Units 1-2 Exam
A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client's rights and supporting the client's decisions? a. Advocate b. Caregiver c. Manager d. Educator
Correct: a. Advocate Response Feedback: Potter et al, p. 3: Advocacy involves protecting a client's human and legal rights.
A client asks the nurse "what does spirituality have to do with health?" What is the nurse's best response? a. "Faith, hope, and love have been found to have positive physiological effects on healing." b. "Prayer is necessary for inner peace and healing." c. "People who do not believe in God experience more health issues." d. "Energy generated by religion helps people feel well."
Correct: a. "Faith, hope, and love have been found to have positive physiological effects on healing." Response Feedback: ATI Chapter 35, p. 194 PowerPoint presentation Faith hope and love have been found to have positive physiological effects on healing.
A nurse is caring for a client who wants to stop cancer treatments. The client's daughter disagrees and wants the treatments continued. The nurse explains to the daughter that the client has a right to make choices about his or her care. Which ethical principle does the nurse's action best demonstrate? a. Advocacy b. Responsibility c. Accountability d. Confidentiality
Correct: a. Advocacy Response Feedback: ATI Chapter 3, p. 11: Advocacy supports and defends a client's health, wellness, safety, wishes, and personal rights.
Which of the following clients is most at risk for developing an infection? a. An 82 year old client who is malnourished. b. A 28 year old client who is pregnant. c. A 48 year old client with gastroesophageal reflux disease (GERD). d. A 12 year old client who had an appendectomy.
Correct: a. An 82 year old client who is malnourished Response Feedback: ATI Chapter 11, p. 54: The 82-year old client is most at risk because of two risk factors: age and nutritional status.
A nurse witnesses a nursing assistant under her supervision reprimanding a client for not using the urinal properly. The nursing assistant threatens to put a diaper on the client if he does not use the urinal more carefully next time. Which of the following torts is the nursing assistant committing? a. Assault b. Battery c. False imprisonment d. Invasion of privacy
Correct: a. Assault Response Feedback: ATI Chapter 4, p. 15: Assault occurs when the conduct of one person makes another person fearful and apprehensive.
A nurse is floated to work on a nursing unit and is given an assignment beyond the nurse's capability. Which is the best nursing action to take? a. Contact the charge nurse to discuss the assignment. b. Discuss the problem with a coworker. c. Leave the nursing unit and go home. d. Say nothing and accept the assignment.
Correct: a. Contact the charge nurse to discuss the assignment Response Feedback: ATI Chapter 4, p. 17-18: Nurses should refuse to practice beyond the legal scope of practice or outside their areas of competence regardless of the reason. The nurse should contact the charge nurse to discuss the assignment.
A nurse is preparing to care for a client who is in contact precautions. Which item should the nurse put on first? a. Gloves b. Gown c. Face shield d. Mask
Correct: a. Gown Response Feedback: Potter et al p. 462-463 ATI Chapter 11, p. 56 In contact precautions, the nurse dons the gown first, followed by mask and face shield (if indicated) and then gloves before entering a room.
A nurse is caring for a client who is recovering from surgery to repair a fractured hip and needs assistance learning to walk and regaining strength. The nurse should initiate a referral to which of the following members of the interprofessional team? a. Physical therapist b. Occupational therapist c. Speech language pathologist d. Social worker
Correct: a. Physical therapist Response Feedback: ATI Chapter 2, p. 7: Physical therapists address and plan for clients to increase musculoskeletal function, especially of the lower extremities, to maintain mobility.
Which of the following clients is most at risk for developing a hospital acquired infection (HAI)? a. Post-operative client with a urinary catheter. b. Client who just gave birth. c. Client who is scheduled for a diagnostic procedure. d. Client who attends cardiac rehabilitation.
Correct: a. Post-operative client with a urinary catheter Response Feedback: ATI Chapter 11, p. 54: The post-operative client with a urinary catheter is most at risk because of the presence of two risk factors: surgery and an indwelling device.
