ATI Final Exam ~ Review Questions and Answers 100% Correct.

ATI Final Exam ~ Review Questions and Answers 100% Correct. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family? 1. Remove the outer cannula cautiously for routine cleaning. 2. Use tracheostomy covers when outdoors. 3. Use sterile technique when performing tracheostomy care at home. 4. Cleanse irritated skin with full-strength hydrogen peroxide. - CORRECT ANSWER-2. Use tracheostomy covers when outdoors. A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide? 1. Admitting diagnosis 2. Diagnostic test results 3. Body temperature 4. Breath sounds - CORRECT ANSWER-4. Breath sounds **ABCs** A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for primary hypertension? 1. A client who is pregnant 2. A client who has an elevated LDL 3. A client who takes oral contraceptives 4. A client who has kidney disease - CORRECT ANSWER-2. A client who has an elevated LDL A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? (Select all that apply.) - Assist the client with a partial bed bath. - Measure the client's BP after the nurse administers an antihypertensive medication. - Test the client's swallowing ability by providing thickened liquids. - Use a communication board to ask what the client wants for lunch. - Irrigate the client's indwelling urinary catheter. - CORRECT ANSWER-- Assist the client with a partial bed bath. - Measure the client's BP after the nurse administers an antihypertensive medication. - Use a communication board to ask what the client wants for lunch. A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? 1. Tie restraints to the lower edge of the side rail. 2. Remove each restraint one at a time every 2 hr. 3. Ensure 3 finger-widths of space between the restraint and the client's wrist. 4. Use a square knot to securely tie the restraints to the bed. - CORRECT ANSWER-2. Remove each restraint one at a time every 2 hr. **To perform ROM exercises and neurovascular checks** A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the following is an appropriate nursing intervention? 1. Return the unused medication to the automatic dispensing system. 2. Keep the remaining medication at the client's bedside for later use. 3. Have a second nurse witness the disposal of remaining medication. 4. Lock remaining medication in secure cabinet. - CORRECT ANSWER-3. Have a second nurse witness the disposal of remaining medication. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate response by the nurse? 1. "It allows the court to overrule an adult client's refusal of medical treatment." 2. "It permits a client to withhold medical information from health care personnel." 3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness." 4. "It allows health care personnel in the emergency department to stabilize a client's condition." - CORRECT ANSWER-3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness." A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident? 1. Incident report completed. 2. Client climbed over the bedrails. 3. Client found lying on floor. 4. Client was trying to get out of bed. - CORRECT ANSWER-3. Client found lying on floor. **remember, be Objective in documentation** A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the preoperative teaching regarding pain control has been effective when the client states which of the following? 1. "I think I should take my pain medication more often, since it is not controlling my pain." 2. "Breathing faster will help me keep my mind off of the pain." 3. "It may help me to listen to music while I'm lying in bed." 4. "I don't want to walk today, because I'm experiencing some pain." - CORRECT ANSWER-3. "It may help me to listen to music while I'm lying in bed." **nonpharmacological intervention to pain** A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse? 1. "I'm sorry, but another client needed my attention." 2. "I arrived as soon as I could. What can I do for you?" 3. "It must be frustrating. I have a few minutes now." 4. "We had an emergency on the unit, but now I'm here." - CORRECT ANSWER-3. "It must be frustrating. I have a few minutes now." **therapeutic by acknowledging client's feelings** A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family - CORRECT ANSWER-1. During the admission process **discharge planning starts at admission (patient needs for during and after hospital)** A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPPA guidelines? 1. The assigned nurse reviews the medical chart with a nursing student. 2. A nursing student discusses a client's status with the assigned nurse at the bedside. 3. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care. 4. A nursing student consults a former classmate to assist with her documentation. - CORRECT ANSWER-4. A nursing student consults a former classmate to assist with her documentation. **only those in direct care** A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a need for further teaching? 1. The client inserts the needle at a 30°-angle. 2. The client rolls the vial between both hands. 3. The client holds the syringe in place for 5 seconds following injection. 4. The client uses her anterior thigh as the injection site. - CORRECT ANSWER-1. The client inserts the needle at a 30°-angle. **Insert needle at 45° to 90° (depending on adipose/fat tissue)** A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L - CORRECT ANSWER-4. Potassium 5.4 mEq/L **Electrolytes (ranges):** Sodium ~ 135-145 mEq/L Chloride ~ 95-105 mEq/L Potassium ~ 3.5-5.0 mEq/L Bicarbonate ~ 22-28 mEq/L Magnesium ~ 1.5-2.0 mEq/L A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. Which of the following guidelines should the nurse follow when working with the interpreter? 1. Speak slowly to allow the interpreter to interpret each word. 2. Explain the purpose of the communication to the interpreter. 3. Address the interpreter when explaining the procedure information. 4. Supplement words with gestures and nonverbal reinforcement. - CORRECT ANSWER-2. Explain the purpose of the communication to the interpreter. A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate? 1. Use the clean technique throughout the procedure. 2. Insert the catheter as the client exhales. 