ATI CBC Level 4 (A)
A nurse is teaching a client who has been newly diagnosed with systemic lupus
erythematosus (SLE). Which statement by the client indicates an understanding of the
teaching?
"I should wear SPF 15 sunscreen when outdoors."
"I should inspect my skin daily for cuts and rashes."
"I will avoid using lotion on my skin."
"I will limit using a tanning bed to once a month." - answer"I should inspect my skin daily
for cuts and rashes"
-The client who has SLE should inspect her skin daily for cuts and abrasions and report
them to her provider.
A nurse is caring for a client who has Parkinson's disease. Which of the following
actions should the nurse take to promote the client's mobility?
Provide the client with a cool bath.
Encourage the client to jog on the treadmill daily.
Instruct the client to perform range-of-motion exercises.
Assist the client to walk with a narrow-based gait. - answerInstruct the client to perform
range-of-motion exercises
-exercising and walking help to delay the progression of the disease
A nurse is caring for a client who has had a myocardial infarction and suspects
cardiogenic shock. The nurse should monitor for which of the following manifestations?
Pulmonary congestion
Bradycardia
Hypertension
Bounding pulse - answerPulmonary Congestion
-Pulmonary congestion is a result of decreased cardiac output due to damage to the
cardiac muscle
A nurse is assessing a client who has a DNR order and has stopped breathing. The
family asks the nurse to resuscitate the client. Which action should the nurse take?
Begin CPR on the client.
Respect the client's preferences.
Apply oxygen at 4 L/min via nasal cannula.
Gather equipment for mechanical ventilation. - answerRespect the client's preferences.
-The nurse should inform the client's family that he is obligated to respect the client's
preferences and follow the DNR order.
,A nurse manager is teaching a group of nurses about OSHA. What information should
the nurse include?
Provides fact sheets containing biological agent information for health care providers
Establishes universal protocols and language for disaster response
Sets standards for hazardous exposures in the workplace
Regulates school breakfast and lunch programs - answerSets standards for hazardous
exposures in the workplace.
-The nurse manager should include in the teaching that OSHA sets standards for
hazardous exposures in the workplace and also sets the objectives for Healthy People
2020 that focus on occupational health.
A nurse manager identifies that the number of client medication administration errors on
the unit has increased. When creating a cause-and-effect chart, which of the following
information should the nurse manger include?
Possible reasons for the medication errors
Number of medication errors per month
The staff responsible for reporting medication errors
The facility's policy for preventing medication errors - answerPossible reasons for the
medication errors
-The nurse manager should identify and include possible reasons for the occurrence of
medication errors when creating a cause and effect chart. This data assists in the
prevention of future medication errors.
A nurse manager notices that he has exceeded the amount of money allocated for labor
costs for the quarter. Which action should the nurse manager take?
Involve staff nurses in budget planning.
Ask case management to increase client length of stay.
Increase the number of assistive personnel on each shift.
Schedule additional training sessions on prioritizing client care. - answerinvolve staff
nurses in budge planning.
-this promotes awareness of the costs of staffing a unit and encourages cost-effective
care.
A nurse is providing teaching to a client who has a halo device applied to prevent further
cervical spinal cord injury following a diving accident. What info should the nurse
include?
"Avoid using a pillow when sleeping."
"Resume driving a vehicle after 1 month."
"Abstain from sexual activity."
"Avoid leaning forward when attempting to stand." - answer"Avoid leaning forward when
attempting to stand."
, -the weight of the halo device can alter balance. leaning forward could cause the client
to fall.
A nurse is working on an interprofessional collaboration plan of care for a client who has
a stage 3 pressure ulcer. Which action should the nurse recognize as the. role of the
licensed practical nurse (LPN)?
Administer pain medication.
Initiate the plan of care.
Determine protein needs for the client.
Prescribe a referral for physical therapy. - answerAdminister pain medication
A nurse manager is facilitating conflict resolution between two nurses who disagree
about the need to make a referral to a social worker. Which conflict management
strategies should the nurse manager use?
Implement soothing technique to permanently resolve the issue.
Offer self to constructively facilitate communication.
Encourage the nurses to email each other to resolve the issue.
Send the nurses to behavior management training. - answerOffer self to constructively
facilitate communication.
-The nurse manager will be the impartial third party in this communication
A nurse is having a disagreement with a coworker about a client assignment. When
following the chain of command, which of the following individuals should the nurse
contact to discuss the conflict?
The client's provider
The facility risk manager
The chief nursing officers
The charge nurses - answerThe charge nurse
-the charge nurse is the nurse's immediate supervisor
A triage nurse is prioritizing clients following a mass casualty disaster. Which of the
following clients should the nurse treat first?
A client who has extensive full-thickness burns to 85% of her body
A client who is exhibiting manifestations of shock
A client who has an open distal fibula fracture
A client who has multiple abrasions to the chest and lower extremities - answerA client
who is exhibiting manifestations of shock.
-a client exhibiting manifestations of shock requires immediate intervention for survival.
A nurse is caring for a client who has a partial-thickness burn and a prescription for a
silver sulfadiazine cream. Which intervention should the nurse take?
Check the client's D-dimer levels every 12 hr.
Apply the medication cream to the client's wound every 4 hr.