A healthy client attends a yoga class at a community health center. Which type of health care service is the client utilizing? a. Primary health care b. Secondary health care c. Tertiary health care d. Restorative health care
Correct: a. Primary health care Response Feedback: ATI Chapter 1, p. 4: Primary health care emphasizes health promotion and includes a sustained partnership between clients and providers.
Which of the following statements about nursing theories is correct? a. Theories help to explain a phenomenon in nursing. b. Theories provide a method for client assessment. c. Theories help to formulate health care legislation. d. Theories provide a solution to the nursing shortage.
Correct: a. Theories help to explain a phenomenon in nursing Response Feedback: Potter et al. p. 41: Nursing theories are designed to explain a phenomenon such as self-care or caring.
Which activity demonstrates a nurse engaged in secondary prevention of illness? a. A nurse provides colon cancer screening kits to clients in a clinic. b. A nurse teaches a class for high school students on sexually transmitted diseases. c. A nurse teaches a client with diabetes about foot care. d. A nurse teaches a client with heart failure about a low sodium diet.
Correct: a. nurse provides colon cancer screening kits to clients in a clinic Response Feedback: ATI Chapter 16, p. 86: Secondary prevention focuses on identifying illness and providing treatment. Colon cancer screening can identify illness so that treatment can be provided.
A nurse is caring for a client who recently had abdominal surgery and is now on the postoperative unit. Which of the following are legal sources of standards of care that the nurse uses to deliver safe health care? Select all that apply a. Information provided by the charge nurse. b. Policies and procedures of the hospital. c. State Nurse Practice Act. d. The Joint Commission (TJC) regulations for prevention of surgical site infections. e. The American Nurses Association standards of nursing practice.
Correct: b,c,d,e Response Feedback: Potter et al p. 303 and 313 Standards of care are the legal requirements for nursing practice that describe minimal acceptable nursing care. Nursing standards of care are described in the Nurse Practice Act of every state, in federal and state laws regulating hospitals and other health care agencies, by professional and specialty organizations, and by the policies and procedures established by health care agencies. Information provided by individuals are not considered legal standards of care.
A nurse is caring for a client who is a devout Muslim and is three days postoperative following a hip arthroplasty. The client is scheduled for physical therapy sessions twice a day. Which of the following statements by the nurse demonstrates patient centered, culturally and spiritually responsive care? a. "I will make sure the menu includes kosher options." b. "I will ask the client about prayer practices and discuss how the therapy schedule can accommodate these." c. "I will make sure to use direct eye contact when speaking with the client." d. "I will make sure the client can go to daily communion in the chapel."
Correct: b. "I will ask the client about prayer practices and discuss how the therapy schedule can accommodate these." Response Feedback: ATI Chapter 35, p. 196 Many Muslim clients pray five times a day facing Mecca; it is important to ask the client about practices so that accommodations can be made.
Which activity demonstrates a nurse engaged in primary prevention of illness? a. A clinic nurse checks the blood glucose level of a client with diabetes. b. A school nurse presents a program on nutrition and exercise for students and parents. c. A home health nurses visits a client to change a wound dressing. d. A cardiac rehabilitation nurse provides smoking cessation education to a client who recently had a heart attack.
Correct: b. A school nurse presents a program on nutrition and exercise for students and parents Response Feedback: ATI Chapter 16, p. 86: Primary prevention addresses the needs of healthy clients to promote health and prevent disease with specific protections. Education on nutrition and exercise for students and parents is an example of primary prevention.
The nurse is using Maslow's Hierarchy of Needs to plan discharge for a homeless client with hypertension. What is the priority nursing intervention for this client? a. Identifying job training resources in the community. b. Assisting the client with placement in a local shelter. c. Teaching about the benefits of exercise in controlling hypertension. d. Recommending meditation techniques to decrease stress.