3. Apply suction for up the 20 seconds. 4. Perform suctioning while removing the catheter. - CORRECT ANSWER-4. Perform suctioning while removing the catheter. A nurse is caring for a client and performing blood glucose monitoring. Which of the following is an appropriate nursing intervention? 1. Wipe away the first drop of blood from the client's finger. 2. Gently massage the client's finger in a distal to proximal direction. 3. Puncture the tip of the client's finger. 4. Hold the client's finger in an elevated position prior to testing. - CORRECT ANSWER-1. Wipe away the first drop of blood from the client's finger. **first drop is more serous; contains fewer RBCs** A nurse is caring for a client who cannot bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking? 1. "When I get out of a chair, I'll hold both crutches on the side next to my weak leg." 2. "When I sit down, I'll transfer my weight to my crutches and my strong leg." 3. "When I go up stairs, I'll alternate putting weight on my crutches and my strong leg." 4. "When I go down stairs, I'll start by moving both my crutches to the step below." - CORRECT ANSWER-1. "When I get out of a chair, I'll hold both crutches on the side next to my weak leg." A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse? 1. Have the client drink water from a straw after taking the medication. 2. Instruct the client to lift his chin upward when swallowing medications. 3. Offer each medication one at a time. 4. Place the medication in the client's mouth. - CORRECT ANSWER-3. Offer each medication one at a time. A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route 1. increases infection rates. 2. is the safest option. 3. has the slowest absorption rate. 4. decreases the client's risk for reactions. - CORRECT ANSWER-1. increases infection rates. **breaking skin integrity increases risk for infection** A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which of the following interventions is appropriate? 1. Ask the family if there are any special rituals that they would like to follow at this time. 2. Inform the parents of the importance of conforming to hospital policy regarding the death of a fetus. 3. Remain in the room, giving the parents the opportunity to initiate a discussion about cultural rituals. 4. Take the fetus out of the room, and allow the parents time to grieve together. - CORRECT ANSWER-1. Ask the family if there are any special rituals that they would like to follow at this time. A nurse is caring for four clients. Which of the following actions should the nurse take to prevent the spread of infection? 1. Carry a client's soiled linens out of the room in a mesh linen bag. 2. Place a client who has tuberculosis in a room with negative-pressure airflow. 3. Provide disposable plates and utensils to a client who has HIV. 4. Dispose of a client's blood-saturated dressing in a garbage bag placed inside a second garbage bag. - CORRECT ANSWER-2. Place a client who has tuberculosis in a room with negative-pressure airflow. **negative = air in positive = air out** A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "All I have had since midnight is water and some juice." Which of the following nursing actions is appropriate? 1. Document the caloric intake. 2. Reschedule this lab test for the next morning. 3. Notify the lab to obtain another specimen. 4. Obtain a prescription for a glucose tolerance test. - CORRECT ANSWER-2. Reschedule this lab test for the next morning. **should fast for 8 to 12 hr before sample is drawn** A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated? 1. Leave the necklace on the client. 2. Give the necklace to a family member. 3. Place the necklace in the client's chart. 4. Notify security for placement of the necklace. - CORRECT ANSWER-4. Notify security for placement of the necklace. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse? 1. "I will tape electrical cords to the baseboards in each room." 2. "I will hire someone to trim the tree that overhangs the front porch stairs." 3. "I will remove the table from the hall." 4. "I will replace the old throw rug in the kitchen with a new one." - CORRECT ANSWER-4. "I will replace the old throw rug in the kitchen with a new one." **use of throw rugs increase risk for falls** A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? 1. Clean sutures along with the incision site. 2. Grasp the sutures at the know with a pair of forceps. 3. Cut the sutures close to the skin on one side. 4. Pull out the sutures with forceps in one piece. - CORRECT ANSWER-1. Clean sutures along with the incision site. **greatest risk to this client is infection; clean to minimize risk** A nurse is planning care to promote improved self-feeding for a client who has visual impairment. Which of the following interventions should nurse include in the plan of care? 1. Direct the client in what order to consume the food. 2. Provide small-handled utensils for the client. 3. Thicken liquids on the client's tray. 4. Use a clock pattern to describe food on the plate to the client. - CORRECT ANSWER-4. Use a clock pattern to describe food on the plate to the client. A nurse is reviewing laboratory data for a client who has contusions to the chest wall following a motor vehicle crash. Which of the following values should the nurse report? 1. Hct 40% 2. SaO2 86% 3. WBC 9,000 mm³ 4. Serum potassium 4.1 mEq/L - CORRECT ANSWER-2. SaO2 86% **low oxygen (90%); may indicate hypoxia** A nurse is caring for a client with a diagnosis of terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following? 1. "I am ready to learn about chemotherapy to help cure my cancer." 2. "I just want you to give me something to get this over with soon." 3. "I know that many people have recovered fully from cancer, and so will I." 4. "I want you to tell me about measures available to keep me comfortable." - CORRECT ANSWER-4. "I want you to tell me about measures available to keep me comfortable." **palliative care = comfort and symptom control** A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? 1. Document the provider's statement in the medical record. 2. Complete an incident report. 3. Consult the facility's risk manager. 4. Notify the nursing manager. - CORRECT ANSWER-4. Notify the nursing manager.