ATI QUESTIONS UNIT 2&3

a nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states " i have changed my mind; i do not want to have this surgery" which of the following ethical principles is the client using 1. Justice 2. Fidelity 3. Autonomy 4. Nonmalefience

Autonomy

a nurse is preparing to assess a newly admitted client which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? 1. Penlight 2. Tape measure 3. Doppler 4. Tongue depressor 5. Electrocardiogram monitor.

Penlight, Tape measure, tongue depressor

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? 1. The client is sitting in a relaxed posture. 2. The client asks for a tissue and uses it to wipe away an occasional tear. 3. The client tells the nurse that visits from their friends and family make them smile. 4. The client reports they feel sad and lonely most of the time.

The client reports they feel sad and lonely most of the time.

A nurse is completing documentation in a client's medical record. which of the following actions should the nurse take? 1. The clients abdomen is soft and nondistented 2. The client is feeling better 3. The client is not in any pain 4. The clients status is unchanged.

The clients abdomen is soft and nondistented

A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Take the client's blood pressure in a seated position. 2. Take the client's blood pressure in the supine position. 3. Keep the cuff in place and assist the client to a seated position. 4. Place the client in a supine position and allow them to rest. 5. Assist the client to stand and obtain their blood pressure.

1. Place the client in a supine position and allow them to rest 2. Take the client's blood pressure in the supine position 3. Keep the cuff in place and assist the client to a seated position 4. Take the client's blood pressure in a seated position 5.Assist the client to stand and obtain their blood pressure

a nurse in the emergency department has received report on a child who has a laceration to the right calf which of the following steps of the nursing process should the nurse perform first 1. Analylisis 2. Planning 3. Evaluation 4. Assessment

Assessment

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? 1. Do not expose any more of the client's body than required at a time 2. Ask the client if they would like to empty their bladder and bowel before the physical examination begins. 3. Remain in the clients room while they are changing 4. Close the examination room, but keep the curtain open

Do not expose and more of the clients body than required at a time

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take?1. Have an informal conversation with the client before beginning observation of the client. 2. Complete all focused assessments prior to formulating thoughts regarding the client's general health status. 3. Engage in active listening with the client and allow the client to express concerns early in the assessment process. 4. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible.

Engage in active listening with the client and allow the client to express concerns early in the assessment process.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? 1. Measure the client's shoe heel height with a tape measure and deduct this amount. 2. Have the client gently lift their chin and look toward the ceiling. 3. Ensure the client's feet are in contact with the wall or measuring pole. 4. Skip the height measurement if the client cannot stand.

Ensure the clients feet are in contact with the wall or measuring pole

A nurse is preparing to irrigate a client's leg wound what PPE should the nurse wear? 1. N95 Surgical mask 2. Gown 3. Gloves 4. Surgical cap 5. Goggles

Gown, Gloves, Goggles

A nurse is assisting a client with ambulating around the nurses' station. which of the following steps of the nursing process is the nurse performing 1. implementation 2. Analysis 3. Planning 4. Evaluation 5.

Implemation

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant which of the following is the first step the nurse should perform during the abdominal assessment? 1. Inspection 2. Palpation 3. Auscultation 4. Percussion

Inspection

a nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication which of the following actions demonstrates the use of a nonverbal communication technique by the nurse 1. Asking the client their birthdate 2. Ask the client what they had for lunch today 3. Maintaining an arms length between self and client 4. Asking open ended questions

Maintaining an arms length between self and client

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? 1. Temperature 101° F 2. Pulse rate indicates tachycardia 3. Oxygen saturation 96% on oxygen 2 L/min via nasal cannula 4. Blood pressure 108/65 mm Hg in left arm

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

A nurse is performing a physical assessment of a client who has reported abdominal tenderness which of the following actions should the nurse take? 1. Use the soft end of a cotton swab over the clients abdomen 2. Palpate the tender areas of the clients abdomen last 3. Use deep palpation when assessing the clients abdomen 4. Auscultate the tender areas of the clients abdomen through clothing

Palpate the tender areas of the clients abdomen last

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading? 1. Hypertension 2. Fever 3. Recent scan with contrast dye 4. Thin, brittle nails

Recent scan with contrast dye

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? 1. Elist the aid of the clients school-aged child to interpret for the nurse and the client 2. Ask the client's best friend to interpret for the nurse and the client. 3. Use jokes and laughter to make the client feel more at ease. 4. Request assistance from an interpreter during the assessment.

Request assistance from an interpreter during the assessment

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure which of the following actions should the nurse take to display empathy towards the client 1. Tell the client everything will be fine 2. Change the subject while the client is discussing their feelings 3. Tell the client that this situation is nothing to be crying about 4. Show interest in the clients feelings by acknowledging that they are upset.

Show interest in the clients feelings by acknowledging that they are upset.

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? 1. The clients cleanliness and grooming 2. Skin temperature, moisture, or unexpected findings 3. Heart sounds, lung sounds, bowel sounds 4. Unexpected sounds made by tapping on the clients skin

Skin temperature, moisture, or unexpected findings

A nurse is performing auscultation during a client's physical assessment which of the following tools should the nurse use for this part of the assessment? 1. Penlight 2. Reflex hammer 3. Tongue depressor 4. Stethoscope

Stethoscope

a nurse is performing an assessment on a client the client states" i have a dry cough every morning when i wake up" which of the following is the type of date the nurse is collecting? 1. Objective 2. Subjective 3. Olfactory 4. Social determines of health

Subjective

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate? 1. The client has been a chronic smoker for 10 years. 2. The client takes a narcotic pain medication for chronic pain. 3. The client reports anxiety due to being in the hospital. 4. The client has a history of anemia.

The client takes a narcotic pain medication for chronic pain.