Correct: b. Assisting the client with placement in a local shelter Response Feedback: Potter et al, p. 68: An emergent physiological need takes precedence over a higher-level need, so the need for shelter is the priority.
The nurse enters the room and tells the client that the client must take a medication which is an injection. The client refuses the medication, but the nurse continues to administer the medication. Which of the following torts is the nurse committing? a. Assault b. Battery c. Invasion of privacy d. False imprisonment
Correct: b. Battery Response Feedback: ATI Chapter 4, p. 15: Battery is the intentional and wrongful physical contact with a person that involves an injury or offensive contact.
Which of the following is considered a health care associated infection (HAI)? a. Measles b. Catheter associated urinary tract infection (CAUTI) c. Tuberculosis d. Community acquired pneumonia
Correct: b. CAUTI Response Feedback: ATI Chapter 11, p. 50 PowerPoint presentation Health care associated infections are infections that a client acquires while receiving care in a health care setting. A urinary tract infection associated with placement of a urinary catheter is an example of a health care associated infection.
A nurse plans care and implements strategies to promote the client's physical, psychosocial, and spiritual well-being and attain maximal level of function and independence. The nurse is acting in which of the following professional roles? a. Advocate b. Caregiver c. Manager d. Educator
Correct: b. Caregiver Response Feedback: Potter et al, p. 3: Caregivers help clients maintain and regain health, manage disease and symptoms and attain maximal function by providing holistic interventions.
A nurse is transferring a client to a skilled care facility. What is the responsibility of the nurse who is coordinating the transfer of the client? a. Have specialized equipment ready. b. Confirm that the skilled care facility is expecting the client. c. Inform other healthcare team members of the client's arrival and needs. d. Assess how the client tolerates the transfer.
Correct: b. Confirm that the skilled care facility is expecting the client Response Feedback: ATI Chapter 9, p. 41: The nurse who is transferring the client must confirm that the skilled care facility is expecting the client.
A nurse teaches a client and family how to change a dressing. The nurse is acting in which of the following professional roles? a. Advocate b. Educator c. Caregiver d. Manager
Correct: b. Educator Response Feedback: Potter et al, p. 3: As an educator, nurses explain facts and concepts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or client behavior, and evaluate client progress in learning.
Which of the following statements regarding chronic illness is correct? a. Symptoms in chronic illness appear abruptly and are intense. b. Many chronic illnesses are related to modifiable risk factors. c. Chronic illness has a shorter duration than an acute illness. d. Chronic illness requires few adjustments in daily lifestyle.
Correct: b. Many chronic illnesses are related to modifiable risk factors Response Feedback: Potter et al. p. 74: Many chronic illnesses are related to four modifiable risk factors: physical inactivity, poor nutrition, use of tobacco, and excessive alcohol consumption.
A nurse is planning care with a client who has left sided weakness due to a stroke. The client identifies a goal of being able to perform bathing and dressing independently. The nurse should initiate a referral to which of the following members of the interprofessional team? a. Physical therapist b. Occupational therapist c. Speech language pathologist d. Social worker
Correct: b. Occupational therapist Response Feedback: ATI Chapter 2, p. 7: Occupational therapists assess and plan for clients to regain activities of daily living.
A nurse is providing care to a client who is Muslim. Which of the following actions should the nurse take first? a. Read about the Muslim faith on the internet. b. Reflect on own biases that might affect care delivery. c. Attend a conference on world religions. d. Ask a co-worker who is Muslim about cultural practices.
Correct: b. Reflect on own biases that might affect care delivery Response Feedback: ATI Chapter 35, p. 193: Cultural awareness, or self-awareness and the examining of personal attitudes related to various aspects of culture to identify possible bias is the first step to culturally sensitive care.
A nurse is caring for an elderly client with cancer who is alert and oriented. The client is refusing treatment yet the client's son insists that everything should be done to save his father. The nurse consults the ethics committee. After gathering related information, which step do the committee members implement next in the ethical decision making process? a. List and analyze all possible options for resolving the dilemma. b. Reflect on personal values as they relate to the dilemma. c. Review the implications of each option for resolving the dilemma. d. Select the ethical principle that applies to the situation.
