NURSING 230 ATI FINAL REVIEW QUESTIONS

NURSING 230 ATI FINAL REVIEW QUESTIONS 1. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction two to three times with a 60-second pause between passes. B. Perform chest physiotherapy prior to suctioning. C. Lubricate the suction catheter tip with sterile saline. D. Hyperventilate the client on 100% oxygen prior to suctioning. 2. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic. 3. A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? A. “The infusion rate has stopped but the tubing is not kinked.” B. “The area surrounding the insertion site feels warm to the touch.” C. “There is fluid leaking around the insertion site.” D. “There is no blood return when the tubing is aspirated.” 4. A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L Glucose 102 mg/dLPotassium 3.6 mEq/L BUN 18 mg/dLChloride 105 mEq/L Creatinine 0.7 mg/dL A. Renal failure B. Low-protein diet C. Dehydration D. Syndrome of inappropriate antidiuretic hormone (SIADH) 5. A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water 6. A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client’s potential allergies during which phase of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation 7. A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot 8. A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent? A. ?Obtain the client’s consent. B. ?Witness the client’s signature. C. ?Explain the risks and benefits of the procedure. D. Explain the procedure to the client if they do not understand. 9. A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? A. “I will begin 48 hr before the client’s discharge.” B. “I will begin once the client’s discharge order is written.” C. “I will begin upon the client’s admission to the facility.” D. “I will begin once the client’s insurance company approves discharge coverage.” 10. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? A. Transpersonal B. Intrapersonal C. Interpersonal D. Public 11. A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? A. ?Nurse B. ?Anesthesiologist C. ?Surgeon D. ?Surgical suite nurse 12. A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)? A. ?Admission assessment of a new client B. Scheduling a diagnostic study for a client C. ?Evaluating changes to a client's pressure ulcer D. ?Teaching a client insulin injection technique 13. A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? A. ?Measuring vital signs B. ?Removing the abdominal dressing C. ?Helping the client into the shower D. ?Ambulating the client in the hallway 14. A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. BUN B. Potassium C. RBC count D. WBC count 15. A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen 16. A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? A. Pain B. Hearing loss C. The client's culture D. Motor impairment 17. A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? A. The left second intercostal space B. The right second intercostal space C. The left fifth intercostal space D. The left fifth intercostal space at the midclavicular line 18. A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? A. Blood pressure B. Cyanosis C. Nausea D. Petechiae 19. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, “I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.” The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving? A. ?Bargaining B. ?Denial C. ?Depression D. ?Anger 20. A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? A. “I know that I will get a kidney transplant. I am a good candidate.” B. “I can now eat whatever I want. The dialysis will remove it from my system.” C. “I just can't believe that this dialysis is going to ruin my whole life." D. “I know that kidney disease runs in my family, but I can prevent it.” 21. A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? A. Serve foods that have a hot/cold balance. B. Serve milk products separately from meals. C. Request a meal tray without pork. D. Remove tea and coffee from meal trays. 22. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? A. Elicit information from the client. B. Encourage the client to use self-exploration. C. Review the client’s progress toward personal objectives. D. Talk with others who have information about the client. 23. A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. “I will be able to tell how much oxygen I’m getting by looking at the flowmeter.” B. “I should call my doctor if I find it harder to concentrate.” C. “I will make sure my visitors smoke outside.” D. “I will wear synthetic clothing and woolen socks when using my oxygen.” 24. A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make? A. "Please explain what you mean by the word 'nervous.'" B. "What is making you feel nervous?" C. "Would a backrub ease your nervousness?" D. "You shouldn't feel nervous." 25. A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take? A. Explore the client's feelings. B. Discuss the competency of the surgeon. C. Review another client's similar surgical experience. D. Talk with the client's partner. 26. A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? A. Make sure a family member is present to interpret for the staff. B. Determine the client's level of fluency in his primary language. C. Speak directly to the interpreter when teaching the client. D. Encourage the client to nod to indicate understanding. 