Exam 1 - Questions

Question 1

25 - Asepsis & Infection Control

A nurse is changing a patient’s bed linens after drainage from an infected abdominal wound leaked. Which nursing action reflects proper use of medical asepsis?
a. Carrying soiled bed linens close to the body to prevent spreading microorganisms into the air
b. Placing soiled bed linens and hospital gowns on the floor when making the bed
c. Moving the patient table away from the body when wiping it off
d. Cleaning the most soiled items at the bedside first, followed by cleaner items

Answer 1

c. Moving the patient table away from the body when wiping it off

Question 2

25 - Asepsis & Infection Control

An outbreak of measles has occurred at the local elementary school. The parents of a child in the prodromal phase of the illness are told the child should stay home until well. What is important for the nurse to teach the parents about the prodromal phase?
a. The organisms enter the body and multiply while the patient is asymptomatic.
b. A person typically has vague, nonspecific symptoms and is highly contagious.
c. The presence of infection-specific signs and symptoms develop, manifesting as local or systemic responses.
d. The signs and symptoms of the illness disappear, and the person returns to their preillness state.

Answer 2

b. A person typically has vague, nonspecific symptoms and is highly contagious.

Question 3

25 - Asepsis & Infection Control

A nursing unit has multiple patients with MRSA infections requiring contact isolation. In which situations is it appropriate for the nurses to use an alcohol-based hand sanitizer to decontaminate their hands? [Select all that apply]
a. Before providing a bed bath
b. Having visibly soiled hands after patient contact
c. Removing gloves after patient care
d. Inserting a urinary catheter
e. Assisting with a surgical placement of a cardiac stent
f. Removing old magazines from a patient’s table

Answer 3

a. Before providing a bed bath
c. Removing gloves after patient care
d. Inserting a urinary catheter
f. Removing old magazines from a patient’s table

Question 4

25 - Asepsis & Infection Control

A nursing student is performing hand hygiene after providing care to a patient who is in isolation for C. diff related to antibiotic therapy. Which actions by the nursing student will the primary nurse need to correct? [Select all that apply]
a. Removing all jewelry including a platinum wedding band
b. Decontaminating the hands with an alcohol-based hand sanitizer
c. Using approximately 1 teaspoon of liquid soap
d. Keeping hands higher than elbows when placing under the faucet
e. Using friction motion when washing for at least 20 seconds
f. Rinsing thoroughly with water flowing toward the fingertips

Answer 4

b. Decontaminating the hands with an alcohol-based hand sanitizer
d. Keeping hands higher than elbows when placing under the faucet

Question 5

25 - Asepsis & Infection Control

When performing a dressing change requiring surgical asepsis, a nurse opens sterile supplies and dons sterile gloves. What additional action by the nurse is appropriate? [Select all that apply]
a. Avoid splashing while pouring irrigant onto the sterile field
b. Covering the nose and mouth with gloved hands if a sneeze is coming
c. Using forceps soaked in a disinfectant to place dressings on sterile field
d. Considering the outer 1-inch of the sterile field sterile

Answer 5

a. Avoid splashing while pouring irrigant onto the sterile field
d. Considering the outer 1-inch of the sterile field sterile

Question 6

25 - Asepsis & Infection Control

The nurse on a med-surg unit is admitting a patient with a diagnosis of active tuberculosis. Which infection control precautions will the nurse put into place? [Select all that apply]
a. Wearing sterile gloves for patients with visible body fluids
b. Placing the patient on airborne precautions
c. Wearing an N95 respirator mask when in the room
d. Placing the patient in a single-occupancy room
e. Ensuring the room provides positive pressure
f. Restricting visitors for the duration of the patient’s stay

Answer 6

b. Placing the patient on airborne precautions
c. Wearing an N95 respirator mask when in the room
d. Placing the patient in a single-occupancy room

Question 7

25 - Asepsis & Infection Control

Nursing students enrolled in a med-surg nursing course are learning about infection control measures. They have learned that nurses use droplet precautions for patients with which infections? [Select all that apply]
a. Rubella
b. Herpes simplex
c. Varicella
d. Tuberculosis
e. MRSA
f. Adenovirus

Answer 7

a. Rubella
b. Herpes simplex
f. Adenovirus

Question 8

25 - Asepsis & Infection Control

A nurse and health care provider are preparing for insertion of a central venous catheter when the patient accidentally touches the sterile field. What action will the nurse take next?
a. Ask another nurse to hold the patient’s hand and continue setting up the field
b. Remove any objects the patient touched and resume setting up the sterile field
c. Have someone hold the patient’s hand, discard the supplies, and prepare a new sterile field
d. No action since the patient has touched their own sterile field

Answer 8

c. Have someone hold the patient’s hand, discard the supplies, and prepare a new sterile field

Question 9

25 - Asepsis & Infection Control

When performing sterile wound irrigation and dressing change for a postoperative patient, a new graduate nurse creates a sterile field. Which actions require correction by the preceptor? [Select all that apply]
a. Placing the bottle cap for the irrigating solution off the sterile field with the edges down
b. Holding the bottle of irrigating solution inside the edge of the sterile field
c. Applying the second sterile glove by lifting it from beneath the cuff with the thumb held away from the glove
d. Pouring the irrigating solution into a sterile container from a height of 4 to 6 inches (10 to 15 cm)
e. Opening packages of sterile gauze dressings, prior to applying sterile gloves

Answer 9

d. Pouring the irrigating solution into a sterile container from a height of 4 to 6 inches (10 to 15 cm)
e. Opening packages of sterile gauze dressings, prior to applying sterile gloves

Question 10

25 - Asepsis & Infection Control

A nurse has finished providing care for a patient in contact isolation for a MRSA infection. Place the steps the nurse should follow to remove PPE in the correct order.
Untie gown at the front waist
Remove mask
Remove gloves
Remove gown
Remove goggles

Answer 10

1. UNTIE GOWN AT THE FRONT WAIST
2. REMOVE GLOVES
3. REMOVE GOGGLES
4. REMOVE GOWN
5. REMOVE MASK
   [UNTIE GO, GL, GO, GOW, M]

Question 11

25 - Asepsis & Infection Control

During morning huddle, a nurse manager and some nurses are identifying patients on the unit who are at risk for hospital-acquired infections (HAIs). Which patients will the nurses identify? [Select all that apply]
a. Smoker, two packs of cigarettes daily
b. White blood cell count of 2,000/mm3
c. Indwelling urinary catheter in place
d. Vegetarian and slightly underweight
e. Central venous catheter present
f. Postoperative colostomy

Answer 11

b. White blood cell count of 2,000/mm3
c. Indwelling urinary catheter in place
e. Central venous catheter present
f. Postoperative colostomy

Question 12

25 - Asepsis & Infection Control

A nurse is caring for a patient who is incontinent of stool and has developed a stage 3 pressure wound on the buttocks. What intervention will the nurse set as the priority of care?
a. Increasing nutrition
b. Promoting mobility
c. Managing chronic pain
d. Preventing infection

Answer 12

d. Preventing infection

Question 13

25 - Asepsis & Infection Control

When bathing a patient with C. diff infection, the nurse wears personal protective equipment (PPE). Which additional intervention promotes safe, effective care?
a. Donning PPE after entering the patient room
b. Bathing the perianal area last
c. Personalizing care by substituting glasses for goggles
d. Removing PPE after bathing the patient to talk with them in the room

Answer 13

b. Bathing the perianal area last

Question 14

28 - Safety/Restraints

The nurse manager and nurses in an acute care hospital participate in a safety huddle to identify patients at risk for falling. Which patients will the nurses determine to require follow-up? [Select all that apply]
a. Age >50 years
b. History of falling
c. Taking antibiotics
d. Presence of postural hypotension
e. Nausea from chemotherapy
f. Transferred from long-term care

Answer 14

b. History of falling
d. Presence of postural hypotension
f. Transferred from long-term care

Question 15

28 - Safety/Restraints

A nurse in a long-term care facility is on an interprofessional safety committee focusing on protecting older adults from injury and trauma. Which action does the nurse suggest they prioritize?
a. Ensuring proper function of fire alarms
b. Preventing exposure to temperature extremes
c. Screening for partner or elder abuse
d. Maintaining clutter-free rooms and hallways

Answer 15

d. Maintaining clutter-free rooms and hallways

Question 16

28 - Safety/Restraints

An experienced nurse and new graduate nurse are caring for a confused older adult who gets out of bed and wanders. The preceptor intervenes when observing which action by the graduate nurse?
a. Raising all four side rails to keep the patient in bed
b. Performing documentation in the patient’s room
c. Suggesting obtaining a patient “sitter”
d. Using a bed alarm to alert staff the patient leaving the bed

Answer 16

a. Raising all four side rails to keep the patient in bed

Question 17

28 - Safety/Restraints

The hospital’s fire alarm sounds, and an announcement is made that there is a fire in a patient room. What is the priority for nurses on the unit?
a. Removing patients from the room or vicinity
b. Attempting to put out the fire with water or appropriate extinguishers
c. Closing all the doors on the unit to contain the fire
d. Running to the closest unit and requesting help

Answer 17

a. Removing patients from the room or vicinity

Question 18

28 - Safety/Restraints

A disoriented older resident likes to wander the halls of their long-term care facility but becomes agitated when they cannot find their room. Which action is most appropriate as an alternative to restraints?
a. Placing them in a geriatric chair near the nurses’ station
b. Using the sheets to secure them snugly in the bed
c. Keeping the bed in a high position
d. Identifying their door with his photograph and a balloon

Answer 18

d. Identifying their door with his photograph and a balloon

Question 19

28 - Safety/Restraints

A nurse has exhausted every effort to keep a confused, postoperative patient safe and in bed. Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice?
a. Positioning the patient in the supine position prior to applying wrist restraints
b. Ensuring that two fingers can be inserted between the restraint and patient’s wrist
c. Applying a cloth restraint to the left hand of the patient with an IV catheter in the right wrist
d. Tying an elbow restraint to the raised side rail of the patient’s bed

Answer 19

b. Ensuring that two fingers can be inserted between the restraint and patient’s wrist

Question 20

28 - Safety/Restraints

During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority?
a. Explaining how to use the telephone
b. Introducing the patient to their roommate
c. Reviewing the hospital policy on visiting hours
d. Demonstrating how to operate the call bell

Answer 20

d. Demonstrating how to operate the call bell

Question 21

32 - Hygiene

A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient’s personal hygiene?
a. When the patient had their most recent bath
b. The patient’s usual hygiene practices and preferences
c. Where the bathing fits in the nurse’s schedule
d. The time that is convenient for the AP

Answer 21

b. The patient’s usual hygiene practices and preferences

Question 22

32 - Hygiene

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? [Select all that apply]
a. Promoting the patient’s sense of well-being
b. Preventing deterioration of the oral cavity
c. Contributing to decreased incidence of aspiration pneumonia
d. Eliminating the need for flossing
e. Decreasing oropharyngeal secretions
f. Compensating for an inadequate diet

Answer 22

a. Promoting the patient’s sense of well-being
b. Preventing deterioration of the oral cavity
c. Contributing to decreased incidence of aspiration pneumonia

Question 23

32 - Hygiene

A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is “itchy.” Which intervention is appropriate?
a. Bathe the patient more frequently.
b. Use an emollient on the dry skin.
c. Explain that this is expected as people age.
d. Limit the patient’s fluid intake.