Correct: b. Reflect on personal values as they relate to the dilemma Response Feedback: ATI Chapter 3, p. 12: The ethical decision-making process includes the following steps: Identify the issue as an ethical dilemma. Gather relevant information. Reflect on personal values as they relate to the dilemma. State the ethical dilemma including all surrounding issues and the individuals it involves. List and analyze all possible options for resolving the dilemma and review the implications of each option. Select an option that is in concert with the ethical principle that applies to this situation, the decision makers values and beliefs, and the profession's values for client care. Justify selecting that one option in light of relevant variables. Apply this decision to the dilemma and evaluate the outcomes.
A nurse walks into the medication room and observes a co-worker removing pain medication for a client, opening the medication, and taking the medication orally. The nurse has also noticed that this co-worker has been drowsy and unable to focus during the last week. Which of the following actions should the nurse take? a. Leave the co-worker alone to avoid retaliation. b. Report the observations to the nurse manager on the unit. c. Alert the local police department. d. Share the information on social media.
Correct: b. Report the observations to the nurse manager on the unit Response Feedback: ATI Chapter 4, p. 18: A nurse who suspects a co-worker of any behavior that jeopardizes client care or could indicate a substance abuse disorder has a duty to report the coworker to the appropriate manager.
A client is hospitalized for acute appendicitis and has an appendectomy. Which type of health care service is the client utilizing? a. Primary health care b. Secondary health care c. Tertiary health care d. Restorative health care
Correct: b. Secondary health care Response Feedback: ATI Chapter 1, p. 4: Secondary health care includes diagnosis and treatment of acute illnesses and injury such as hospitals, diagnostic centers, and urgent care centers.
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes the American Nurses Association (ANA) ethical principle of client confidentiality? a. Logging out of the computer before leaving a terminal. b. Sharing computer passwords with coworkers. c. Using a computer terminal in a non-public area. d. Preventing an unidentified health care worker from viewing a health record on the computer screen.
Correct: b. Sharing computer passwords with coworkers Response Feedback: Potter et al p. 293 Nurses should never share computer passwords with coworkers.
What is the responsibility of the nurse in obtaining informed consent? a. To explain the risks and benefits of the procedure. b. To provide options for other treatments. c. To ensure the client understood the information. d. To describe professionals who will participate in the procedure.
Correct: b. To ensure the client understood the information Response Feedback: ATI Chapter 4, p. 17-18 The responsibility of the nurse in obtaining informed consent is to ensure that the client understood the information.
The nurse is caring for a client who suddenly becomes nauseated and vomits without warning. The nurse has visibly soiled hands. What step should the nurse do next? a. Clean hands with wipes from the bedside table. b. Wash hands with soap and water. c. Use an alcohol-based waterless hand gel. d. Apply gloves to prevent further exposure.
Correct: b. Wash hands with soap and water Response Feedback: ATI Chapter 10, p. 45: Nurses should wash hands immediately if they are visibly soiled .
A nurse is creating a discharge plan. Which of the following statements indicates the nurse understands when discharge planning should be implemented? a. "I will begin 48 hours before the client's 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 client's insurance company approves discharge coverage."
Correct: c. "I will begin upon the client's admission to the facility." Response Feedback: ATI Chapter 9, p. 41 Discharge planning starts at admission.
A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations best describes an ethical dilemma? a. A nurse on a medical-surgical unit demonstrates signs of substance abuse. b. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed she will have to use restraints. c. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill. d. A client who is terminally ill hesitates to name her spouse on the durable power of attorney form.
Correct: c. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill Response Feedback: ATI Chapter 3 p. 13-14: Ethical dilemmas are problems that involve more than one choice and stem from differences in the values and beliefs of the decision makers. The best example is a family who has conflicting feelings about the initiation of enteral tube feedings for their critically ill father because it involves a conflict between two moral imperatives and the answer will have a profound effect on the situation and client.