27. A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? A. Nonverbal communication conveys less truth than what the client states verbally. B. The client's sociocultural background influences nonverbal communication. C. Nonverbal communication is a poor reflection of what the client feels. D. The client enacts nonverbal communication consciously. 28. A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship? A. Determine the reason the client sought care. B. Instruct the client about methods to achieve goals. C. Discuss the client's new skill sets. D. Review the client's demographic information. 29. A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? A. Blood in the IV tubing B. Absence of blanching at the insertion site C. Edema in the palm of the hand D. Warmth around the insertion site 30. A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Prepare to administer antibiotics. D. Place the client on bed rest in semi-Fowler’s position. 31. A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse? A. Determine what the client knows about the surgery. B. Identify the client’s usual coping mechanisms. C. Review the client’s current home environment. D. Discuss if family members will assist with postoperative care. 32. A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? A. ?Brachial B. ?Carotid C. ?Femoral D. ?Popliteal 33. A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate B. Dyspnea C. Increased blood pressure D. Weak pulse 34. A nurse is caring for a client who has returned to the unit following a surgical procedure. The client’s oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. B. Administer prescribed analgesic medication. C. Encourage coughing and deep breathing. D. Raise the head of the bed. 35. A nurse is preparing to discontinue a client’s indwelling urinary catheter. Which of the following actions should the nurse take first? A. Deflate the catheter balloon using a sterile syringe. B. Measure and document the urine in the drainage bag. C. Remove the tape or device securing the catheter to the client’s thigh. D. Position the client supine. 36. A nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following conditions? A. ?Metabolic acidosis B. ?Metabolic alkalosis C. ?Respiratory acidosis D. ?Respiratory alkalosis 37. A nurse is reviewing a client’s laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? A. Decreased pH and metabolic acidosis B. Decreased pH and respiratory acidosis C. Elevated pH and metabolic alkalosis D. Elevated pH and respiratory alkalosis 38. A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. Delivers a constant rate of a specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the client’s ability to eat, speak, or drink 39. A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take? A. Raise the side rail on the working side of the bed. B. Use the non-dominant hand to insert the catheter. C. Stand on the left side of the bed. D. Raise the bed to a comfortable height. 40. A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter. B. Remove the nasal cannula while the client eats. C. Secure the oxygen tubing to the bed sheet near the client’s head. D. Apply petroleum jelly to the nares as needed to soothe mucous membranes. 41. A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia 42. A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. ?Crackles B. ?Rhonchi C. ?Stridor D. ?Wheezes 43. A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis 44. A nurse is assessing a client’s abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. ?Auscultate B. ?Percuss C. ?Inspect D. ?Palpate 45. A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment? A. “I am thinking of getting a second opinion.” B. “I am hoping this will limit my discomfort.” C. “This treatment should help me live a little longer.” D. “This is not working and I plan to stop treatment.” 46. A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take? A. Discuss initiating hospice care with the client and family. B. Write a referral to place the client in a nursing home. C. Talk with the provider about extending the client's hospital stay. D. Inform the client's family that they are responsible for providing palliative care. 47. A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect? A. The client reports numbness at the site. B. Purulent drainage is noted from the site. C. The vein appears cordlike. D. Skin over the site is sloughing. 48. A nurse is reviewing a client’s lab results. Which of the following lab values should the nurse report to the provider? A. Sodium 126 mEq/L B. Potassium 3.6 mEq/L C. Magnesium 1.9 mEq/L D. Chloride 99 mEq/L 49. A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? A. 25 mg/dL B. 13 mg/dL C. 10 mg/dL D. 18 mg/dL 50. A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? A. Emphasize four important points at each session. B. Use a passive voice to explain the information. C. Refer to the client in the third person during the session. D. Have short teaching sessions. 51. A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? A. "The spacer increases the amount of medication delivered to the oropharynx." B. "The spacer increases the amount of medication delivered to the lungs." C. "Inhale rapidly using the spacer with the MDI." D. "Cover exhalation slots of the spacer with lips when inhaling."