Answer 23

b. Use an emollient on the dry skin

Question 24

32 - Hygiene

A charge nurse in a skilled nursing facility is working to reduce patients’ foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? [Select all that apply]
a. Patient taking antibiotics for chronic bronchitis
b. Patient with type 2 diabetes
c. Patient who has obesity
d. Patient who frequently bites their nails
e. Patient with prostate cancer
f. Patient who frequently washes their hands

Answer 24

b. Patient with type 2 diabetes
c. Patient who has obesity
d. Patient who frequently bites their nails
f. Patient who frequently washes their hands

Question 25

32 - Hygiene

When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? [Select all that apply]
a. Comparing bilateral parts for symmetry
b. Proceeding in a toe-to-head, systematic manner
c. Using standard terminology to communicate and document findings
d. Avoiding using data from the nursing history to direct the assessment
e. Documenting only skin abnormalities on the health record
f. When risk factors are identified, following up with a related skin assessment

Answer 25

a. Comparing bilateral parts for symmetry
b. Proceeding in a toe-to-head, systematic manner
c. Using standard terminology to communicate and document findings
f. When risk factors are identified, following up with a related skin assessment

Question 26

32 - Hygiene

A nurse is performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next?
a. Recommend a consultation with an oral surgeon.
b. Communicate the condition to the health care team.
c. Gently scrape the oral cavity with a tongue depressor.
d. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

Answer 26

d. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

Question 27

32 - Hygiene

A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse’s response? [Select all that apply]
a. To help with pain management
b. To provide comfort
c. To communicate to patients through touch
d. To energize patients, especially those with dementia
e. To facilitate healing after back or spinal surgery
f. To help increase circulation

Answer 27

a. To help with pain management
b. To provide comfort
c. To communicate to patients through touch
f. To help increase circulation

Question 28

32 - Hygiene

A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? [Select all that apply]
a. Bathing the feet thoroughly in a mild soap and tepid water solution
b. Soaking the resident’s feet in warm water and bath oil
c. Drying the feet and area between the toes thoroughly
d. Applying an alcohol rub for odor and dryness to the feet
e. Applying an antifungal foot powder
f. Cutting the toenails at the lateral corners when trimming the nail

Answer 28

b. Soaking the resident’s feet in warm water and bath oil
d. Applying an alcohol rub for odor and dryness to the feet
f. Cutting the toenails at the lateral corners when trimming the nail

Question 29

32 - Hygiene

A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety?
a. Shifting the focus of the interaction to the “process of bathing”
b. Washing the face and hair at the beginning of the bath
c. Using music to soothe anxiety and agitation
d. Avoiding towel baths or forms of bathing with which the patient is unfamiliar

Answer 29

c. Using music to soothe anxiety and agitation

Question 30

32 - Hygiene

A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? [Select all that apply]
a. For male and female patients, wash the groin area with a small amount of soap and water and rinse.
b. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.
c. For male and female patients, always proceed from the most contaminated area to the least contaminated area.
d. For male and female patients, use a clean portion of the washcloth for each stroke.
e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
f. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.

Answer 30

a. For male and female patients, wash the groin area with a small amount of soap and water and rinse.
d. For male and female patients, use a clean portion of the washcloth for each stroke.
e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.

Question 31

32 - Hygiene

A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?
a. Adding bath oil to the water to prevent dry skin
b. Allowing the patient to lock the door to guarantee privacy
c. Assisting the patient in and out of the tub to prevent falling
d. Keeping the water temperature very warm because older adults chill easily

Answer 31

c. Assisting the patient in and out of the tub to prevent falling

Question 32

32 - Hygiene

An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct?
a. When providing perineal care, washing the area from front to back
b. Insisting the older adult must take a bath or shower each day
c. Telling the patient to avoid soaking feet, helps the patient dry between the toes
d. Covering areas not being bathed with a bath blanket

Answer 32

b. Insisting the older adult must take a bath or shower each day

Question 33

ATI - Infection Control

A nurse is caring for a client who has a healthcare associated infection (HAI). Which describes and exogenous HAI?
a. A Salmonella infection that occurs after eating contaminated foods from the cafeteria
b. An infection that occurs during a therapeutic procedure
c. A yeast infection that occurs while receiving broad spectrum abx
d. A UTI that occurs afer a sterile catheter insertion

Answer 33

a. A Salmonella infection that occurs after eating contaminated foods from the cafeteria

[exogenous HAI = infection acquired from pathogens found outside the client’s body, such as in contaminated foods]

Question 34

ATI - Infection Control

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which action should the nurse take?
a. Cleanse their hands with an alcohol-based gel
b. Wash their hands with soap and water
c. Brush off the soil against a cloth surface
d. Use a wet paper towel to remove the soil

Answer 34

b. Wash their hands with soap and water

Question 35

ATI - Infection Control

A nurse is about to irrigate a client’s open wound. Besides gloves, which of the following personal protective equipment should the nurse wear?
a. A sterile gown
b. Goggles
c. A face shield
d. An N95 respirator

Answer 35

c. A face shield

Question 36

ATI - Infection Control

After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which should the nurse remove first when removing PPE separately?
a. Gloves
b. Gown
c. Face shield
d. N95 respirator

Answer 36

a. Gloves

[gloves = most contaminated and should be removed first, then followed by face/eye protection, gown, and mask/respirator]

Question 37

ATI - Infection Control

To decomtaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which is the correct rationale for why hands should be rubbed together until dry?
a. Drying provides the full antiseptic effect
b. Residual alcohol can easily stain clothing
c. Excess gel could transfer to the client
d. Slippery gel can make the nurse drop supplies

Answer 37

a. Drying provides the full antiseptic effect

Question 38

ATI - Infection Control

A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which action should the nurse take when caring for the client?
a. Wear a respirator
b. Protect their eyes
c. Put on clean gloves
d. Wear shoe covers

Answer 38

b. Protect their eyes

Question 39

ATI - Infection Control

A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which action?
a. Make sure the water is hot
b. Wash for at least 20 seconds
c. Use liquid soap preparation
d. Remove rings and watches first

Answer 39

b. Wash for at least 20 seconds

Question 40

ATI - Infection Control

What should the nurse do to maintain standard precaution?
a. Rinse gloves that become visibly soiled during use
b. Use an antimicrobial soap for routine handwashing
c. Disinfect hands immediately after removing gloves
d. Keep gloves on when touching environmental surfaces

Answer 40

c. Disinfect hands immediately after removing gloves

Question 41

ATI - Infection Control

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?
a. Hepatitis B
b. Measles
c. Meningitis
d. Infectious diarrhea

Answer 41

d. Infectious diarrhea

Question 42

ATI - Infection Control

Which product can affect the permeability of latex gloves?
a. Antimicrobial soap and water
b. Alcohol based antiseptic gel
c. Petroleum based hand lotion
d. Water based hand lotion

Answer 42

c. Petroleum based hand lotion

Question 43

ATI - Infection Control

Which is an advantage of using alcohol based gel?
a. It takes less time to use than washing with soap and water
b. It removes gross contamination better than soap and water does
c. Its protective nature reduces the need for frequent handwashing
d. It provides adequate protection before surgical applications

Answer 43

a. It takes less time to use than washing with soap and water

Question 44

ATI - Surgical Asepsis

When opening a sterile pack, which action by the nurse might compromise the sterility of the instruments and supplies inside of the pack?
a. Allowing movement of team members around the field
b. Holding the sterile pack below the waist or table level
c. Keeping sterile items away from the edge of the table
d. Opening the sterile pack just prior to the procedure

Answer 44

b. Holding the sterile pack below the waist or table level

Question 45

ATI - Surgical Asepsis

A nurse is preparing to flush and change the dressing on a client’s central venous catheter. Which should the nurse identify as the primary purpose for performing this intervention using surgical asepsis?
a. To promote the catheter’s patency
b. To assess the skin’s integrity around the catheter site
c. To provide a clean, dry environment for the catheter
d. To control the introduction of microorganisms at the catheter site

Answer 45

d. To control the introduction of microorganisms at the catheter site

Question 46

ATI - Surgical Asepsis

A nurse is preparing a sterile field. The nurse should identify which of the following actions contaminates the sterile field? [Select all that apply]
a. A cotton ball dampened with sterile normal saline is placed on the field
b. A contaminated instrument touches the outer edge of the sterile field
c. A sterile instrument is dropped onto the near side of the sterile field
d. The nurse turns to address the client’s question concerning the procedure
e. The procedure is postponed for 30 min to accommodate the client
f. A liquid is poured into a sterile container from a distance of 25 cm (10 in)

Answer 46

a. A cotton ball dampened with sterile normal saline is placed on the field
d. The nurse turns to address the client’s question concerning the procedure
e. The procedure is postponed for 30 min to accommodate the client
f. A liquid is poured into a sterile container from a distance of 25 cm (10 in)

Question 47

ATI - Surgical Asepsis

When donning sterile gloves, what explains the method a nurse should use for gloving the dominant hand?
a. Slipping the fingers beneath the cuff maintains the gloves’ sterility
b. The inner edge of the cuff will lie against the skin and thus will not be sterile
c. Gloving the dominant hand first allows for better control over the process
d. The hand has been surgically scrubbed and is considered uncontaminated

Answer 47

b. The inner edge of the cuff will lie against the skin and thus will not be sterile

Question 48

ATI - Surgical Asepsis

A nurse should identify what is the goal of surgical asepsis?
a. To create and maintain a microorganism free environment
b. To kill all microorganisms on all instruments involved in a procedure
c. To reduce the presence of pathogenic organisms in the environment
d. To minimize exposure to the client’s blood during an invasive procedure

Answer 48

a. To create and maintain a microorganism free environment

Question 49

ATI - Surgical Asepsis

While waiting for a sterile procedure to begin, how should a nurse position their hands and arms?
a. With hands clasped together in front of the body above waist level
b. At the sides of the body with hands pointing downward
c. Folded across the chest with hands on the shoulders
d. With hands clasped together in the back of the body at waist leve

Answer 49

a. With hands clasped together in front of the body above waist level

Question 50

ATI - Surgical Asepsis

A nurse is providing teaching to an AP about the buse of sterile gloves. What instruction regarding the open-gloving method should the nurse give?
a. Ask another team member to assist with donning glove
b. Choose a pair of gloves at least one size smaller than usual
c. Grasp only the underside of the cuff with your ungloved hand
d. Grasp only the inside of the glove with your gloved hand

Answer 50

d. Grasp only the inside of the glove with your gloved hand

Question 51

ATI - Surgical Asepsis

A nurse is preparing to wash their hands prior to surgery. For what reason should the nurse keep their hands above their elbows?
a. To prevent them from coming into contact with a contaminated object
b. To facilitate the application of sufficient friction to the hands
c. To provide good visualization of the hands as they are scrubbed
d. To encourage water and soap to flow away from the clean hands

Answer 51

d. To encourage water and soap to flow away from the clean hands

Question 52

ATI - Surgical Asepsis

A nurse is preparing to open a sterile package of instruments. What order should the nurse perform the following steps?
1. Position the tray so that the top flap is farthest away from their body
2. Open the flap furthest from the body
3. Open the side flaps
4. Open the flap closest to the body

Answer 52

1. Position the tray so that the top flap is farthest away from their body
2. Open the flap furthest from the body
3. Open the side flaps
4. Open the flap closest to the body

Question 53

ATI - Surgical Asepsis

Prior to enerting the surgical scrub area, what PPE items should a nurse don? [Select all that apply]
a. Gown
b. Protective eyewear
c. Hair cover
d. Mask
e. Shoe covers

Answer 53

b. Protective eyewear
c. Hair cover
d. Mask
e. Shoe covers

Question 54

ATI - Surgical Asepsis

A nurse should identify what area of the hands requires special attention during the prescrub wash?
a. The area between each finger
b. The area under each fingernail
c. The palm of the hand
d. The back of the hands

Answer 54

b. The area under each fingernail

Question 55

34 - Mobility

A nurse is developing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? [Select all that apply]
a. Teach the patient to avoid sudden position changes that may cause dizziness.
b. Recommend that the patient restrict fluid intake until after exercise.
c. Instruct the patient to push a little further beyond fatigue each session.
d. Tell the patient to avoid exercising in very cold or very hot temperatures.
e. Encourage the patient to modify exercise if weak or ill.
f. Recommend that the patient consume a high-carb, low-protein diet.

Answer 55

a. Teach the patient to avoid sudden position changes that may cause dizziness.
d. Tell the patient to avoid exercising in very cold or very hot temperatures.

Question 56

34 - Mobility

A nurse is providing active-assistive range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient reports that they are “too tired to go on.” What actions are appropriate at this time? [Select all that apply]
a. Stop performing the exercises.
b. Decrease the number of repetitions performed.
c. Reevaluate the plan of care.
d. Move to the patient’s other side to perform exercises.
e. Encourage the patient to finish the exercises and then rest.
f. Assess the patient for additional symptoms of intolerance.

Answer 56

a. Stop performing the exercises.
c. Reevaluate the plan of care.
f. Assess the patient for additional symptoms of intolerance.

Question 57

34 - Mobility

A nurse assists a patient with ambulation for the first time following a knee replacement. Shortly after beginning to walk, the patient tells the nurse that they are dizzy and feel like they might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient:
a. Grasp the gait belt.
b. Stay with the patient and call for help.
c. Place feet wide apart with one foot in front.
d. Gently slide the patient down to the floor, protecting their head
e. Pull the weight of the patient backward against your body
f. Rock your pelvis out on the side of the patient.

Answer 57

1. C. PLACE FEET WIDE APART WITH ONE FOOT IN FRONT
2. F. ROCK YOUR PELVIC OUT ON THE SIDE OF THE PATIENT
3. A. GRASP THE GAIT BELT
4. E. PULL THE WEIGHT OF THE PATIENT BACKWARD AGAINST YOUR BODY
5. D. GENTLY SLIDE THE PATIENT DOWN TO THE FLOOR, PROTECT THEIR HEAD
6. B. STAY WITH THE PATIENT AND CALL FOR HELP

Question 58

34 - Mobility

A nursing student asks the primary nurse why an immobile patient developed two urinary tract infections (UTIs) in the 6 months. How does the nurse best explain this patient’s risk for UTI?
a. Improved renal blood supply to the kidneys
b. Urinary stasis
c. Decreased urinary calcium
d. Acidic urine formation

Answer 58

b. Urinary stasis

Question 59

34 - Mobility

A nurse on a medical-surgical unit notes a patient with pneumonia and is experiencing dyspnea. What action will the nurse take to improve the dyspnea?
a. Encourage the patient to ambulate.
b. Suggest the patient use music or television as distraction.
c. Place the patient in Fowler’s position.
d. Tell the patient to take several deep breaths, then hold their breath for 5 seconds.