A nurse is teaching a client with clostridium difficile (C. difficile) about the mode of transmission of this organism. Which of the following statements indicates the client's need for further teaching? a. Hands should be cleaned with soap and water versus alcohol based hand sanitizer. b. Everyone coming into the room must wear a gown and gloves. c. C. difficile dies quickly once outside the body. d. C. difficile is transmitted through the fecal oral route.
Correct: c. C. difficile dies wuickly once outside the body Response Feedback: ATI Chapter 11, p. 49; C. Difficile article: C. difficile can live for a long time on inanimate surfaces because of the spores.
A group of nurses on a fall prevention committee want to determine best practice for reducing falls. They search the literature for the most recent and relevant evidence, critically appraise and integrate the evidence, and make practice changes based on the evidence. What process is being used? a. Research b. Quality improvement c. Evidence-Based Practice d. Dimensional Analysis
Correct: c. Evidenced-Based Practice Response Feedback: Potter et al, p. 62: The focus of evidence-based practice is implementation of evidence already known into practice. Data comes from research studies.
A nurse is caring for a client who is trying to leave the nursing unit. The nurse becomes frustrated and places the client in restraints and does not obtain a provider order. Which of the following torts is the nurse committing? a. Assault b. Defamation of character c. False imprisonment d. Invasion of privacy
Correct: c. False imprisonment Response Feedback: ATI Chapter 4, p. 15 False imprisonment is the confinement or restraint of a person against his/her will.
A nurse plans care for a client with a focus on the environment and opens shades, limits noise, makes sure that the client has a bath, and assists the client to order breakfast. Which theorist is the nurse using for the basis of client care? a. Orem b. Peplau c. Nightingale d. Rogers
Correct: c. Nightingale Response Feedback: Potter et al. p. 45: Florence Nightingale's theory focuses on the environment and the importance of manipulation of the environment (light, ventilation, noise, hygiene, nutrition) so that nature is able to restore a client to health.
A nurse is caring for a client who has a decreased heart rate. The nurse holds a medication that could potentially decrease the client's heart rate further and contacts the provider. Which ethical principle does the nurse's action best demonstrate? a. Justice b. Autonomy c. Non-malificence d. Fidelity
Correct: c. Non-malificience Response Feedback: ATI Chapter 3, p. 11: Non-malificence is a commitment to do no harm.
A nurse attends a conference to learn more about caring for clients with dementia in order to improve quality of care for this population. Which of the American Nurses Association (ANA) code of ethics principles does this action best demonstrate? a. Confidentiality b. Advocacy c. Responsibility d. Social Networking
Correct: c. Responsibility Response Feedback: Potter et al p. 293: Responsibility refers to a willingness to respect one's own professional obligations and to follow through. Nurses take responsibility to remain competent to practice in order to follow through on responsibilities reliably.
A client who had a stroke is transferred to an acute rehabilitation unit for intense therapy with the goal of improving function and independence. Which type of health care service is the client utilizing? a. Primary health care b. Secondary health care c. Restorative health care d. Continuing health care
Correct: c. Restorative health care Response Feedback: ATI Chapter 1, p. 4: Restorative health care involves intermediate follow up care for restoring health and promoting self-care including home health care, rehabilitation centers, and skilled nursing facilities.
A nurse is caring for a client and identifies several variables that influence the client's health beliefs and practices. Which of the following would be an example of an external factor? a. The client's developmental stage. b. The client's perception of functioning. c. The client's socioeconomic status. d. The client's emotional status.
Correct: c. The client's socioeconomic status Response Feedback: Potter et al p. 69: External factors include family practices, psychosocial and socioeconomic factors, and cultural background.
