ATI Proctored Flashcards
A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?
A. Managing a home
B. Establishing a sense of self in the adult world
C. Forming new friendships
D. Ceasing to compare personal identity with others
D. Ceasing to compare personal identity with others
Middle-aged adults usually feel more comfortable with themselves and cease to make comparisons with others
A, B, and C are for young adults.
A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client’s routine health screening?
A. Annual Papanicolaou (Pap) testing
B. Mammogram every 2 years
C. Eye examination every 2 years
D. Annual colonoscopy
C. Eye examination every 2 years
Eye exams are essential for monitoring vision and checking for glaucoma. Eye exams should be annual once clients reach age 65.
A is wrong; every 3 years
B is wrong; annually once you are 45+
D is wrong; every 10 years
A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching?
A. The RDA is a comprehensive term that includes various dietary standards and scales
B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups
C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects
D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein
B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups
The RDA represents daily requirements considered adequate for healthy people. RDAs are based one estimated amounts for each nutrient, including additional amounts for individuals such as women or infants
A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?
A. 3+ Achilles reflex
B. Faint pedal pulses
C. Feet warm to the touch bilaterally
D. Capillary refill of <2 sec
B. Faint pedal pulses
Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity
A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include?
A. With your palm facing down, move your wrist sideways toward your thumb
B. Move your palm toward the inner part of your forearm
C. With your palm facing down, move your wrist sideways toward your littler finger
D. Bring the back of your hand as far back toward your wrist as you can
A. With your palm facing down, move your wrist sideways toward your thumb
Adduction is towards the baseline of body
B is flexing the wrist
C is abducting the wrist
D is hyperextending the wrist
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
A. Lateral thigh
B. Lower abdomen
C. Mid-abdominal region
D. Medial thigh
B. Lower abdomen
Upper thigh or lower abdomen is correct location to prevent tension and trauma
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instruction should the nurse include?
A. Blow into the spirometer to elevate the balls in the device
B. Cough deeply after each use
C. Clean the mouthpiece with an alcohol swab after each use
D. Use the spirometer every 8 hr
B. Cough deeply after each use
Cough to facilitate the removal of secretions from the lungs
A is wrong; inhale not blow
C is wrong; clean with water and dry it after each use
D is wrong; several times each hour while awake
A nurse is obtaining a capillary blood sample to determine a client’s blood glucose level. The nurse prepares and punctures the client’s finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?
A. Smear the small amount of blood onto the testing strip
B. Hold the finger above heart level
C. Massage the client’s fingertip
D. Wrap the client’s finger in a warm washcloth
D. Wrap the client’s finger in a warm washcloth
Warmth helps increase blood flow
A; inaccurate result
B. to improve blood flow, hand should be in a dependent position
C; massaging can hemolyze the specimen, leading to an inaccurate result
A nurse is assessing a client’s nutritional status. The nurse determines the client is consuming 500 calories 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 lb)?
A. 10 months
B. 5 months
C. 5 weeks
D. 10 weeks
D. 10 weeks
1 lb of body fat = 3,500 calories
500 calories/day * 7 days = 3500 calories –> 1 lb gain each week
10 lbs gained in 10 weeks
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), HR 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?
A. HR 105/min
B. Soft, nontender abdomen
C. Temperature
D. Overdue menses
C. Temperature
Elevated temp is an emergency physiological need. The nurse should consider Maslow’s Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow’s Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client’s needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation.
A is wrong; expected with fever/pain
B is normal
D is normal when stressed
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
A. Evaluate pedal pulses
B. Obtain a medical history
C. Measure vital signs
D. Assess for leg pain
A. Evaluate pedal pulses
For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
A. Hold the irrigator 1.25 cm (0.5 in) above the eye
B. Direct the irrigation solution upward toward the upper eyelid
C. Exert pressure on the bony prominences when holding the eyelids open
D. Direct the irrigation from outer canthus to the inner canthus of the eye
C. Exert pressure on the bony prominences when holding the eyelids open
The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
A. Maintain suction while removing the NG tube
B. Instill 100 mL of air into the NG tube before removal
C. Pinch the NG tube while removing the tube
D. Instruct the client to breathe in and out during the removal of the NG tube
C. Pinch the NG tube while removing the tube
Pinching during removal decreases the risk of aspiration of any gastric contents
B is wrong; 50 mL of air
D is wrong; deep breath and hold it to close off the glottis
A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for the injection?
A. The lower, medial quadrant of the buttock near the coccyx
B. The side hip between the iliac crest and anterior iliac spine
C. The tissue of the posterior upper arm
D. The lower, inner thigh 4 finger widths above the patella
B. The side hip between the iliac crest and anterior iliac spine
The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client’s greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a “V” shape.
C should be outer, posterior tissue
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
A. Encourage the client to drink fluids before swallowing food
B. Offer the client tart or sour foods first
C. Tilt the client’s head backward when swallowing
D. Turn on the television
B. Offer the client tart or sour foods first
Sour/tart foods stimulate saliva production
A is wrong; dry swallows between bites of food
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client’s diet?
A. Vitamin C and zinc
B. Vitamin D
C. Vitamin K and iron
D. Calcium
A. Vitamin C and zinc
The client’s body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing.
B and D do not promote wound healing
C is for normal clotting of blood; iron is to rebuild RBCs
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
A. Withdraw the specimen from the drainage bag
B. Cleanse the collection port with soap and water
C. Place the specimen in a clean specimen cup
D. Clamp the tubing below the collection port
D. Clamp the tubing below the collection port
B; antimicrobial swab
C; sterile cup
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
A. Teaching clients to perform self-examinations of breasts and testicles
B. Educating clients about the recommended immunization schedule for adults
C. Teaching clients who have type 1 diabetes mellitus about care of the feet
D. Recommending that clients over the age of 50 have a fecal occult blood test annually
B. Educating clients about the recommended immunization schedule for adults
Primary prevention includes health education about disease prevention.