Answer 59

c. Place the patient in Fowler’s position.

Question 60

34 - Mobility

A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan?
a. Support weight on the stronger leg and cane and advance weaker foot forward.
b. Hold the cane in the same hand of the leg with the most severe deficit.
c. Stand with as much weight distributed on the cane as possible.
d. Avoid using the cane to rise from a sitting position, as this is unsafe.

Answer 60

a. Support weight on the stronger leg and cane and advance weaker foot forward.

Question 61

34 - Mobility

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?
a. Lean on the crutches using the axillae to bear body weight.
b. Keep elbows close to the sides of the body.
c. When rising, extend the uninjured leg to prevent weight bearing.
d. To climb stairs, place weight on affected leg first.

Answer 61

b. Keep elbows close to the sides of the body.

Question 62

34 - Mobility

A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?
a. Carefully assessing the patient care environment
b. Using two nurses to lift a patient who cannot assist
c. Wearing a back belt to perform routine duties
d. Properly documenting the patient lift

Answer 62

a. Carefully assessing the patient care environment

Question 63

34 - Mobility

A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient’s knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?
a. Supporting the patient as she stands, waiting a few moments, then continuing the move to the chair
b. Calling for assistance and continuing the move with the assistance of another nurse
c. Lowering the patient back to the side of the bed and pivoting her back into bed
d. Having the patient sit down on the bed and dangle her feet before moving

Answer 63

c. Lowering the patient back to the side of the bed and pivoting her back into bed

Question 64

34 - Mobility

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position?
a. Side-lying
b. Fowler’s
c. Sims’
d. Prone

Answer 64

d. Prone

Question 65

34 - Mobility

Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses?
a. Telling the patient to cross their arms and legs
b. Pulling the patient from underneath the axilla toward the top of the bed
c. Avoiding using a draw sheet to lift or reposition the patient
d. Ensuring the bed is at the level of the nurses’ hips
e. Facing the head of the bed and rocking in synchrony

Answer 65

d. Ensuring the bed is at the level of the nurses’ hips

Question 66

34 - Mobility

A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient?
a. “Stand on the weaker leg and pivot toward the chair.”
b. “I will call the lift team to carry you to the chair.”
c. “The chair is by your non-affected leg for smoother movement.”
d. “Avoid putting your hospital socks on, as that will restrict your feet moving.”

Answer 66

c. “The chair is by your non-affected leg for smoother movement.”

Question 67

ATI - Personal Hygiene

A nurse is planning morning hygiene care for a postoperative patient. Which action should the nurse take?
a. Inform the client when morning hygiene care is provided at the hospital
b. Schedule the client’s morning hygiene care at the same time as their roommate
c. Ask the client in what order they typically perform their morning routine
d. Plan to provide care before the next scheduled dose of pain medication

Answer 67

c. Ask the client in what order they typically perform their morning routine

Question 68

ATI - Personal Hygiene

A nurse is observing an AP make a client’s bed while the client is out of the room. Which action by the AP indicates an understanding of the procedure?
a. The AP records the task when it is completed
b. The AP wears sterile gloves while making the bed
c. The AP changes the client’s pillowcase
d. The AP reuses the client’s clean blanket and bedspread

Answer 68

d. The AP reuses the client’s clean blanket and bedspread

Question 69

ATI - Personal Hygiene

A nurse is teaching a newly licensed nurse about providing oral hygeine for clients who are unconscious. Which statement by the newly licensed nurse indicates an understanding of the teaching?
a. “I’ll swab the client’s mouth with lemon-glycerin swabs”
b. “I’ll swab the client’s mouth with mouthwash”
c. “I’ll swab the client’s mouth with chlorhexidine”
d. “I’ll swab the client’s lips with a very small amount of mineral oil”

Answer 69

c. “I’ll swab the client’s mouth with chlorhexidine”

Question 70

ATI - Personal Hygiene

A nurse is performing a complete bed bath for a client. Which action should the nurse take?
a. Raise the room temperature
b. Completely remove the linens
c. Add soap and water to the basin before the beginning of the bath
d. Bathe one side of the body at a time

Answer 70

a. Raise the room temperature

Question 71

ATI - Personal Hygiene

A nurse is assisting a client with personal hygiene care. Which action should the nurse take to reduce the risk of infection?
a. Massage reddended areas of the client’s skin
b. Wash eyes from the outer canthus to the inner canthus
c. Wash the client from the shoulder down to the fingertips with smooth, short strokes
d. Clean the least-soiled areas prior to cleaning the most-soiled areas

Answer 71

d. Clean the least-soiled areas prior to cleaning the most-soiled areas

Question 72

ATI - Personal Hygiene

A nuse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which should the nurse identify as the priority rationale for frequent linen changes?
a. Moisture from excessive diaphoresis can cause skin breakdown
b. Moisture on the sheets can cause discomfort to the client
c. It provides an opportunity to frequently evaluate the skin on the client’s backside
d. It provides an opportunity to turn the client from side to side to facilitate clearing potential fluid from the lungs

Answer 72

a. Moisture from excessive diaphoresis can cause skin breakdown

Question 73

ATI - Personal Hygiene

A nurse is preparing to provide oral care for a client who is NPO. The client tells the nurse, “I don’t need oral care because I haven’t eaten anything.” Which response should the nurse make?
a. “Since you are not eating, we can wait and do it before bedtime”
b. “Oral care is still important even though you are not eating”
c. “I’ll give you a sip of water to swish around in your mouth, and then you can spit it out”
d. “We will wait until your family gets here to help”

Answer 73

b. “Oral care is still important even though you are not eating”

Question 74

ATI - Personal Hygiene

A nurse is preparing to assist a client with a tub bath. Identify the sequence of steps the nurse should take:
a. Place a rubber mat on the tub floor
b. Instruct the client to remain in the tub for no longer than 20 min
c. Gather all the necessary supplies
d. Instruct the client on using safety bars when getting in and out of the tub
e. Assist the client into the bathroom

Answer 74

1. c. Gather all the necessary supplies
2. a. Place a rubber mat on the tub floor
3. e. Assist the client into the bathroom
4. d. Instruct the client on using safety bars when getting in and out of the tub
5. b. Instruct the client to remain in the tub for no longer than 20 min

Question 75

ATI - Mobility

A nurse in an ED is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which instruction should the nurse include?
a. Lean on the crutches to support your body weight when standing
b. Fully extend your arms when holding onto the hand grips
c. Hold the crutches on your unaffected side when preparing to sit in a chair
d. Hold the crutches 9 inches in front of and to the side of each foot

Answer 75

c. Hold the crutches on your unaffected side when preparing to sit in a chair

Question 76

ATI - Mobility

A nurse is caring for a client who has a prescription for knee-length anti-embolic stockings. Which action should the nurse take?
A. Place the stockings on the client after the client ambulates to the restroom
B. Ensure the client’s toes are visible after placing the stockings on the client
C. After applying the stockings, place two fingers between the client’s legs and stocking to check the fit
D. Measure the client’s calf circumference and leg length from heel to knee

Answer 76

D. Measure the client’s calf circumference and leg length from heel to knee

Question 77

ATI - Mobility

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which action by the nurse demonstrates the correct transfer technique?
A. Positioning the chair slightly behind the nurse so that the seat faces the client’s bed
B. Placing the client’s left leg in front of the right leg just prior to the transfer
C. Aligning the nurse’s knees with the client’s knees just before the transfer
D. Grasping the client under the axillae to assist them to their feet

Answer 77

C. Aligning the nurse’s knees with the client’s knees just before the transfer

Question 78

ATI - Mobility

A nurse is caring for a client who has been hospitalized and is performing active ROM exercises. Which body movement should indicate to the nurse that the client has full ROM of the shoulder?
A. Adducting the arm so that it lies next to the client’s side
B. Flexing the shoulder by raising the arm from a side position to a 180-degree angle
C. Abducting the arm to a 90-degree angle from the side of the body
D. Circumducting the shoulder in a 180 degree half circle

Answer 78

B. Flexing the shoulder by raising the arm from a side position to a 180-degree angle

Question 79

ATI - Mobility

A nurse is assisting with ambulating a client who becomes light-headed and begins to fall. Which action should the nurse take?
A. Wrap both arms around the client’s arms and shoulders
B. Move both feet together when the client begins to fall
C. Protect the client’s extremities while lowering them to the floor
D. Extend one leg and allow the client to slide down the leg to the floor

Answer 79

D. Extend one leg and allow the client to slide down the leg to the floor

Question 80

ATI - Mobility

A nurse observes an AP using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which action by the AP should the nurse intervene?
A. Place a removable cover on the sling
B. Leaves the bed in the lowest position throughout the procedure
C. Locks the hydraulic valve before attaching the sling to the lift
D. Raises the head of the bed to a sitting position just before transfer

Answer 80

B. Leaves the bed in the lowest position throughout the procedure

Question 81

ATI - Mobility

A nurse stands facing a client to demonstrate active ROM exercises. Which action should the nurse take to demonstrate hyperextension of the hip?
A. Move their leg behind their body
B. Move their leg forward and up
C. Move their leg medially toward the other leg
D. Turn their foot and leg away from their other leg

Answer 81

A. Move their leg behind their body

Question 82

ATI - Comprehensive Physical Assessment

A nurse is performing a complete, head-to-toe physician examination for a client. Which following physical assessment technique should the nurse perform first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation

Answer 82

B. Inspection

Question 83

ATI - Comprehensive Physical Assessment

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify which of the following findings is common with aging?
A. Lordosis
B. Kyphosis
C. Ankylosis
D. Scoliosis

Answer 83

B. Kyphosis

COMMON FINDING…BUT NOT A NORMAL FINDING

Question 84

ATI - Comprehensive Physical Assessment

A nurse is palpating a tender area of a client’s abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which finding should the nurse document?
A. Borborygmi
B. Rebound tenderness
C. Tympany
D. Abdominal guarding

Answer 84

B. Rebound tenderness

Question 85

ATI - Comprehensive Physical Assessment

A nurse is teaching a newly licensed nurse about using a stethoscope. Which instruction should the nurse include?
A. Insert the earpieces at a downward angle toward your nose
B. Use the diaphragm to listen to low-pitched sounds
C. Drape the stethoscope over your neck when not in use
D. Clean the stethoscope by immersing it in soapy water

Answer 85

A. Insert the earpieces at a downward angle toward your nose

Question 86

ATI - Comprehensive Physical Assessment

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client’s breathing. Which of the following findings should the nurse identify this observation?
A. Crackles
B. Stridor
C. Wheezes
D. Friction rub

Answer 86

A. Crackles

Question 87

ATI - Comprehensive Physical Assessment

A nurse is performing a cardiovascular assessment on a client. Which finding should the nurse expect?
A. A continuous sensation of vibration is felt over the second and third left intercostal spaces
B. A high-pitched, scraping sound was heard in the third intercostal space to the left of the sternum
C. A brief thump was felt near the fourth or fifth intercostal space near the left midclavicular line
D. A whooshing or swishing sound over the second intercostal space along the left sternal border

Answer 87

C. A brief thump was felt near the fourth or fifth intercostal space near the left midclavicular line

Question 88

ATI - Comprehensive Physical Assessment

A nurse is preparing to perform a comprehensive physical assessment on a client. Which action should the nurse plan to take first?
A. Document accurate data
B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care

Answer 88

B. Develop a plan of care

Question 89

ATI - Comprehensive Physical Assessment

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client’s abdomen should the nurse attempt to auscultate active bowel sounds first?
A. Right upper quadrant
B. Left upper quadrant
C. Right lower quadrant
D. Left lower quadrant

Answer 89

C. Right lower quadrant

Question 90

ATI - Comprehensive Physical Assessment

A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which characteristic?
A. Gait
B. Hearing
C. Vision
D. Balance

Answer 90

D. Balance

Question 91

ATI - Comprehensive Physical Assessment

A nurse is assessing a client’s cranial nerves. Which client action is an indication that cranial nerve I is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can hear whispered words
D. The client can identify a minty scent

Answer 91

D. The client can identify a minty scent

Question 92

ATI - Comprehensive Physical Assessment

A nurse is assessing a client’s peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client’s foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which pulse?
A. Posterior tibial
B. Popliteal
C. Dorsalis pedis
D. Femoral

