ray. Prior to client being transported for procedure which of the following actions should the nurse take first?

identify the client using 2 identifiers.

A nurse is caring for a client who is 48-hour post op following small bowel resection. The client reports gas pains in periumbilical area. The nurse should plan care based on which of the following factors contributing to this post op complication

impaired peristalsis of the intestine

A nurse is performing a physical exam on client. The nurse should use percussion to evaluate which of the following body parts?

lungs

A nurse n long term care is admitting client who is incontinent and smells strongly of urine, his partner is embarrassed and apologizes for the smell. Which response should nurse make?

must be difficult to care for someone confined to a bed"

A nurse is caring for a client who has xerostomia with lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

starch

A nurse is caring for a client who has history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal painful stimuli has no respirations and pulseless. Which action should nurse take first?

start chest compressions

A nurse is assisting client who has right sided weakens while ambulating using a cane. Which of the following client actions should indicate to nurse that client understands the procedure of cane waling?

the client keeps 2 points of support on the ground