ATI Test

Question 1

A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Answer 1

Use tracheostomy covers when outdoors.

Question 2

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

Answer 2

The client’s caregiver washes out the feeding bag with warm water once every 24 hours.

Question 3

A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I am not sure I want to retire.” Which of the following responses should the nurse make?

Answer 3

Let’s talk about how the change in your job status will affect you.

Question 4

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client’s pain?

Answer 4

Is your pain sharp or dull

Question 5

A nurse is caring for a client who is expressing anger about his diagnoses of colorectal cancer. Which of the following actions should the nurse take?

Answer 5

Reassure the client that this is an expected response to grief

Question 6

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Answer 6

Pad the client’s wrist before applying the restraints

Question 7

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol.

Answer 7

The client identifies the location of a fire extinguisher

Question 8

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Answer 8

Apply intermittent suction when withdrawing the catheter

Question 9

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Answer 9

Administer the medication with the need at a 45 degree angle

Question 10

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Answer 10

Advocacy ensures clients’ safety, health, and rights.

Question 11

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Answer 11

Press gently on the tragus of the client’s ear

Question 12

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Answer 12

Use a bed exit alarm system

Question 13

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client?

Answer 13

Make sure the client wears a mask when outside her room if there is construction in the area.

Question 14

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching

Answer 14

I will hire someone to trim the tree that hands low over the stairs of my front porch

Question 15

A nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement?

Answer 15

Use the planning step of the nursing process to prioritize client care delivery

Question 16

A nurse is planning to insert a peripheral IV catheter or an older adult client. Which of the following actions should the nurse plan to take

Answer 16

Place the client’s arm in a dependent position

Question 17

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel?

Answer 17

• Assist the client with a partial bed bath
• Measure the client’s BP after the nurse administers and antihypertensive medication
• Use a communication board to ask what the client wants for lunch

Question 18

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indicate of a skin malignancy?

Answer 18

A mole with an asymmetrical appearance

Question 19

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Answer 19

Abdominal cramping

Question 20

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Answer 20

SBAR

Question 21

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care, when should the nurse initiate discharge planning?

Answer 21

During the admission process

Question 22

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nruse make?

Answer 22

We would give you oxygen through a tube in your nose

Question 23

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Answer 23

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

Question 24

Steps to take for a pt who died

Answer 24

Step one: Obtain the death pronouncement from the provider
Step two: Remove tubes and indwelling lines prior to cleansing the client’s body
Step three: Ask family members if they wish to see the body
Step four: Place a name tag on the body before transfer

Question 25

Client teaching for self-administration of heparin

Answer 25

Administer the medication into the abdomen

Question 26

Purpose of advance directives

Answer 26

They indicate the form of treatment a client is willing to accept in the event of serious illness

Question 27

Which assessment should a nurse use to identify a client’s safety from falls

Answer 27

-Pupil clarity, visual fields, and visual acuity

Question 28

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Answer 28

Calf swelling

Question 29

A nurse is administering 1 L of sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Answer 29

Decrease in heart rate

Question 30

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Answer 30

Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min

Question 31

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Answer 31

Check the client for injuries

Question 32

A nurse is caring for a child who has a prescription for a blood transfusion. The child’s parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

Answer 32

Examine personal values about the issue

Question 33

A nurse is caring for a client who has a terminal illness is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Answer 33

Turn the client every 2 hours

Question 34

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Answer 34

Place a client who has tuberculosis in a room with negative-pressure airflow

Question 35

A nurse is using an open irrigation technique to irrigate a client’s indwelling urinary catheter. Which of the following actions should the nurse take?

Answer 35

Subtract the amount of irrigant used from the client’s urine output.

Question 36

What type of precaution is used for a client who has pharyngeal diphtheria

Answer 36

Droplet precautions

Question 37

A nurse is caring for a client who is postop and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 minutes and report back in 1 hour. What is the nurses next step

Answer 37

Notify the nursing manager.

Question 38

What fluid and electrolyte status should a nurse report to the provider?

Answer 38

Potassium 5.4 mEq/L

Question 39

When changing a clients dressing, if they say it hurts what should you do?

Answer 39

Administer pain medication 45 min before changing the client’s dressing

Question 40

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Answer 40

Compare prescriptions with medications the client received while at the facility.

Question 41

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

Answer 41

A client who has asthma

Question 42

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Answer 42

Droplet

Question 43

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Answer 43

Gently shake the container of medication prior to administration

Question 44

A nurse is caring for a client who reports pain. When documenting the quality of the client’s pain on an initial pain assessment, the nurse should record which of the following client statements?

Answer 44

The pain is like a dull ache in my stomach

Question 45

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

Answer 45

I can take echinacea to improve my immune system

Question 46

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Answer 46

Compare prescriptions with medications the client received while at the facility

Question 47

A nurse is reviewing a client’s medication prescription that reads, “digoxin 0.25 by mouth every day” Which of the following components of the prescription would the nurse verify with the provider?