Answer 92

C. Dorsalis pedis

Question 93

ATI - Comprehensive Physical Assessment

A nurse is performing a general client survey and finds that the client has a BMI of 23. Which should the nurse document?
A. The client has no nutritional issues or deficits
B. The client is at high risk for obesity-related health problems
C. The client will need a referral to a dietician
D. The client has BMI within the expected reference range

Answer 93

D. The client has BMI within the expected reference range

Question 94

ATI - Safety / Restraints

A nurse is assisting with teaching a new nurse about using a lift device to transfer a client. Which action by the nurse indicates an understanding of the teaching? [Select all that apply]
A. Locks the brakes on clients bed
B. Checks the max weight of the lift before using it
C. Places the client on the edge of the sling
D. Uses the lift without assistance from another team member
E. Performs a safety check before lifting the client

Answer 94

A. Locks the brakes on clients bed
B. Checks the max weight of the lift before using it
E. Performs a safety check before lifting the client

Question 95

ATI - Safety / Restraints

A nurse is assisting with teaching a class about evidence-based protocols to prevent HAIs. Which infections should the nurse include? [Select all that apply]
A. Influenza infection
B. Catheter-associated UTI
C. Mycobacterium tuberculosis
D. Central line-associated bloodstream infection
E. Surgical site infection

Answer 95

B. Catheter-associated UTI
D. Central line-associated bloodstream infection
E. Surgical site infection

Question 96

ATI - Safety / Restraints

A nurse is assisting with teaching a class about hospital acquired injuries. Which should the nurse include as a hospital acquired injury? [Select all that apply]
A. Blood transfusion incompatibility
B. Wrong site sx
C. Ineffective insulin usage
D. Dysphagia following a stroke
E. Dehydration due to diarrhea

Answer 96

A. Blood transfusion incompatibility
B. Wrong site sx
C. Ineffective insulin usage

Question 97

ATI - Safety / Restraints

A nurse is assisting with teaching a class about events that require an occurrence/incidence report. Which events should the nurse include? [Select all that apply]
A. A client’s visitor falls in the hallway
B. A nurse forgets their computer password
C. A client develops an unexpected reaction to a medication
D. A client’s dentures are lost
E. An antibiotic was administered to a client 30 min after the scheduled time

Answer 97

A. A client’s visitor falls in the hallway
C. A client develops an unexpected reaction to a medication
D. A client’s dentures are lost

Question 98

ATI - Safety / Restraints

A nurse is preparing to conduct a fall risk screening on a client. What variables will the nurse use to evaluate the client? [Select all that apply]
A. Fall history
B. Medical diagnosis
C. Use of assistive devices
D. Mental status
E. Do-not-resuscitate status

Answer 98

A. Fall history
B. Medical diagnosis
C. Use of assistive devices
D. Mental status

Question 99

ATI - Safety / Restraints

A nurse caring for a client who has an indwelling urinary catheter in place. Which action is the priority for the nurse to take to reduce the risk of the client developing a HAI?
A. Wipe down their bedside table with antiseptic wipe
B. Conduct informal audits of medical records to identify number of HAI
C. Perform hand hygiene
D. Instruct the client on ways to reduce the risk for infection

Answer 99

C. Perform hand hygiene

Question 100

ATI - Safety / Restraints

A nurse is caring for a client who has a prescription for wrist restraints. Which action should the nurse take?
A. Tie the restraints to the side rails on the bed
B. Remove the restraints for each vital sign check
C. Use a square knot to secure the restraints
D. Make sure one finger can fit under the restraints

Answer 100

B. Remove the restraints for each vital sign check

Question 101

ATI Chapter - Medical & Surgical Asepsis

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? [Select all that apply]
a. Apply 3-5 mL of liquid soap to dry hands
b. Wash the hands with soap and water for at least 15 seconds
c. Rinse the hands with hot water
d. Use a clean paper towel to turn off hand faucets
e. Allow the hands to air dry after washing

Answer 101

b. Wash the hands with soap and water for at least 15 seconds
d. Use a clean paper towel to turn off hand faucets

Question 102

ATI Chapter - Medical & Surgical Asepsis

When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?
a. Keep the sterile field at least 6 ft away from the client’s bedside
b. Instruct the client to refrain from coughing and sneezing during the dressing change
c. Place a mask on the client to limit the spread of microorganisms into the surgical wound
d. Keep a box of facial tissues nearby for the client to use during the dressing change

Answer 102

c. Place a mask on the client to limit the spread of microorganisms into the surgical wound

Question 103

ATI Chapter - Medical & Surgical Asepsis

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? [Select all that apply]
a. The provider drops a sterile instrument onto the near side of the sterile field
b. The nurse moistens a cotton ball with sterile normal saline and places it on to the sterile field.
c. The procedure is delayed 1 hr because the provider receives an emergency call
d. The nurse turns to speak to someone who enters through the door behind the nurse
e. The client’s hand brushes against the outer edge of the sterile field

Answer 103

b. The nurse moistens a cotton ball with sterile normal saline and places it on to the sterile field.
c. The procedure is delayed 1 hr because the provider receives an emergency call
d. The nurse turns to speak to someone who enters through the door behind the nurse

A - As long as the provider has not reached over the sterile field (by placing the instrument on a near portion of the field), the field remains sterile.
E. The 1-inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile.

Question 104

ATI Chapter - Medical & Surgical Asepsis

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? [Select all that apply]
a. A bottle containing a sterile solution
b. The edge of the sterile drape at the base of the field
c. The inner wrapping of an item on the sterile field
d. An irrigation syringe appropriately placed on the sterile field
e. One gloved hand with the other gloved hand

Answer 104

c. The inner wrapping of an item on the sterile field
d. An irrigation syringe appropriately placed on the sterile field
e. One gloved hand with the other gloved hand

A - A bottle of sterile solution is sterile on the inside and non-sterile on the outside. Place the solution in a sterile container on the field before putting on sterile gloves.
B - The 1-inch border at the outer edge of the sterile field is not sterile. Do not touch it with sterile gloves.

Question 105

ATI Chapter - Medical & Surgical Asepsis

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
a. The flap closest to the body
b. The right side flap
c. The left side flap
d. The flap farthest from the body

Answer 105

d. The flap farthest from the body

The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client’s safety. Unless the nurse pulls the top flap (the one farthest from her body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it.

Question 106

ATI Chapter - Infection Control

A nurse is reviewing the stages of infection with new nurses. Place the stages in the order in which they occur.
Prodromal
Convalescence
Incubation
Illness

Answer 106

1. Incubation
2. Prodromal
3. Illness
4. Convalescence

I P I C

Question 107

ATI Chapter - Infection Control

A nurse is caring for a client who has an infection. Sort the manifestations the nurse would expect to find if the infection is LOCALIZED
Fever
Malaise
Edema
Pain or Tenderness
Increased heart rate & respiratory rate

Answer 107

Edema
Pain or Tenderness

Question 108

ATI Chapter - Infection Control

A nurse is caring for a client who has an infection. Sort the manifestations the nurse would expect to find if the infection is SYSTEMIC
Fever
Malaise
Edema
Pain or Tenderness
Increased heart rate & respiratory rate

Answer 108

Fever
Malaise
Increased heart rate & respiratory rate

Question 109

ATI Chapter - Infection Control

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest? [Select all that apply]
a. Place the client in a room that has negative air pressure of at least six exchanges per hour
b. Wear a mask when providing care within 3 ft of the client
c. Place a surgical mask on the client if transportation to another department is unavoidable
d. Use sterile gloves when handling soiled linens
e. Wear a gown when performing care that might result in contamination from secretions

Answer 109

b. Wear a mask when providing care within 3 ft of the client
c. Place a surgical mask on the client if transportation to another department is unavoidable
e. Wear a gown when performing care that might result in contamination from secretions

Question 110

ATI Chapter - Infection Control

The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Which infectious diseases require CONTACT precautions?
a. Tuberculosis
b. SARS-CoV-2 [COVID-19]
c. Influenza
d. C. difficile
e. MRSA

Answer 110

d. C. difficile
e. MRSA

Question 111

ATI Chapter - Infection Control

The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Which infectious diseases require DROPLET precautions?
a. Tuberculosis
b. SARS-CoV-2 [COVID-19]
c. Influenza
d. C. difficile
e. MRSA

Answer 111

c. Influenza

Question 112

ATI Chapter - Infection Control

The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Which infectious diseases require AIRBORNE precautions?
a. Tuberculosis
b. SARS-CoV-2 [COVID-19]
c. Influenza
d. C. difficile
e. MRSA

Answer 112

a. Tuberculosis
b. SARS-CoV-2 [COVID-19]

Question 113

ATI Chapter - Client Safety

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? [Select all that apply]
a. Place a belt restraint on the client when they are sitting on the bedside commode
b. Keep the bed in its lowest position with all side rails up
c. Make sure that the client’s call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall-risk assessment

Answer 113

c. Make sure that the client’s call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall-risk assessment

Question 114

ATI Chapter - Client Safety

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?
a. Complete a fall-risk assessment
b. Educate the client and familly about fall risks
c. Eliminate safety hazards from the client’s environment
d. Make sure the client uses assistive aids in their possession

Answer 114

a. Complete a fall-risk assessment

The nurse should identify that the first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client’s fall risk. This will work as a guide in implementing appropriate safety measures.

Question 115

ATI Chapter - Client Safety

Restraints should…[Select all that apply]
a. Never interfere with treatment
b. Restrict movement as little as is necessary
c. Fit properly and be as discreet as possible
d. Be easy to remove or change
e. Never come off

Answer 115

a. Never interfere with treatment
b. Restrict movement as little as is necessary
c. Fit properly and be as discreet as possible
d. Be easy to remove or change

Question 116

ATI Chapter - Hygiene

A nurse is providing information about age- related physical changes to the family member of an older adult. Which of the following information should the nurse include?
a. Older adults have oilier skin than younger persons
b. Dry mouth is common for older adults
c. It is common for older adults to have increased perspiration
d. Hair in the eyebrows decreases

Answer 116

b. Dry mouth is common for older adults

It is common for older adults to experience dry mouth due to decreased saliva production, and many older adults take medications that lead to dry mouth.

Question 117

ATI Chapter - Hygiene

A nurse is providing a client with a complete bed bath. When providing the care, the nurse must recognize the order in which areas of the body will be bathed. Place the options in the correct order:
a. Trunk
b. Feet
c. Face
d. Legs

Answer 117

1. Face
2. Trunk
3. Legs
4. Feet

Question 118

ATI Chapter - Hygiene

A nurse is providing instructions about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? [Select all that apply]
a. Wear wool socks
b. Apply lotion between the toes
c. Wash the feet daily, using warm water
d. Warm the feet using a heating pad
e. Smooth the edges of the toenails with an emery board

Answer 118

c. Wash the feet daily, using warm water
e. Smooth the edges of the toenails with an emery board

A - The nurse should instruct the client to wear cotton socks because cotton can absorb excessive moisture
B - The client should apply lotion to the feet to moisten the skin but avoid applying lotion between the toes because this action can lead to skin breakdown and possible infection
D - The client should warm the feet using socks and blankets. Due to lack of sensation, the use of heating pads or hot water bottles places the client at risk for burns

Question 119

ATI Chapter - Hygiene

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take?
a. Turning the client’s head to the side
b. Placing two fingers in the client’s mouth to open it
c. Brushing the client’s teeth once per day
d. Injecting a mouth rinse into the center of the client’s mouth

Answer 119

a. Turning the client’s head to the side

The nurse should turn the clients head toward the mattress so that the mouth is in a dependent position. This promotes drainage of secretions away from the throat and reduces the risk of aspiration

Question 120

ATI Chapter - Hygiene

A nurse is providing denture care for a client. Which of the following actions should the nurse take?
a. Using a gauze pad to grasp and pull forward and downward to remove the upper denture
b. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouth wash
c. After brushing the dentures, rinsing them in hot water
d. Donning sterile gloves prior to performing denture care

Answer 120

a. Using a gauze pad to grasp and pull forward and downward to remove the upper denture

A: The nurse should use gauze to remove the client’s dentures because dentures can be slippery and the gauze helps to ensure a firm grip.

B - The nurse should store the dentures overnight in a labeled denture cup but should fill the cup with tepid water
C - After brushing the dentures, the nurse should rinse them in tepid water because hot water can cause the dentures to warp and cold water can cause the dentures to crack
D - The nurse should don clean gloves prior to performing denture care to reduce the risk of infection

Question 121

ATI Chapter - Mobility & Immobility

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client?
a. Decreased subcutaneous fat
b. Muscle atrophy
c. Pressure injury
d. Fecal impaction

Answer 121

c. Pressure injury

When prioritizing hypotheses, the nurse should identify that the greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift their weight every 15 mins, and reposition the client after 1 hour.