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
A. Place the client in Trendelenburg’s position
B. Perform percussions directly over the client’s bare skin
C. Use a flattened hand to perform percussions
D. Remind the client that chest percussions can cause mild pain
A. Place the client in Trendelenburg’s position
Promotes drainage from the client’s left lower lobe. feet above the head in this position
B wrong; percussions should be performed over a single layer of clothing
C; cupped hand
A nurse is reviewing the lab values for a client who has a positive Chvostek’s sign. Which of the following findings should the nurse expect?
A. decreased calcium
B. decreased potassium
C. increased potassium
D. increased calcium
A. decreased calcium
Calcium is necessary for nerve conduction and muscle contractions. When the client’s total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client’s ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek’s sign and an indication of hypocalcemia.
A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
A. Changing the dressing for a client who has a stage 3 pressure injury
B. Determining a client’s response to a diuretic
C. Comparing radial pulses for a client who is postoperative
D. Providing postmortem care to a client
D. Providing postmortem care to a
client
A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms
C. I use ginger when I get car sick
A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room.
A. Wear a mask when working within 3 feet of the client
A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client’s bed.
B. Apply the restraints to allow as little movement as possible
C. Allow room for two fingers to fit between the clients skin and the restraints
d. Remove the restraints every 4 hours
C. Allow room for two fingers to fit between the clients skin and the restraints
A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airborne
C. Protective environment
D. Contact
B. Airborne
A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make?
A. Have your child drink one large glass of water.
B. Hang up and call a poison control center hotline.
C. Bring your child into the clinic later today.
D. Induce vomiting in your child with syrup of ipecac
A. Have your child drink one large glass of water.
D is incorrect; paint thinner is corrosive, you would do more damage to organs by inducing vomiting and having it come back up
B & C are wrong because it neglects the current concerns.
A nurse is documenting a client’s medical record. Which of the following entries should the nurse record?
A. Oral temperature slightly elevated at 0800
B. Administered pain medication
C. Incision without redness or drainage
D. Drank adequate amounts of fluid with meals
B. Administered pain medication
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
A. Place the client in a side-lying position.
B. Brush the clients teeth daily
C. Apply mineral oil to the client’s lips
D. Rinse the client’s mouth with an alcohol-based mouthwash
A. Place the client in a side-lying position.
A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify which of the following situations is an example of negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility
C. A nurse begins a blood transfusion without obtaining consent.
A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take?
A. Wear sterile gloves when collecting the specimen.
B. Offer the client oral hygiene after the collection
C. Collect the specimen in the evening.
D Collect 1 ml of sputum.
B. Offer the client oral hygiene after the collection
A nurse is assessing an older client. Which of the following findings should the nurse expect?
A. Decreased sense of balance
B. Increased night time sleeping
C. Heightened sense of pain
D. Night time urinary incontinence
A. Decreased sense of balance
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (select all that apply)
- “Cut the opening of the pouch 1⁄8 of an inch larger than the stoma “
- “Place a piece a gauze over the stoma while changing the pouch”
- “Use povidone-iodine to clean around the stoma”
- “Empty the ostomy pouch when it becomes one-third full of contents”
- “Expect the stoma to turn a purple-blue color as its heals”
1, 2, 3, 4
A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
A. “Request that an assistive personnel interpret the information for the client”
B. “Use proper medical terms when giving information to the client”
C. “Offer written information in the client’s language”
D. “Avoid using gestures when speaking to the client”
C. “Offer written information in the client’s language”
A nurse is teaching a client about home care equipment. Which of the following information should the nurse include in the teaching?
- “Avoid using wool blankets when receiving oxygen”
- “Check the O2 delivery rate at least once a day”
- “Align the middle of the ball in the flow meter with the line of the prescribed flow rate”
- “Keep the oxygen delivery system 0.6 m (2 feet) from any heat source”
- “Lay the oxygen tank flat when storing”
1, 2, 3
A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?
A. Provide a late supper.
B. Offer a wet washcloth for the client to wash her face
C. Perform range-of-motion exercises
D. Prepare hot cocoa or tea for the client
A. Provide a late supper.
Find rationale for this
A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
A. A client who has acute abdominal pain of 4 on a scale from 0 to 10
B. A client who has pneumonia and an oxygen saturation of 96%
C. A client who has new onset of dyspnea 24hr after a total hip arthroplasty
D. A client who has a urinary tract infection and low-grade fever
C. A client who has new onset of dyspnea 24hr after a total hip arthroplasty
A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following requires the completion of an incident report?
A. A client’s prescribed laboratory testing was not obtained
B. A client withdrew consent for a procedure
C. An oncoming nurse arrived to work late
D. A nurse transfused a unit of packed RBCs in 2 hr.
A. A client’s prescribed laboratory testing was not obtained
A nurse is caring for a client who has a new prescription for negative-pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention?
A. The client’s plan of care
B. The nurse practice act
C. The material safety data sheet
D. The policy and procedure manual
D. The policy and procedure manual
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
A. Cover the area of percussion with a towel
B. Instruct the client to exhale quickly during vibration
C. Schedule postural drainage after meals
D. Perform percussion over the lower back
D. Perform percussion over the lower back
Rationale?
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has
difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the
following images indicates the correct number of mL the nurse should administer? (round
answer to the nearest whole number.)
DOSAGE CALCULATION
Correct Answer: 8ml