A nurse is teaching a client who has been newly diagnosed with systemic lupus
erythematosus (SLE). Which statement by the client indicates an understanding of the
teaching?
"I should wear SPF 15 sunscreen when outdoors."
"I should inspect my skin daily for cuts and rashes."
"I will avoid using lotion on my skin."
"I will limit using a tanning bed to once a month." - answer"I should inspect my skin daily
for cuts and rashes"
-The client who has SLE should inspect her skin daily for cuts and abrasions and report
them to her provider.
A nurse is caring for a client who has Parkinson's disease. Which of the following
actions should the nurse take to promote the client's mobility?
Provide the client with a cool bath.
Encourage the client to jog on the treadmill daily.
Instruct the client to perform range-of-motion exercises.
Assist the client to walk with a narrow-based gait. - answerInstruct the client to perform
range-of-motion exercises
-exercising and walking help to delay the progression of the disease
A nurse is caring for a client who has had a myocardial infarction and suspects
cardiogenic shock. The nurse should monitor for which of the following manifestations?
Pulmonary congestion
Bradycardia
Hypertension
Bounding pulse - answerPulmonary Congestion
-Pulmonary congestion is a result of decreased cardiac output due to damage to the
cardiac muscle
A nurse is assessing a client who has a DNR order and has stopped breathing. The
family asks the nurse to resuscitate the client. Which action should the nurse take?
Begin CPR on the client.
Respect the client's preferences.
Apply oxygen at 4 L/min via nasal cannula.
Gather equipment for mechanical ventilation. - answerRespect the client's preferences.
-The nurse should inform the client's family that he is obligated to respect the client's
preferences and follow the DNR order.
,A nurse manager is teaching a group of nurses about OSHA. What information should
the nurse include?
Provides fact sheets containing biological agent information for health care providers
Establishes universal protocols and language for disaster response
Sets standards for hazardous exposures in the workplace
Regulates school breakfast and lunch programs - answerSets standards for hazardous
exposures in the workplace.
-The nurse manager should include in the teaching that OSHA sets standards for
hazardous exposures in the workplace and also sets the objectives for Healthy People
2020 that focus on occupational health.
A nurse manager identifies that the number of client medication administration errors on
the unit has increased. When creating a cause-and-effect chart, which of the following
information should the nurse manger include?
Possible reasons for the medication errors
Number of medication errors per month
The staff responsible for reporting medication errors
The facility's policy for preventing medication errors - answerPossible reasons for the
medication errors
-The nurse manager should identify and include possible reasons for the occurrence of
medication errors when creating a cause and effect chart. This data assists in the
prevention of future medication errors.
A nurse manager notices that he has exceeded the amount of money allocated for labor
costs for the quarter. Which action should the nurse manager take?
Involve staff nurses in budget planning.
Ask case management to increase client length of stay.
Increase the number of assistive personnel on each shift.
Schedule additional training sessions on prioritizing client care. - answerinvolve staff
nurses in budge planning.
-this promotes awareness of the costs of staffing a unit and encourages cost-effective
care.
A nurse is providing teaching to a client who has a halo device applied to prevent further
cervical spinal cord injury following a diving accident. What info should the nurse
include?
"Avoid using a pillow when sleeping."
"Resume driving a vehicle after 1 month."
"Abstain from sexual activity."
"Avoid leaning forward when attempting to stand." - answer"Avoid leaning forward when
attempting to stand."
, -the weight of the halo device can alter balance. leaning forward could cause the client
to fall.
A nurse is working on an interprofessional collaboration plan of care for a client who has
a stage 3 pressure ulcer. Which action should the nurse recognize as the. role of the
licensed practical nurse (LPN)?
Administer pain medication.
Initiate the plan of care.
Determine protein needs for the client.
Prescribe a referral for physical therapy. - answerAdminister pain medication
A nurse manager is facilitating conflict resolution between two nurses who disagree
about the need to make a referral to a social worker. Which conflict management
strategies should the nurse manager use?
Implement soothing technique to permanently resolve the issue.
Offer self to constructively facilitate communication.
Encourage the nurses to email each other to resolve the issue.
Send the nurses to behavior management training. - answerOffer self to constructively
facilitate communication.
-The nurse manager will be the impartial third party in this communication
A nurse is having a disagreement with a coworker about a client assignment. When
following the chain of command, which of the following individuals should the nurse
contact to discuss the conflict?
The client's provider
The facility risk manager
The chief nursing officers
The charge nurses - answerThe charge nurse
-the charge nurse is the nurse's immediate supervisor
A triage nurse is prioritizing clients following a mass casualty disaster. Which of the
following clients should the nurse treat first?
A client who has extensive full-thickness burns to 85% of her body
A client who is exhibiting manifestations of shock
A client who has an open distal fibula fracture
A client who has multiple abrasions to the chest and lower extremities - answerA client
who is exhibiting manifestations of shock.
-a client exhibiting manifestations of shock requires immediate intervention for survival.
A nurse is caring for a client who has a partial-thickness burn and a prescription for a
silver sulfadiazine cream. Which intervention should the nurse take?
Check the client's D-dimer levels every 12 hr.
Apply the medication cream to the client's wound every 4 hr.