Question 122

ATI Chapter - Mobility & Immobility

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? [Select all that apply]
a. Instructing the client to not perform the Valsalva maneuver
b. Applying elastic stockings
c. Reviewing laboratory values for total protein level
d. Placing pillows under the client’s knees and lower extremities
e. Assisting the client to change positions often

Answer 122

b. Applying elastic stockings
e. Assisting the client to change positions often

A - The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation.
C - A review of the client’s total protein level is important for evaluating their ability to heal and prevent skin breakdown.
D - Placing pillows under the knees and lower extremities can impair circulation of the lower extremities!!!

Question 123

ATI Chapter - Mobility & Immobility

A nurse is instructing a client who has an injury on the left lower extremity about the use of a cane. Which of the following instructions should the nurse include? [Select all that apply]
a. Hold the cane on the right side
b. Keep two points of support on the floor
c. Plane the cane 38 cm [15 in] in front of the feet before advancing
d. After advancing the cane, move the weaker leg forward
e. Advance the stronger leg so that it aligns evenly with the cane

Answer 123

a. Hold the cane on the right side
b. Keep two points of support on the floor
d. After advancing the cane, move the weaker leg forward

A - When taking actions, the nurse should instruct the client to hold the cane on the uninjured side to provide support for the injured left leg.
B - When taking actions, the nurse should instruct the client to keep two points of support on the ground at all times for stability.
D - When taking actions, the nurse should instruct the client to advance the weaker leg first, followed by the stronger leg.

C - The client should place the cane 15 to 25 cm (6 to 10 in) in front of their feet before advancing.
E - The client should advance the stronger leg past the cane.

Question 124

ATI Chapter - Mobility & Immobility

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?
a. Encouraging the client to perform antiembolic exercises every 2 hours
b. Instructing the client to cough and deep breathe every 4 hours
c. Restricting the client’s fluid intake
d. Repositioning the client every 4 hours

Answer 124

a. Encouraging the client to perform antiembolic exercises every 2 hours

B - The nurse should instruct the client to cough and deep breathe every 1 to 2 hours to reduce the risk of atelectasis.
C - The nurse should increase the client’s intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction.
D - The nurse should plan to reposition the client every 1 to 2 hours to reduce the risk for pressure injuries.

Question 125

ATI Chapter - Mobility & Immobility

Claire is preparing to apply the sequential compression sleeves to Mr. Tuttle’s legs. Which technique should Claire use to determine the correct size of the stocking?
a. Measuring the length of the leg from the groin to the heel
b. Measuring the thickest part of the calf
c. Measuring the distance between the top of the thigh to the bottom of the knee
d. Measuring around the largest part of the thigh

Answer 125

d. Measuring around the largest part of the thigh

Question 126

ATI Chapter - Mobility & Immobility

Claire is evaluating Mr. Tuttle’s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding?
a. “This device will keep me from getting sores on my skin.”
b. “This device will keep the blood pumping through my legs.”
c. “With this device on, my leg muscles won’t get weak.”
d. “This device is going to keep my joints in good shape.”

Answer 126

b. “This device will keep the blood pumping through my legs.”

Question 127

ATI Skills - Infection Control

What type of precaution are RESPIRATORS used for?
a. Airborne
b. Contact
c. Droplet
d. Enteric

Answer 127

a. Airborne

Question 128

ATI Skills - Infection Control

What are examples of infections AIRBORNE precautions are instituted?

Answer 128

NEGATIVE AIRFLOW ROOM - HEPA filter
N95 RESPIRATORY
Gloves
Gown

Question 129

ATI Skills - Infection Control

What are examples of infections DROPLET precautions are instituted?

Answer 129

Influenza
Mycoplasma pneumonia

Question 130

ATI Skills - Infection Control

What do DROPLET precautions include?

Answer 130

Surgical mask [when within 3 ft of client]
Proper hand hygiene
Gloves
Mask

Question 131

ATI Skills - Infection Control

What are examples of infections CONTACT precautions are instituted?

Answer 131

VRE
MRSA
C. difficile
Wound infection
Herpes simplex

Question 132

ATI Skills - Infection Control

What do CONTACT precautions include?

Answer 132

Hand hygiene
Gloves
Gown

Question 133

ATI Skills - Infection Control

What are examples of infections AIRBORNE precautions are instituted?

Answer 133

Pulmonary tuberculosis

Question 134

ATI Skills - Infection Control

How can I protect elderly clients and other immunocompromised clients from healthcare associated infections?

Answer 134

STANDARD PRECAUTIONS should be used with ALL clients to prevent the spread of pathogens

Question 135

Quiz

A new grad nurse is preparing to perform oral care for a client who is sedated and unconscious. Which of the following actions indicates that the nurse understands how to safely perform this care?
a. The nurse positions the patient supine
b. The nurse ensures to use alot of water to rinse the oral cavity
c. The nurse positions the client on their side for care
d. The nurse vigorously scrubs teeth and mucosa

Answer 135

c. The nurse positions the client on their side for care

Question 136

Quiz

A student nurse is working with a co-assigned nurse on a medical surgical unit. For which of the following actions by the student should the nurse intervene when changing bed linens?
a. The student raises the bed to a workable height before changing linens
b. The student nurse places linens in the soiled linen hamper
c. The student nurse places the soiled linens on the floor while changing the sheets
d. The student nurse holds soiled linens away from their body while carrying

Answer 136

c. The student nurse places the soiled linens on the floor while changing the sheets

Question 137

Quiz

A nurse is preparing to assist a client with foot care. Which of the following are appropriate actions for this care? [Select all that apply]
a. Applying lotion inbetween the toes
b. Washing the feet with warm water
c. Allowing feet to air dry
d. Trimming toenails with a rounded angle
e. Use dry towels to ensure that feet and toes are completely dry

Answer 137

b. Washing the feet with warm water
e. Use dry towels to ensure that feet and toes are completely dry

Question 138

Quiz

Which of the following are considered healthcare associated infections? [Select all that apply]
a. Client with a central line has cellulitis at the insertion site
b. Surgical site infection
c. Pneumonia after being on a ventilator
d. UTI after catheter insertion
e. Tuberculosis

Answer 138

a. Client with a central line has cellulitis at the insertion site
b. Surgical site infection
c. Pneumonia after being on a ventilator
d. UTI after catheter insertion

Question 139

Quiz

A new grad nurse is working with PT during orientation to review body mechanics/ergonomics. Which of the following should the new grad nurse recall to ensure safety while moving/lifting/carrying/transferring? [Select all that apply]
a. Bending at the hips when lifting an item
b. Keep feet close together when lifting an item
c. Keeping the back straight to maintain good spine alignment
d. Bending at the knees when lifting an item
e. Stand close to the object being moved

Answer 139

c. Keeping the back straight to maintain good spine alignment
d. Bending at the knees when lifting an item
e. Stand close to the object being moved

Question 140

Quiz

A nurse is teaching a client about safe ambulation with assistance of a cane. Which of the following should the nurse include in the teaching?
a. When starting to walk, move the affected leg first
b. Advance the cane 12-18 inches forward when walking
c. When going up stairs, ensure the cane and the affected leg are at the same level for support
d. Hold the cane on the same side as the affected leg

Answer 140

c. When going up stairs, ensure the cane and the affected leg are at the same level for support

Question 141

Quiz

When preparing to transfer a client from bed to a chair, if the client has a weak side the chair should be placed at the clients strong side.
True
False

Answer 141

True

Question 142

Quiz

A nurse is admitting a client with dehydration related to excessive diarrhea x3 days. The client reports prior to experiencing diarrhea, they had just had a terrible sinus infection requiring 10 days of antibiotics, which the client completed as ordered. What infection control measures should the nurse institute based on this information? [Select all that apply]
a. Wear an N95 mask when caring for the patient
b. Ensure to wear a protective gown and gloves when caring for the client
c. Ensure the client is in a single occupancy room
d. Wash hands with soap and water after caring for the client

Answer 142

b. Ensure to wear a protective gown and gloves when caring for the client
c. Ensure the client is in a single occupancy room
d. Wash hands with soap and water after caring for the client

Question 143

Quiz

Which of the following are considered principles of sterility? [Select all that apply]
a. Items can be below waist level
b. 1 inch border of a sterile field is considered non-sterile
c. 0.5 inch border of a sterile field is considered non-sterile
d. If there is ever a doubt of contamination, the provider should stop and set up a new sterile field
e. Open flaps of a package one side at a time, opening away from the body first
f. Inspect packages/kits for holes, punctures, and expiration dates

Answer 143

b. 1 inch border of a sterile field is considered non-sterile
d. If there is ever a doubt of contamination, the provider should stop and set up a new sterile field
e. Open flaps of a package one side at a time, opening away from the body first
f. Inspect packages/kits for holes, punctures, and expiration dates

Question 144

Quiz

Match the stages of infection with the description:
Start of immune response, has vague & mild symptoms
Prodromal
Incubation
[Acute] Illness
Convalescence

Answer 144

Prodromal

This phase includes early, nonspecific symptoms like fatigue, mild fever, or malaise as the immune system starts responding

Question 145

Quiz

Match the stages of infection with the description: Pathogens are multiplying but host has no symptoms at this point
Prodromal
Incubation
[Acute] Illness
Convalescence

Answer 145

Incubation

This is the time between exposure to the pathogen and the first appearance of symptoms

Question 146

Quiz

Match the stages of infection with the description: Pathogens at peak concentration. Symptoms will be characteristic for an illness
Prodromal
Incubation
[Acute] Illness
Convalescence

Answer 146

Acute Illness

The most severe phase, where symptoms are fully developed and the pathogen is at its highest level in the body

Question 147

Quiz

Match the stages of infection with the description: Body in recovery
Prodromal
Incubation
[Acute] Illness
Convalescence

Answer 147

Convalescence

This is the recovery phase, where symptoms resolve, and the body begins to restore normal function

Question 148

Quiz

Match the example to the mode of transmission: infected host coughs, exhales, talks…microparticles then stay suspended in the air for a while
Airborne
Droplet
Vector
Indirect Contact

Answer 148

Airborne

Question 149

Quiz

Match the example to the mode of transmission: infected host coughs, sneezes, etc….small particles (larger than micro) travel in the air, but may land on surfaces (tables, beds, etc.)
Airborne
Droplet
Vector
Indirect Contact

Answer 149

Droplet

Question 150

Quiz

Match the example to the mode of transmission: disease occurs after being bitten by a tick
Airborne
Droplet
Vector
Indirect Contact

Answer 150

Vector

Question 151

Quiz

Match the example to the mode of transmission: touching inanimate, contaminated object {doorhandles, towels, surfaces, etc.}
Airborne
Droplet
Vector
Indirect Contact

Answer 151

Indirect Contact

Question 152

Quiz

Which of the following is true regarding safe application of soft wrist restraints?
a. Only utilize a quick release knot when securing
b. Secure the restraints to the moveable bedrail
c. 3-4 fingers should easily slide under the restraint
d. Restraints should be removed q 6 hrs

Answer 152

a. Only utilize a quick release knot when securing

Question 153

Quiz

Match the terms with the description:
ERYTHEMA
Redness
Swelling
Bluish
Yellow
Pale-ish
Sweating

Answer 153

REDNESS

Question 154

Quiz

Match the terms with the description:
Jaundice
Redness
Swelling
Bluish
Yellow
Pale-ish
Sweating

Answer 154

YELLOW

Question 154

Quiz

Match the terms with the description:
EDEMA
Redness
Swelling
Bluish
Yellow
Pale-ish
Sweating

Answer 154

SWELLING

Question 154

Quiz

Match the terms with the description:
CYANOSIS
Redness
Swelling
Bluish
Yellow
Pale-ish
Sweating

Answer 154

BLUEISH

Question 155

Quiz

Match the terms with the description:
Pallor
Redness
Swelling
Bluish
Yellow
Pale-ish
Sweating

Answer 155

PALE-ISH

Question 156

Quiz

Match the terms with the description:
DIAPHORESIS
Redness
Swelling
Bluish
Yellow
Pale-ish
Sweating

Answer 156

SWEATING

Question 157

Quiz

Match the lung sounds: Bubbling, popping, or rice cripsies [rub two strands of hair together]
Crackles
Ronchi
Friction Rub
Stridor
Wheeze

Answer 157

CRACKLES

Question 158

Quiz

Match the lung sounds: Low pitch, like snoring or gurgling
Crackles
Ronchi
Friction Rub
Stridor
Wheeze

Answer 158

RONCHI

Question 159

Quiz

Match the lung sounds: Grating sound, or like a creaking old wood floor
Crackles
Ronchi
Friction Rub
Stridor
Wheeze

Answer 159

FRICTION RUB

Question 160

Quiz

Match the lung sounds: High pitch, “barking” like a seal
Crackles
Ronchi
Friction Rub
Stridor
Wheeze

Answer 160

STRIDOR

Question 161

Quiz

Match the lung sounds: High pitch, musical or whistling
Crackles
Ronchi
Friction Rub
Stridor
Wheeze

