ATI - Test 2 Practice Assessment Flashcards
ATI - Test 2 Practice Assessment
A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear protective eye equipment? (Select all that apply)
A. Giving personal care to an infant who is HIV positive.
B. Bathing a newborn for the first time.
C. Drawing cord blood form a neonate.
D. Transporting a cerebral spinal fluid specimen to the laboratory.
E. Suctioning a child who has newly placed tracheostomy tube.
C. Drawing cord blood form a neonate.
E. Suctioning a child who has newly placed tracheostomy tube.
ATI - Test 2 Practice Assessment
A nurse is caring for a toddler in contact isolation. Which of following is an appropriate toy to offer the toddler?
A. Plush stuffed animal
B. Chapter book
C. Plastic building blocks
D. Puzzle
C. Plastic building blocks
Rationale:
Plastic building blocks can be sterilized. Therefore, it is an appropriate toy to bring into contact isolation.
ATI - Test 2 Practice Assessment
A nurse is reinforcing teaching to an assistive personnel to count respiration rate on a newborn. Which of the following statements indicate understanding of why the respiratory rate should be counted for a complete minute?
A. “Newborns are abdominal breathers.”
B. “Newborns do not expand their lungs fully with each respiration.”
C. “Activity will increase the respiration rate.”
D. “The rate and rhythm are irregular in newborns.”
D. “The rate and rhythm are irregular in newborns.”
ATI - Test 2 Practice Assessment
A nurse is collecting data on a client’s circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
A. Brachial
B. Carotid
C. Femoral
D. Popliteal
B. Carotid
Rationale:
The nurse should avoid assessing the carotid pulse bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.
ATI - Test 2 Practice Assessment
A nurse is collecting data from a client about lower extremity edema by pressing an index finger against the shin and noting an indentation of 6 mm (about 1/4 inch). The nurse should document the client’s degree of pitting edema as which of the following?
A. 4+
B. 3+
C. 2+
D. 1+
B. 3+
Rationale:
ATI - Test 2 Practice Assessment
The nurse is caring for a client with a nosocomial infection. The nurse understands that a nosocomial infection is usually acquired
A. in an industrial setting.
B. during hospitalization.
C. during a visit to the physician.
D. in a crowded environment.
B. during hospitalization.
Rationale:
A nosocomial infection occurs following exposure of the client to a contaminated environment during hospitalization.
ATI - Test 2 Practice Assessment
A nurse is reinforcing teaching with a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
A. “If you wear gloves, you do not have to wash your hands.”
B. “Hand hygiene is crucial in preventing the spread of germs.”
C. “Use an alcohol rub when your hands are visibly soiled.”
D. “If you don’t have an infection, your hands won’t infect others.”
B. “Hand hygiene is crucial in preventing the spread of germs.”
Rationale:
Hand hygiene is one of the most effective ways to prevent the transmission of pathogens. Either the nurse or the client may have microorganisms on or in their body that do not harm them but may harm others.
ATI - Test 2 Practice Assessment
A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear gloves? (Select all that apply)
A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
D. Delivering a food tray to a client who has AIDS
E. Placing oral medication tablets into a client’s hand
A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
ATI - Test 2 Practice Assessment
A nurse is evaluating an older adult client who is receiving end-of-life care for Cheyne-Stokes breathing respirations. Which of the following observations confirms this respiratory pattern?
A. Breathing ranging from very deep to very shallow with periods of apnea.
B. Shallow breathing alternating with periods of apnea.
C. Rapid respirations that are usually deep and regular.
D. An inability to breathe without dyspnea unless sitting upright.
A. Breathing ranging from very deep to very shallow with periods of apnea.
Rationale:
This describes Cheyne-Stokes respirations, an indication that the client is approaching death.
ATI - Test 2 Practice Assessment
A nurse is reinforcing teaching for a client who has hepatitis about preventing transmission of the virus. The nurse should emphasize which of the following strategies?
A. Not eating at fast food restaurants
B. Not eating raw foods
C. Practicing effective hand hygiene.
D. Wearing barrier protection during vaginal intercourse.
C. Practicing effective hand hygiene.
Rationale:
Hepatitis A is an enterovirus (enters the body through the GI tract).
ATI - Test 2 Practice Assessment
A nurse is caring for a client with MRSA in an abdominal wound. The nurse enters the room to check the client’s pulse. Which of the following actions is appropriate?
A. Wear a gown.
B. Apply sterile gloves.
C. Apply clean gloves.
D. Don protective eyewear.
C. Apply clean gloves.
ATI - Test 2 Practice Assessment
A nurse is caring for a client on droplet precautions. Which of the following equipment is required when setting up the client’s meal tray?
A. Gloves
B. Goggle
C. Gown
D. Mask
D. Mask
Rationale:
Droplets are transmitted in the air and can travel 3 to 6 feet; therefore, a mask is necessary equipment when setting up the client’s meal tray.
ATI - Test 2 Practice Assessment
A nurse is collecting data on a client who has diabetes and is experiencing foot pain. Which of the following are signs and symptoms of an infection? (Select all that apply)
A. Bradycardia B. Increased neutrophils C. Increased RBC D. Increased platelets E. Localized edema
B. Increased neutrophils
E. Localized edema
ATI - Test 2 Practice Assessment
A nurse is removing an isolation gown after caring for a client who requires contact precautions. Which of the following steps should the nurse take to properly remove the isolation gown that has ties in the front?
A. Untie the neck strings, remove gloves and untie waist strings.
B. Untie front waist strings, remove gloves, and untie neck ties.
C. Remove gloves, wash hands, and until waist strings.
D. Remove gloves, untie neck strings, and untie waist strings.
B. Untie front waist strings, remove gloves, and untie neck ties.
Rationale:
When removing an isolation gown that has ties in the front, the nurse should untie the waist ties first while still wearing the gloves as the front ties are considered dirty.
ATI - Test 2 Practice Assessment
A nurse is checking a client’s bowel sounds. The understands that the bowel sounds should be auscultated
A. after palpating the abdomen.
B. prior to percussing the abdomen.
C. after checking for kidney tenderness.
D. prior to inspecting the abdomen.
B. prior to percussing the abdomen.
Rationale:
Auscultation should be performed prior to percussing the abdomen to prevent altering the bowel sounds.
ATI - Test 2 Practice Assessment
A nurse is caring for a client one day post-operative from an appendectomy and is HIV positive. Which of the following actions requires the nurse to wear a gown as personal protective equipment.
A. Talking to the client at the bedside.
B. Administering an IV piggyback medication.
C. Completing a dressing change.
D. Administering an IM injection.
C. Completing a dressing change.
Rationale:
Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. While performing a dressing change on a client who is HIV positive, the nurse should wear appropriate personal protective equipment, which includes a gown.