Answer 47

Medication Dose

Question 48

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

Answer 48

A client who has asthma

Question 49

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Answer 49

Droplet

Question 50

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Answer 50

Gently shake the container of medication prior to administration

Question 51

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client’s partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Answer 51

Withhold the blood transfusion

Question 52

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

Answer 52

Current medications

Question 53

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Answer 53

Erythema on pressure points

Question 54

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Answer 54

Practice sessions

Question 55

A nurse is caring for a client who reports pain. When documenting the quality of the client’s pain on an initial pain assessment, the nurse should record which of the following client statements?

Answer 55

The pain is like a dull ache in my stomach

Question 56

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Answer 56

Initiate an enteral feeding through a gastrostomy tube

Question 57

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Answer 57

Evacuate the client

Question 58

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

Answer 58

I can take echinacea to improve my immune system

Question 59

A nurse enters a client’s room and finds her on the floor. The client’s roomate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Answer 59

Client found lying on floor

Question 60

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Answer 60

Have the client stand with their arms at their sides and their feet together

Question 61

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

Answer 61

When descending stairs, I will first shift my weight to my right leg

Question 62

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Answer 62

Flush the tube with 15 mL of sterile water

Question 63

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

Answer 63

A client who smokes on pack of cigarettes each day

Question 64

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Answer 64

Arrange food in a consistent pattern on the client’s plate

Question 65

A nurse is planning an education program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

Answer 65

You should receive a pneumococcal vaccine when you are 65 years old

Question 66

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Answer 66

Rapid heart rate

Question 67

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Answer 67

Auscultate lung sounds

Question 68

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client’s risk of developing plantar flexion contractures?

Answer 68

Apply an ankle-foot orthotic device to the clients feet

Question 69

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the followign pieces of personal protective equipment when providing care for the client?

Answer 69

N95 respirator

Question 70

A nurse in a surgical suite notes documentation on a client’s medical record that he has a latex allergy. In preparation for the client’s procedure, which of the following precautions should the nurse take?

Answer 70

Wrap monitoring cords with stockinette and tape them in place

Question 71

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess

Answer 71

Distended neck veins

Question 72

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Answer 72

Have the client use a trapeze bar when changing position

Question 73

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?

Answer 73

Instruct the family to refrain from pushing the button for the client while she is asleep

Question 74

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

Answer 74

An x-ray shows the end of the tube above the pylorus

Question 75

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

Answer 75

The caregiver insists on remaining in the room

Question 76

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next

Answer 76

Assess the client for orthostatic hypotension

Question 77

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client’s plan of care?

Answer 77

Wrap blankets around all four sides of the bed

Question 78

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

Answer 78

• Check the cord routinely for frays or tearing
• Consider purchasing a generator for power backup
• Observe for signs of hypoxia

Question 79

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Answer 79

Tell the client to keep the head of the bed elevated at least 30 degrees

Question 80

A nurse is calculating a client’s fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client’s intake and output record as 120mL of fluid?

Answer 80

8 oz of ice chips

Question 81

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Answer 81

Cleanse the wound from the center outward

Question 82

A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Answer 82

Have family members wear a gown and gloves when visiting.

Question 83

A nurse is caring for a client who requires a 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching.

Answer 83

I flushed what I urinated at 7 a.m. and have saved all urine since

Question 84

A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate

Answer 84

Ambulating a client who is postoperative

Question 85

Three tenths

Answer 85

0.3

Question 86

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

Answer 86

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

Question 87

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

Answer 87

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively

Question 88

A middle adult client tells the nurse, I feel so useless now that my children do not need me anymore. Which of the following responses should the nurse make?

Answer 88

People in middle adulthood often find satisfaction in nurturing and guiding young people

Question 89

A nurse is caring for a client who is receiving fluid through a peripheral Iv catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration

Answer 89

Skin blanching

Question 90

Basic Principles of Ethics

Answer 90

• Advocacy: Support and defend clients’ health, wellness, safety, wishes, and personal rights, including privacy.
• Responsibility: Willingness to respect obligations and follow through on promises.
• Accountability: Ability to answer for one’s own actions
• Confidentiality: Protection of privacy without diminishing access to high-quality care.

Question 91

Ethical Principles For Client Care

Answer 91

• Autonomy: The right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest
• Beneficence: Action that promotes good for others, without any self-interest
• Fidelity: fulfillment of promises
• Justice: fairness in care delivery and use of resources
• Nonmaleficence: A commitment to do no harm
• Veracity: A commitment to tell the truth

Question 92

Unintentional Torts

Answer 92

• Negligence: A nurse fails to implement safety measures for a client at risk for falls.
• Malpractice: A nurse administers a large dose of medication due to a calculation error.

Question 93

Quasi-intentional torts

Answer 93

• Breach of confidentiality: A nurse releases a client’s medical diagnoses to a member of the press.
• Defamation of character: A nurse tells a coworker that they believe the client has been unfaithful to their partner

Question 94

Intentional torts

Answer 94

• Assault: A nurse threatens to place an NG tube in a client who is refusing to eat.
• Battery: A nurse restrains a client and administers an injection against their wishes.
• False Imprisonment: A nurse uses restraints on a competent client to prevent their leaving the health care facility.