Answer 161

WHEEZE

Question 162

Quiz

A nurse is planning care for a client on a neuro ICU floor. The clients most recent GCS was 7. The nurse anticipates what support for care?
a. The client may need some assistance here and there as they are sleepy
b. The client is likely independent
c. The client will require full-assistance with all care
d. The client may need some cueing

Answer 162

c. The client will require full-assistance with all care

Question 163

Quiz

Match the assessment test to the Cranial Nerve: Have the client ID smells…coffee, vanilla, etc.
Olfactory
Oculomotor
Facial
Accessory
Hypoglossal
Trochlear & Abducens

Answer 163

OLFACTORY

Question 164

Quiz

Match the assessment test to the Cranial Nerve: PERRLA
Olfactory
Oculomotor
Facial
Accessory
Hypoglossal
Trochlear & Abducens

Answer 164

OCULOMOTOR

Question 165

Quiz

Match the assessment test to the Cranial Nerve: Have the client smile, frown, and puff cheeks
Olfactory
Oculomotor
Facial
Accessory
Hypoglossal
Trochlear & Abducens

Answer 165

FACIAL

Question 166

Quiz

Match the assessment test to the Cranial Nerve: Shrugs shoulders
Olfactory
Oculomotor
Facial
Accessory
Hypoglossal
Trochlear & Abducens

Answer 166

ACCESSORY

Question 167

Quiz

Match the assessment test to the Cranial Nerve: Controls tongue movement from side to side
Olfactory
Oculomotor
Facial
Accessory
Hypoglossal
Trochlear & Abducens

Answer 167

HYPOGLOSSAL

Question 168

Quiz

Match the assessment test to the Cranial Nerve: Cardinal fields of gaze
Olfactory
Oculomotor
Facial
Accessory
Hypoglossal
Trochlear & Abducens

Answer 168

TROCHLEAR & ABDUCENS

Question 169

Quiz

A new nurse is assessing a clients GI system. Which of the following sequences is correct for GI assessment?
a. Inspection, Auscultation, Percussion, Palpation
b. Auscultation, Inspection, Percussion, Palpation
c. Auscultation, Inspection, Palpation
d. Inspection, Palpation, Auscultation, Percussion

Answer 169

a. Inspection, Auscultation, Percussion, Palpation

Question 170

Quiz

Which of the following findings are considered ‘abnormal’ ? [Select all that apply]
Neuro: PERRLA intact
GCS: 15
Integ: Skin clean, dry, and intact
CV: cap refill >3 seconds
Integ: Petechiae and purpura to upper extremities
GI: 5-30 clicks or gurgles per min
Neuro: AAOx1
CV: +4 pitting edema bilateral lower extremities
GU: Bladder palpable, distended
GI: <5 clicks or gurgles per min
Mucous membranes pink and moist

Answer 170

CV: cap refill > 3 seconds
Integ: Petechiae and purpura to upper extremities
Neuro: AAOx1
CV: +1 pitting edma bilateral lower extremities
GU: Bladder palpable, distended
GI: <5 clicks or gurgles per min

Question 171

Quiz

A client has a newly placed cast to right lower leg. Your clinical instructor asks that you assess CMSTs. What will you assess for? [Select all that apply]
a. Sores
b. Circulation [color, cap refill…]
c. Contractures
d. Sensation
e. Movement
f. Temperature

Answer 171

b. Circulation [color, cap refill…]
d. Sensation
e. Movement
f. Temperature

{Circulation/Color, Motor/Movement. Sensation, Temperature}

Question 172

Quiz

A student nurse is performing a focused CV assessment for a patient. For which of the following actions does the instructor intervene?
a. The student listens to the apical pulse for 1 full minute for an irregular rhythm
b. The student notes a weak/thready pulse at +1 and a bounding pulse at +4
c. The student attempts to palpate bilateral carotid arteries simultaneously
d. The student palpates dorsalis pedis pulses simultaneously

Answer 172

c. The student attempts to palpate bilateral carotid arteries simultaneously

Question 173

ATI Skills - Surgical Asepsis

What is the acceptable standard for removing a mask?

Answer 173

• Remove the mask carefully by the ties, taking care to avoid touching the filter portion of the mask, and then discard it immediately
• Handling the filter portion of the mask after use can transfer bacteria from the nasopharyngeal airway to your hands and initiate cross-contamination

Question 174

ATI Skills - Surgical Asepsis

Which part of the gown is considered sterile?

Answer 174

• Sterile gowns are considered sterile in the front from the shoulder to the level of the sterile field and from 2 inches above the elbow to the cuff
• Because the cuff tends to collect moisture, it is not an effective bacterial barrier and is not considered sterile

That is why you must cover the cuffs with sterile gloves
Other areas of the gown that are not considered sterile are the neckline, shoulders, areas under the arms, and back of the gown

Question 175

ATI Skills - Surgical Asepsis

What is GENERAL HAND HYGIENE?

Answer 175

• refers to decontamination of the hands by handwashing with an antimicrobial or plain soap and water or using an antiseptic handrub
• You can sanitize hands with the handrub if there is no visible soil

Question 176

ATI Skills - Surgical Asepsis

What is SURGICAL ASEPSIS HAND HYGIENE?

Answer 176

refers to the antiseptic surgical hand scrub or antiseptic handrub performed prior to applying sterile surgical attire

Question 177

ATI Skills - Surgical Asepsis

What is a major source of microbial contamination in the surgical environment?

Answer 177

SKIN

Question 178

ATI Skills - Surgical Asepsis

Under what conditions can I use alcohol-based handrubs?

Answer 178

Use alcohol-based handrubs to degerm your hands only if they are not visibly soiled

Question 179

ATI Skills - Surgical Asepsis

Under what conditions should I NOT use alcohol-based handrubs [aka when should soap & water be used]?

Answer 179

• when hands are visibly dirty/soiled
• blood, urine, feces, mucous, etc.

Question 180

ATI Skills - Surgical Asepsis

When must I wear protective eyewear in the surgical site?

Answer 180

whenever you anticipate eye, nose, or mouth contamination as a result of spraying or splashing of blood droplets or other infectious materials

Question 181

ATI Skills - Surgical Asepsis

Examples of contaminating/breaking the sterile field:

Answer 181

• placing an object in the cetner of the sterile field [this required reaching over the field to place anything in the bowl and will increase the risk of contaiminating due to the reaching]
• pouring a solution from 7-8 inches [it should be poured from 4 to 6 inches to minimize the risk of splattering fluid onto the field]
• when any sterile surface comes into contact with a WET surface - the field then becomes contaminated by CAPILLARY ACTION [if the sterile wrap is not moisture-proof, the spilled solution draws the contaminants from the table on to the sterile field]

Question 182

ATI Skills - Surgical Asepsis

What should you do if the sterile field has become contaminated?

Answer 182

1. Remove sterile gloves
2. Wash hands
3. Start entire set up process over again

any break in the sterile technique means that the entire process must be initated again

Question 183

ATI Skills - Surgical Asepsis

When doffing sterile PPE, what should you always remove FIRST?

Answer 183

GLOVES

prevent contamination of your mask and goggles and thus minimizing the possibility of contaminating yourself as well

Question 184

ATI Skills - Surgical Asepsis

Why is hot water NOT recommended to wash hands in the process of a surgical scrub?

Answer 184

• Hot water is hard on the skin because it has a drying effect that can result in cracking [Hot water dries the skin and frequent use can result in cracking]
• Hot water makes it too uncomfortable to wash for the recommended amount of time [This is especially true for hands that are washed frequently]

NOTE: Cold water keeps soap from lathering properly and prevents the effective removal of soil and micro-organisms

Question 185

ATI Skills - Surgical Asepsis

ou ask the student why they consistently kept their hands above their arms throughout the entire surgical scrub procedure. Which of the following statements by the student is the correct answer?
A. “By keeping my hands above my arms, the dirty soapy water runs down my arms and away from my clean hands.”
B. “That is the way I was taught to perform a surgical scrub. Keeping my hands above my arms keeps me from touching something contaminated.”

Answer 185

A. “By keeping my hands above my arms, the dirty soapy water runs down my arms and away from my clean hands.”

Keeping the hands elevated does help minimize the potential for touching a contaminated surface, but it also prevents recontamination of the hands through contact with the dirty, soapy water

Question 186

ATI Skills - Surgical Asepsis

What is the correct order when REMOVING / DOFFING CONTAMINATED PPE?

Answer 186

1. Untie the gown’s waist ties
2. Take off gloves [in the proper way = turning the first one inside out and balling up in the palm of the other glove, and then taking off the other glove in the manner where BOTH gloves will be inside out once off]
3. Untie the gown’s neck ties
4. Slip gown off shoulders
5. Hold on to the INSIDE of the gown at the neck and turn the whole gown [sleeves and all] inside out as you take it off
6. Untie lower ties of face ask

Question 187

ATI Skills - Personal Hygiene

Why are some clients more prone to develop oral problems than others?

Answer 187

ORAL CAVITY PROBLEMS CAN RESULT FROM:
* An inability to perform mouth care
* Dehydration
* Assistive tubes in the mouth
* Chemotherapeutic medications
* Radiation therapy to the head and neck
* Oral surgery or trauma
* Immunosuppression
* Diabetes mellitus
* Some over-the-counter medications that contain large amounts of sugar [Some cough drops and antacids]

Be sure to assess all your clients daily for any oral cavity compromise

Question 188

ATI Skills - Personal Hygiene

Why are unconscious clients placed on their dependent side for oral care?

Answer 188

• Unconscious clients and those who have impairments of one side of the face [post cerebrovascular accident]require a side-lying position during oral care to reduce the risk of aspiration
• THIS ALLOWS SECRETIONS AND TOOTHPASTE TO DRAIN OUT FROM THE CLIENT’S MOUTH

Always assess whether the client has an intact gag reflex prior to performing oral care
Keep suctioning equipment readily available throughout the procedure

Question 189

ATI Skills - Personal Hygiene

Why do we massage [effleurage] older clients / how is this beneficial?

Answer 189

• Promotes relaxation
• Relieves muscular tension
• Decreases perception of pain
• Associated with reductions in: Measured anxiety; Heart rate; Respiratory rate

Question 190

ATI Skills - Personal Hygiene

Why shouldn’t I use cotton-tipped applicators for ear care?

Answer 190

• Cotton-tipped applicators can push cerumen (earwax) further into the canal and cause impaction
• This can increase the risk of infection and of potential rupture of the tympanic membrane

Gentle cleansing externally with a wet washcloth is preferable

Question 191

ATI Skills - Personal Hygiene

Which clients have the greatest need for perineal care?

Answer 191

• Clients who have indwelling urinary catheters or urinary or fecal incontinence
• Clients recovering from rectal or genital surgery or childbirth
• Uncircumcised clients
• Clients who have rectal and perineal surgical dressings
• Clients that are morbid obesity

Poor or incomplete self-care might result in overlooking common infections and problems

Question 192

ATI Skills - Personal Hygiene

When would massaging a client’s back or legs during a bed bath be inappropriate?