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? a. Pertussis b. Mycoplasma pneumonia c. Tuberculosis d. Mumps
Correct: c. Tuberculosis Response Feedback: Potter et al p. 462-463 ATI Chapter 11, p. 56 Tuberculosis requires use of an N-95 respirator mask.
A nurse is teaching an adult client who had a leg amputation about home health services. Which of the following statements demonstrates the client's need for further teaching? a. "I will be able to have physical therapy in my home." b. "A nurse will visit to check my incision." c. "A home health aide will help me with my bath." d. "A nurse will stay with me 24 hours a day so that I don't have to go to a nursing home."
Correct: d. "A nurse will stay with me 24 hours a day so that I don't have to go to a nursing home." Response Feedback: Potter et al p. 20: Home health services do not provide 24- hour care. The focus is on client and family independence. If clients need 24 hour care a skilled nursing and/or long term care facility is indicated, or agencies that provide 24 hour care.
A nurse is admitting a client with a latex allergy to the medical unit. Which of the following actions should the nurse take first? a. Perform a physical assessment. b. Orient the client to the room. c. Inventory personal items. d. Apply the identification bracelet and allergy band.
Correct: d. Apply the identification bracelet and allergy band Response Feedback: ATI Chapter 9, p. 41: It is most important to apply the identification and allergy bands to maintain patient safety.
A client asks the nurse for pain medication and the nurse promises to bring the medication right away. The nurse then obtains the medication and administers it to the client. Which ethical principle does the nurse's action best demonstrate? a. Non-malificence b. Autonomy c. Justice d. Fidelity
Correct: d. Fidelity Response Feedback: ATI Chapter 3, p. 11 Fidelity is fulfillment of promises.
A nurse is removing personal protective equipment after caring for a client who is in contact precautions. Which item should the nurse remove first? a. Mask b. Face shield c. Shoe covers d. Gloves
Correct: d. Gloves Response Feedback: Potter et al p. 462-463 ATI Chapter 11, p. 56 Gloves are removed first, followed by eyewear, mask, and shoe covers.
A nurse is caring for a client and integrates the client's cultural traditions, values and beliefs into the plan of care. Which theorist is the nurse using for the basis of client care? a. Orem b. Nightingale c. Peplau d. Leininger
Correct: d. Leninger Response Feedback: Potter et al. p. 48: Madeline Leininger's culture care theory focuses on the importance of culture and its influence on everything that involves a client including health beliefs, the role of family and community, and dietary practices.
A nurse encourages an elderly client who is a widow and lives alone to attend activities such as playing cards at a senior center. Using Maslow's Hierarchy, which of the following basic needs is the nurse addressing a. Nutrition b. Shelter c. Physical Safety d. Love and belonging
Correct: d. Love and Belonging Response Feedback: Potter et al, p. 68: Attending activities such as playing cards addresses the client's need for love and belonging.
A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? a. Properly disposing of contaminated equipment b. Discarding used syringes in appropriate containers c. Changing soiled linens daily for clients who have draining wounds d. Performing hand hygiene frequently and consistently
Correct: d. Performing hand hygiene frequently and consistently Response Feedback: ATI Chapter 10, p. 45: Hand hygiene is the most effective way to prevent the spread of pathogens
Which of the following actions by the nurse would be considered outside the scope of practice of the registered nurse? a. Initiating a nursing plan of care for a client. b. Educating the client about ways to prevent infection. c. Collaborating with a physical therapist about care for a client. d. Placing an order for a medication without consulting the provider.
Correct: d. Placing an order for a medication without consulting the provider
A nurse is reviewing the American Nurses Association (ANA) Standards of Nursing Practice. Which of the following standards is outside the scope and standard of practice for the registered nurse? a. Assessment b. Nursing diagnosis c. Planning d. Prescriptive authority
Correct: d. Prescriptive authority Response Feedback: Potter et al., p. 2: The registered nurse can assess, make nursing diagnoses, and plan care. The registered nurse does not have prescriptive authority. Only advance practice registered nurses have prescriptive authority.