Question 95

Informed Consent

Answer 95

• Provider: Obtains informed consent
• Client: Gives informed consent
• Nurse: Witnesses informed consent

Question 96

Nurses Role in Advance Directives

Answer 96

• Provide written information about advance directives
• Document the client’s advance directives status
• Ensure that the advance directives reflect the client’ts current decisions
• Inform all members of the health care team of the client’s advance directives.

Question 97

Exudate Types

Answer 97

1st- serous- clear and gold- normal drainage every time you cut the body
2nd- serous sangranious- pink tinged- can be normal
3rd- sangranious- bloody drainage
4th- purulent or puss- yellow/green

Question 98

Disinfectant

Answer 98

A chemical used on surfaces to kill pathogenic organisms, but not necessarily spore forms or viruses

Question 99

Antiseptic

Answer 99

A chemical that is applied to living tissues to reduce the number or microorganisms present

Question 100

Standard precautions

Answer 100

• apply to blood, blood products, all body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes
  -Alcohol-based waterless antiseptic recommended if hands are not visibly soiled.
  -Soap and water for C. diff.
  -

Question 101

Airborne precautions

Answer 101

• Airborne respiratory particle: < 5 microns
• Infection: measles, chickenpox, disseminated varicella zoster, pulmonary or laryngeal tuberculosis
  -Protection:
  Private room
  Negative-pressure airflow of at least 6 to 12 exchanges per hour via high-efficiency particulate air (HEPA) filtration;
  =[mask or respiratory protection device, N95 respirator (depending on condition), gown, gloves, dedicated equipment

Question 102

Droplet precautions

Answer 102

• Respiratory droplets come from coughs, sneezes, or talking. They can travel only a few feet through the air
• For disease that are transmitted by large droplets (> 5 microns) W/in 3 feet of the patient.
• Infection: Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mums, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, pneumonic plague
• Protection: private room or cohort patients; mask or respirator required (depending on condition) Masks, gown and gloves, Dedicated equipment

Question 103

Contact Precautions

Answer 103

• This can be direct skin-to-skin contact or indirect contact such as when an infection carrying person touches a surface and then someone else touches that same surface.
• Blood and bodily fluids can transmit disease if they contact a susceptible host’s broken skin or mucous membranes.
• infection: colonization or infection with multi drug-resistant organisms such as VRE and NRSA, Clostridium difficile, shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated); respiratory syncytial virus in infants, young children, or immunocompromised
• Protection: private room or cohort patients, gloves, gowns (patients may leave their rooms for procedures or therapy if infectious material is contained or covered, placed in a clean gown, and if hands are clean)

Question 104

Examples of tasks nurses may delegate to PN’s

Answer 104

• Monitoring findings (as input to the RN’s ongoing assessment)
• Reinforcing client teaching from a standard care plan
• Performing tracheostomy care
• Suctioning
• Checking NG tube patency
• Administering enteral feedings
• Inserting a urinary catheter
• Administering medication, excluding IV medication

Question 105

Examples of tasks nurses may delegate to AP’s

Answer 105

ADL’s
Bathing, grooming, dressing, toileting, ambulating, feeding, positioning.
Bed making, specimen collection, I&O, Vital signs

Question 106

Sterile Field

Answer 106

• The outer wrappings and 1 inch edges of packaging that contains sterile items are not sterile
• Any object below the waist or above the chest is contaminated.

Question 107

Herpes Zoster

Answer 107

A common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract

Question 108

seizure precautions

Answer 108

-Make sure oxygen, an oral airway, suction equipment, padding for side rails are at the bedside.

Question 109

Restrain prescriptions

Answer 109

• 4 hrs for an adult
• 2 hrs for 9-17 year old
• 1 hour for younger than 9

Question 110

Nursing responsibilities for clients in restrains

Answer 110

• Assess skin integrity and give skin care every 2 hours
• Pad bony prominences
• Make sure restraints are loose enough to fit two fingers between.
• Never leave the client alone without restraints

Question 111

Fire Safety

Answer 111

RACE
Rescue
Alarm
Contain
Extinguish

Question 112

Semi-Fowler’s

Answer 112

• Client supine with HOB elevated 30 degrees
• Prevents regurgitation of enteral feedings and aspiration
• Promotes lung expansion

Question 113

High-Fowler’s

Answer 113

• Client supine with HOB elevated 45-60 degrees

- Promotes lung expansion, Prevents aspiration

Question 114

Supine

Answer 114

Client on their back

Question 115

Prone

Answer 115

Client on their abdomen

Question 116

Aloe

Answer 116

Wound healing

Question 117

Chamomile

Answer 117

Anti-inflammatory, calming

Question 118

Echninacea

Answer 118

Enhances immunity

Question 119

Garlic

Answer 119

Inhibits platelet aggregation

Question 120

Ginger

Answer 120

Antiemetic

Question 121

Ginko biloba

Answer 121

Improves memory

Question 122

Ginseng

Answer 122

Increases physical endurance

Question 123

Valerian

Answer 123

Promotes sleep, reduces immunity