Answer 192

• If a client has any redness that could indicate skin breakdown, increased friction from massage could worsen the problem
• Avoid vigorous rubbing of the legs of clients with a history of deep vein thrombosis or hypercoagulation because small blood clots could embolize as a result

Question 193

ATI Skills - Personal Hygiene

You enter your client’s room and prepare to perform a more thorough skin assessment while bathing him. He seems reluctant to allow you to proceed with this process. You respond appropriately by doing which of the following?
A. Informing him that his lack of hygiene puts the other clients at risk for infection
B. Asking a nursing assistant to help immobilize the client when you bathe him
C. Explaining that you understand his reluctance but must check his skin for injuries

Answer 193

C. Explaining that you understand his reluctance but must check his skin for injuries

Question 194

ATI Skills - Personal Hygiene

You begin the bathing process, promoting the client’s comfort by doing which of the following?
A. Encouraging the client to assist as much as possible
B. Performing the bath procedure as quickly as possible
C. Educating the client about the improper hygiene you previously observed

Answer 194

A. Encouraging the client to assist as much as possible

Question 195

ATI Skills - Personal Hygiene

You notice that the client has mild edema on the lower extremities. Which of the following will encourage venous return?
A. Massaging the leg tissue deeply while washing the skin
B. Applying firm pressure to the calves with a kneading motion
C. Washing the legs using a long, gentle, distal-to-proximal strokes

Answer 195

C. Washing the legs using a long, gentle, distal-to-proximal strokes → using this technique while the client is supine encourages blood return to the heart while applying minimal pressure

A. Deep pressure can cause tissue injury while also contributing to skin breakdown
B. Calf pressure can cause any thrombi present to dislodge and become emboli

Question 196

ATI Skills - Personal Hygiene

While washing the client’s ankles and feet, you note the absence of hair and that the skin has a glossy appearance. The most likely explanation for these findings is which of the following?
A. Fungal infection of the skin
B. Lack of blood flow to these tissues
C. Frequent exposure to cold

Answer 196

B. Lack of blood flow to these tissues
* a decrease in tissue perfusion [poor circulation] results in thinning of the skin and hair loss

A. Fungal infections of the skin [ex. Tinea corporis] are characterized by reddened, flakey lesions
B. Exposure to cold weather can make the tissues pale, but should not cause hair loss

Question 197

ATI Skills - Personal Hygiene

While washing the client’s lower back, you note an area near the sacrum that is erythematous and showing signs of further breakdown. Which of the following should you do next?
A. Massage the area to improve circulation to the skin
B. Gently wash the area with soapy water to help keep it clean
C. Rub the area briskly with a towel after rinsing to dry it thoroughly

Answer 197

B. Gently wash the area with soapy water to help keep it clean
* This will minimize the risk of further loss of skin integrity, as gentle pressure will not macerate the epithelium

A. Applying pressure to an area of non-blanching erythema can cause further tissue damage
B. Although it is important to keep the area dry, gently patting is the preferred technique for drying skin after bathing, especially if the skin’s integrity is questionable or impaired

Question 198

ATI Skills - Personal Hygiene

You have completed the client’s bath, and now retrieve their dentures from their personal belongings. You care for the dentures appropriately by doing which of the following?
A. Soaking the dentures in a denture cup filled with cleansing solution then rinsing them
B. Placing them in a clean, dry storage container after thoroughly brushing them
C. Brushing them with a toothbrush and denture cleaner and rinsing with tepid water

Answer 198

C. Brushing them with a toothbrush and denture cleaner and rinsing with tepid water
* Brushing them is the only way to remove debris that might accumulate on and between the teeth
* It is important to avoid using hot water to rinse dentures, as it can damage some denture materials

A. Soaking dentures in a commercial cleaning solution can help remove staining, but it alone is not sufficient for adequate cleaning of dentures
B. Dentures should be kept moist when not in use to prevent warping and to facilitate later insertion — They should be stored in water in a denture cup properly labeled with the client’s identification

Question 199

ATI Skills - Personal Hygiene

One of your patient’s has a history of T2DM. You proceed with the process of foot care for this client. Which of the following steps will you do for this diabetic client in order to get his feet cleaned?
A. Wash his feet with lukewarm water and dry thoroughly between the toes
B. Allow the client to soak his feet in a basin of warm water for 1 hour
C. Clean his feet by rubbing a lotion all over his feet and toes

Answer 199

A. Wash his feet with lukewarm water and dry thoroughly between the toes
* This is to be done for diabetic clients or clients with peripheral arterial disease
* This prevents the tissues from being macerated and prevents any infection from occurring

B. Soaking feet in warm water for 1 hour is not done for diabetic clients [It macerates the tissues and will dry them out leading to tissue breakdown and infection]
C. This can be done only after washing and drying his feet thoroughly [For diabetic clients, an emollient lotion can be applied over all surfaces of feet but not between the toes]

Question 200

ATI Skills - Mobility

How is the appropriate crutch gait determined for a client?

Answer 200

1. First, assess the client’s disease or injury, abilities, mobility needs, and any specific orders [Make sure that the client can manipulate the crutches correctly]
2. **A key component for safety is the client’s ability to stand upright, support their weight, and keep their balance while using the crutches
   **
3. Once you have assessed these factors, you can teach the client the appropriate crutch gait

Question 201

ATI Skills - Mobility

What should I do if a client feels dizzy right before ambulation?

Answer 201

1. Raise the head of the bed to help them adjust to a change in position
2. Next, have them sit on the edge of the bed with their feet dangling
3. Then have them stand slowly while stabilizing themselves with a secure object such as the bed rail or another person
4. Remain with the client during ambulation if they are at all unstable

Question 202

ATI Skills - Mobility

When should I use passive range-of-motion exercises?

Answer 202

Use passive range-of-motion (ROM) exercises for clients who are weak or otherwise unable to perform active ROM

Passive ROM is not the best form of exercise as it does not allow for muscle contraction…..However, passive ROM will help with flexibility

Question 203

ATI Skills - Mobility

Which of the four clients should you see first?
A. The client who had a fractured femur repaired and must demonstrate proper crutch walking
B. The client who had a hip arthroplasty and needs one person to help him get out of bed to the chair
C. The client who had a lumbar repair and is on strict bed rest
D. The client who has quadriplegia and had sacral redness when last turned 2 hours ago

Question 204

ATI Skills - Mobility

Clients who have quadriplegia are at an increased risk for skin breakdown due to:

Answer 204

• Impaired mobility
• Infrequent repositioning
• Impaired sensation
• Skin exposure to irritants → such as rough linen, urine, and stool

Question 205

ATI Skills - Mobility

A patient is being discharged with the plan to be on crutches for ambulation. You determine that the client performs the prescribed three-point gait appropriately when using his crutches when he does which of the following?
A. Positions each upper crutch pad centered in the axilla
B. Leans his torso forward slightly in the tripod position
C. Advances the crutches first, followed by the unaffected leg

Answer 205

C. Advances the crutches first, followed by the unaffected leg

Question 206

ATI Skills - Mobility

When teaching the client how to ambulate with a cane, which of the following should you say?
A. “When properly fitted, the cane length is twice the distance between the greater trochanter and the floor.”
B. “Place the cane on your stronger side for support.”
C. “After moving the cane, bear weight on the stronger side and swing yourself forward.”

Answer 206

B. “Place the cane on your stronger side for support.”

• Clients who use a cane should place the cane in the hand on the stronger side so that the cane and the stronger leg provide support and balance when ambulating
• The client should move the cane forward, followed by moving the weaker leg so that body weight is divided between the cane and the stronger leg
• The cane length should be equal to the distance between the greater trochanter and the floor

Question 207

ATI Skills - Mobility

Prior to morning therapy, the client requires several nursing interventions. Which nursing action do you and the nursing assistant perform first?
A. Range-of-motion exercises
B. Assistance out of bed via a mechanical/hydraulic lift
C. Morning hygiene care and assessment

Answer 207

C. Morning hygiene care and assessment

• Clients who need total care are at increased risk for skin breakdown due to impaired mobility, and increased risk for other complications of immobility, including respiratory failure, impaired circulation, and sluggish digestion

Question 208

ATI Skills - Mobility

One of your client’s who is fully dependent for care/ambulation has orders for ROM exercises q2hrs. You are working with a new nursing assistant. Since the nursing assistant is a new employee, you plan to supervise and observe her while she performs the range-of-motion exercises.
Based on the client’s condition, which one of the following types of ROM exercises should the nursing assistant initiate?
A. Active
B. Active-assisted
C. Passive

Answer 208

C. Passive

• Passive ROM exercises are performed without the client’s assistance to prevent joint contracture
• These are most appropriate for a client who is totally dependent and unable to follow instructions

Question 209

ATI Skills - Mobility

A client s/p Right TKA needs to get out of bed and into a chair for the first time since sx. She is hesitant and scared it will be painful. Which of the following should be your therapeutic response to this client?
A. “Your doctor’s orders call for you to get out of bed today.”
B. “Everyone is a bit nervous about getting out of bed for the first time.”
C. “Why do you think you aren’t able to get out of bed?”
D. “It sounds like you are concerned that getting out of bed will be painful.”

Answer 209

D. “It sounds like you are concerned that getting out of bed will be painful.”

• This response meets all of these criteria → By acknowledging that you have heard the client’s message, this response encourages further communication
• When responding therapeutically to clients’ questions, always remember that you must use communication skills and avoid communication blocks

Therapeutic responses:
- Open-ended
- Client-centered
- Focused on the client’s feelings

Question 210

ATI Skills - Mobility

Which of the following nursing actions will help improve the client’s tolerance of getting out of bed? [Select all that apply]
A. Administer the prescribed oral pain medication to the client about 20 minutes before they get out of bed
B. Have the client dangle their legs at the side of the bed first for a few minutes before getting out of bed
C. Assign the nursing assistant on the team to help the client get out of bed
D. Explain the steps involved in getting out of bed to the client prior to the procedure
E. Have the client use crutches to help them get out of bed

Answer 210

A. Administer the prescribed oral pain medication to the client about 20 minutes before they get out of bed
* Oral pain medication typically has a time of onset of about 20 minutes, so the client will have the benefit of pain relief while moving – the most difficult and painful aspect of getting up

B. Have the client dangle their legs at the side of the bed first for a few minutes before getting out of bed
* Dangling allows the client’s circulation to equilibrate and helps prevent episodes of dizziness due to orthostatic hypotension and, therefore, injuries from falling

D. Explain the steps involved in getting out of bed to the client prior to the procedure
* Teaching and demonstrating the techniques to be used enhance the client’s understanding, reduce anxiety, and encourage the client to cooperate with the procedure

Question 211

ATI Skills - Mobility

To assist the client in transferring from the bed to the chair, you should do which of the following?
A. Position the chair at a 90° angle to the head of the bed
B. Keep your feet together while rocking the client up to a standing position
C. Flex your hips and knees while lowering the client to the chair

Answer 211

C. Flex your hips and knees while lowering the client to the chair

• Flexing the hips and knees while lifting weight reflects good body mechanics as this prevents injury due to poor body alignment
• Flexion of the knees and hips lowers your center of gravity in relation to the object you are raising or lifting

Question 212

ATI Skills - Mobility

Which of the following instructions is appropriate regarding ambulation with a cane?
A. Hold the cane on the stronger, unaffected side
B. First, move the cane forward about 12 to 15 inches
C. While moving the cane forward, keep your weight on the unaffected side

Answer 212

A. Hold the cane on the stronger, unaffected side

• Placing the cane on the side opposite the involved leg provides added support for the weak (and painful) affected side
• The client should first move the cane forward 6 to 10 inches
• While placing the cane forward, the client should keep her body weight on both legs
• Then, when she moves the weaker leg forward to the cane, her body weight will be divided between the cane and the stronger side

Question 213

ATI - Physical Assessment

Which of the following statements best describes the purpose of a physical assessment?
A. The purpose is to determine what medications the client is currently taking and if they are working
B. The purpose is to gather baseline data about the client’s behavior and feelings toward their health
C. The purpose is to collect objective and subjective data to identify health patterns and evaluate responses to interventions

Answer 213

C. The purpose is to collect objective and subjective data to identify health patterns and evaluate responses to interventions

• The main purpose of the assessment is to be able to plan interventions for care that is individualized to the client’s needs

Question 214

ATI - Physical Assessment

Which of the following statements demonstrates understanding of the importance of documentation?
A. “Accurate documentation is essential to prevent a lawsuit.”
B. “I will document my findings as soon as I complete the assessment so the health care provider will have the information when they make rounds.”
C. “Organized documentation assists the nurse to identify important details in the physical assessment.”

Answer 214

B. “I will document my findings as soon as I complete the assessment so the health care provider will have the information when they make rounds.”

Question 215

ATI - Physical Assessment

You are observing in a client’s room as another nurse assesses a client. Which of the following assessment techniques by the nurse is correct?
A. Keep the client’s chest covered during cardiorespiratory auscultation to maintain privacy
B. Have the client protrude their tongue to assess cranial nerve III
C. Auscultate the four quadrants of the abdomen before percussing and palpating this area

Answer 215

C. Auscultate the four quadrants of the abdomen before percussing and palpating this area

Question 216

ATI - Physical Assessment

Which of the following nursing actions demonstrates understanding of infection control principles related to health assessment?
A. Wash hands at the beginning and the end of the assessment
B. Assess the client starting distally and moving to the proximal areas
C. Wear gloves through the entire health assessment

Answer 216

A. Wash hands at the beginning and the end of the assessment

• The nurse should perform hand hygiene before and after client contact
• Depending on the length of the assessment, the nurse might perform hand hygiene at other times across the assessment

Question 217

ATI - Physical Assessment

Which of the following elements should a nurse assess during a general survey? [Select all that apply]
A. Speech
B. Hygiene
C. System review
D. Indications of stress
E. Body movements
F. Affect / Mood

Answer 217

A. Speech
B. Hygiene
D. Indications of stress
E. Body movements
F. Affect /

• SYSTEM REVIEW IS NOT INCLUDED IN THE GENERAL SURVEY → A review of each individual system is a specific, in-depth assessment process

Question 218

ATI - Physical Assessment

The client’s nursing care plan includes the following nursing diagnoses: activity intolerance, risk for falls, risk for infection, and ineffective breathing pattern.
When planning to assess the client, which of the following actions should you take to prevent activity intolerance?
A. Perform the assessment at the same time that you assist with the client’s bath
B. Perform the assessment as soon as the client finishes breakfast
C. Complete the assessment just prior to the client’s family visiting

Answer 218

A. Perform the assessment at the same time that you assist with the client’s bath

• This shows respect for the need to conserve the client’s energy by performing a portion of the assessment during another intervention

B. While this plan appears to be considerate of the client’s need to eat, the client will likely be fatigued after eating and need rest
C. While this plan appears to be considerate of the client’s family time, it might cause the client to be too tired to visit with family after the assessment

Question 219

ATI - Physical Assessment

Which of the following actions should you take when assessing the client’s respiratory function?
A. Assessing the client’s orthostatic blood pressure
B. Reassessing lung sounds after asking the client to cough
C. Using the bell of the stethoscope to auscultate breath sounds

Answer 219

B. Reassessing lung sounds after asking the client to cough

• Reassessing lung sounds can determine the effectiveness of the client’s cough since coughing could result in expelling mucus from the air passages

Question 220

ATI - Physical Assessment

Assessing the client’s feet is particularly important due to which of the following nursing diagnoses?
A. Risk for falls related to osteoarthritis
B. Activity intolerance related to dyspnea
C. Risk for infection related to type 2 diabetes

Answer 220

C. Risk for infection related to type 2 diabetes

• Type 2 diabetes can increase the risk of infection due to impaired circulation and the resulting poor wound healing

Question 221

ATI - Physical Assessment

The client reports difficulty grasping and holding objects with their hands due to osteoarthritis. Which of the following objective assessment data would confirm this claim?
A. Hands cool to the touch bilaterally
B. Joint pain at 6 on a scale of 0 to 10
C. Diminished grip strength with moderate wrist swelling bilaterally

Answer 221

C. Diminished grip strength with moderate wrist swelling bilaterally

• These assessment findings are objective and would reflect the presence of osteoarthritis

Question 222

ATI Skills - Physical Assessment

Which of the following questions should you ask when first meeting the client? [Select all that apply]
A. “Can you tell me your name?”
B. “Do you know what day it is?”
C. “Do you know where you are?”
D. “What caused you to come to the hospital?”
E. “Did someone cause you to become injured?”

Answer 222

A. “Can you tell me your name?”
* This determines orientation to person/self
B. “Do you know what day it is?”
* This determines orientation to day/time
C. “Do you know where you are?”
* This determines orientation to place
D. “What caused you to come to the hospital?”
* This determines orientation to situation

Question 223

ATI Skills - Physical Assessment

You assess the client for possible indications of a stroke. Which of the following techniques should be used to evaluate facial symmetry?
A. Assess cranial nerve I by touching the surface of the face with a cotton ball
B. Assess cranial nerve II by evaluating downward and lateral movements of the eyes
C. Assess cranial nerve VII by asking the client to smile and puff out cheeks

Answer 223

C. Assess cranial nerve VII by asking the client to smile and puff out cheeks
* This is a correct way to assess cranial nerve VII, and it is commonly used when stroke is suspected

A. Cranial nerve I is tested by assessing ability to determine scent
B. Cranial nerve II controls visual acuity and is assessed using Snellen charts, Jaeger cards, and other measures

Question 224

ATI Skills - Physical Assessment

Which of the following factors should you assess to evaluate the client’s risk for falls and injury? [Select all that apply]
A. Current medications
B. Orthostatic blood pressures
C. Muscle strength and symmetry
D. Forward bend test for kyphosis
E. Gait and use of assistive devices

Answer 224

A. Current medications
* Many medications can affect balance and strength, so this is an important assessment related to falls

B. Orthostatic blood pressures
* Changes in blood pressure when changing positions can be a risk factor for falls

C. Muscle strength and symmetry
* Muscle strength and symmetry are important considerations when assessing balance and risk for falls

E. Gait and use of assistive devices
* Alterations in gait and use of assistive devices are important assessments for when the nurse is evaluating fall risks

D. Kyphosis is assessed by inspection of the spinal column from the client’s side….Scoliosis screening includes the forward bend test

Question 225

SKIN

What are normal skin characteristics?

Answer 225

• Good turgor
• Intact
• Uniform in color
• Warm to the touch

Question 226

SKIN

What are abnormal/alterations in skin characteristics?

Answer 226

• Erythema - redness
• Ecchymosis - bruising [collection of blood in subq tissues]
• Petechiae - capillary bleeding = tiny
• Purpura - capillary bleeding = big
• Cyanosis - blueish color
• Jaundice - yellow color
• Pallor - paleness [usually mucous membranes]
• Diaphoresis - excessive perspiration [puts skin integrity at risk due to constant moist environment]
• Edema excess fluid [caused by CHF, Fluid volume excess, Injury, Infection]
• Poor turgor - elasticity

Question 227

Neurological

LEVEL OF CONSCIOUSNESS
Needs interventions/abnormal findings

Answer 227

• Lethargic - tired
• Stuporous - out of it
• Comatose - not responsive
• Describe positioning

GLASCOW COMA SCALE = GCS: 1. Eyes open; 2. Motor response; 3. Verbal response

Score: 3-15
- 1-3 = probably dead
- 8 or less = evere deficit; something seriously adding to mental deficit/decline

Question 228

CN

Cranial Nerve I
OLFACTORY

Answer 228

• Smell
• Scent test

Question 229

CN

Cranial Nerve II
OPTIC

Answer 229

• Vision
• SNELLEN Chart
• Visual fields / acuity

ABNORMAL:
- visual field loss
- papilledema with increased intracranial pressure
- optic atrophy

Question 230

CN

Cranial Nerve III
OCULOMOTOR

Answer 230

• MOST EYE MOVEMENT
• PERRLA [Pupils are normally equal, round, react to light promptly, and react to accommodation]
• Cardinal positions of gaze

ABNORMAL:
- ptosis / drooping
- unequal size, constricted pupils, dilated pupils, or no response
- deviated gaze / limited movement

Question 231

CN

Cranial Nerve IV
TROCHLEAR

Answer 231

• MOVES EYE TO LOOK AT NOSE

ABNORMAL:
- deviated gaze or limited movement
- nystagmus

Question 232

CN

Cranial Nerve V
TRIGEMINAL

Answer 232

• FACIAL SENSATION & CHEWING
• cotton ball feeling test
• clench jaw
• move jaw up and down

ABNORMAL:
- decreased strength on one or both sides
- pain with clenching of teeth
- decreased/unequal sensation

Question 233

CN

Cranial Nerve VI
ABDUCENS

Answer 233

• ABDUCTS THE EYE
• moves eye from side to side

Question 234

CN

Cranial Nerve VII
FACIAL

Answer 234

• FACIAL EXPRESSION
• TASTE
• smile/frown
• puff cheeks
• raise eyebrows
• close eyes tight
• show teeth

ABNORMAL:
- muscle weakness shows by loss of the nasolabial fold
- dropping of one side of the face
- lower eyelid sagging, and escape of air from only one puffed cheek when both are pressed in

Question 235

CN

Cranial Nerve VIII
VESTIBULOCOCHLEAR

Answer 235

• HEARING
• BALANCE
• whisper test

Question 236

CN

Cranial Nerve IX
GLOSSOPHARYNGEAL

Answer 236

• TASTE
• GAG REFLEX
• swallow test
• tongue depressor

Normal: Uvula and soft palate should rise in the midline, and tonsillar pillars move medially

ABNORMAL: Absence or asymmetry of soft palate movement

Question 237

CN

Cranial Nerve X
VAGUS

Answer 237

• GAG REFLEX
• PARASYMPATHETIC INNERVATION
• sitck out tongue and say ahhhhhhh

NORMAL:
Uvula and soft palate should rise in the midline, and tonsillar pillars move medially

ABNORMAL FINDINGS:
Absence or asymmetry of soft palate movement

Question 238

CN

Cranial Nerve XI
ACCESSORY

Answer 238

• SHOULDER/NECK MUSCLES
• shoulder shrug
• turn head from side to side

Question 239

CN

Cranial Nerve XII
HYPOGLOSSAL

Answer 239

• SWALLOWING
• SPEECH
• move tongue around mouth

Question 240

Head/Neck - Sensory

What is PERRLA?

Answer 240

P = pupils
E = equal?
R = round?
R = reactive to:
L= light?
A = accommodation?

Question 241

Respiratory

What are normal respiratory lung sounds?

Answer 241

BRONCHIAL
* around trachea / body of sternum
* loud
* high-pitch

BRONCHOVESICULAR
* 1st + 2nd intercostal space
* next to sternum
* medium-pitch

VESICULAR - what we listen to most aften
* heard over the entirety of the lungs
* soft
* low-pitch

Question 242

Respiratory

What are abnormal / adventitious lung sounds?

Answer 242

WHEEZE
* airway narrowing
* bronchioles restrict
* high-pitch whistle

RHONCHI
* fluid in bronchi
* low-pitch
* snorkel/gurgling

CRACKLES
* fluid in small airways / alveoli
* velcro
* blowing bubbles in milk
* firewood
* poprocks

STRIDOR
* high up in air way
* could be inflamamtion or obstruction
* gasping
* seal

FRICTION RUB
* no more fluid in pleural space
* lung tissue and pleural tissue rubbing against each other
* can be very painful
* old house creaky wood floors

ABSENT / DIMINISHED

Question 243

Respiratory

What are common lung variations in older adults?

Answer 243

• barrel chest = increased anteroposterior chest diameter
• kyphosis = increase in the dorsal spine curve
• decreased thoracic expansion
• use of accessory muscles to exhale

Question 244

Respiratory

How can Kyphosis affect an older adult’s respiratory system?

Answer 244

• spinal curvature causes chest to collapse in
• affects respiratory depth, effort, & status

Question 245

Cardiovascular

5 points of cardiac auscultation

Answer 245

A - aortic valve/area
P - pulmonic value/area
E - erb’s point
T - tricuspid valve/area
M - mitral valve

Question 246

Cardiovascular

Where do you listen to the APICAL heart rate?

Answer 246

MITRAL AREA
APEX OF HEART
APICAL HEART RATE = STRONGEST & CLEAREST SOUNDS
PMI

Question 247

Cardiovascular

What are common cardiovascular/peripheralvascular variations in older adults?

Answer 247

• Difficult to palpate apical pulse
• Difficult to palpate distal arteries
• Dilated proximal arteries
• More prominent and tortuous blood vessels → varicosities common
• Increased systolic and diastolic BP
• Widening pulse pressure

Question 248

Cardiovascular

What is the grading scale for heart rate?

Answer 248

0 = cannot palpate / feel = no peripheral pulse
+1 = weak / thready
+2 = normal /palpable
+4 = bounding / strong = NOT NORMAL [high pressure = too much fluid on arterial walls]

Question 249

Cardiovascular

What are normal cardiovascular findings in an older adult?

Answer 249

• +2 pulse = normal / palpable
• capillary refill = less than 2-3 seconds
• color = pink - good perfusion
• temperature = warm

Question 250

Cardiovascular

What are alterations / abnormal cardiovascular findings in an older adult?

Answer 250

• bulging + deep varicose veins
• sluggish capillary refill = 3+ seconds
• color = cyanosis OR erythema
• edema = pitting + non-pitting
• clubbing of nails - indication of pulmonary issues [seen in chronic hypoxemia - low tissue oxygenation + chronic low oxygenation to CV system]
• temperature = hot OR cold [cold = decreased circulation]
• decreased hair growth on lower extremities - ndicates decreased circulation [hair needs good arterial blood flow to survive…no hair = insufficient arterial blood flow]
• open skin areas - non-healing wounds [arterial problem…wounds have a hard time healing without proper blood oxgenation] {Venous wounds = peer venous return/ deoxygenated blood → blood has no oxygen = venous system insufficient = cannot bring blood back to heart}
• venoustasis = blood pooling

Question 251

GI

What is the order in which you assses the abdomen?

Answer 251

1. Inspect
2. Auscultate
3. Percuss
4. Palpate

Question 252

GU

What are abnormal findings / alterations in a genitourinary assessment?

Answer 252

• LESS THAN 30 CC / HOUR FOR OUTPUT
• urgency = needs to void NOW
• dysuria = painful / difficult urination
• frequency = needs to void alot & coul be unsafe
• hesitancy = difficulty starting stream
• polyuria = large amounts of urine
• oliguria = dimished urine productio
• nocturia = night voiding = SAFETY CONCERN + NEGATIVELY AFFECTS SLEEP
• dribbling = leakage = prostate issues
• hematuria = blood in urine
• color = brown/red
• cloudy = WBCs?
• odor = foul

Question 253

Musculoskeletal

What are abnormal findings for a musculoskeletal assessment?

Answer 253

• lordosis = lower lumbar curve + belly and hips stick out - toddler stance
• kyphosis = common with aging, BUT NOT NORMAL
• scoliosis = lateral spinal curvature
• joint deformity
• contractures
• muscular atrophy

Question 254

Physical Assessment

“Abnormal” vs “Expected”

Answer 254

Some findings may be abnormal, but expected [dependent on each individual/situation]

Example: Edema - abnormal
* s/p sx = Edema is EXPECTED