ATI CMS Practice Exam A

1. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A. Protective environment B. Airborne precautions C. Droplet precautions D. Contact precautions 2. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer. B. Focus teaching on what the client will need to do in the future to manage his illness. C. Provide the client with written information about the phases of loss and grief. D. Reassure the client that this is an expected response to grief. 3. A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? A. Assist the client into a prone position. B. Place a sleeve over the top of each leg with the opening at the knee. C. Make sure two fingers can fit under the sleeves. D. Set the ankle pressure at 65 mm Hg. 4. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid 5. A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. Advocacy ensures clients' safety, health, and rights. B. Advocacy ensures that nurses are able to explain their own actions. C. Advocacy ensures that nurses follow through on their promises to clients. D. Advocacy ensures fairness in client care delivery and use of resources. 6. A nurse is admitting an new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location. 7. A nurse is assessing an older adult client's risk for falls. Which of the following assessment should the nurse use to identify the client's safety needs? SATA A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity 8. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? lOMoARcPSD| A. "I can place an extension cord across my living room to plug in my television." B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." C. "I will place my alarm clock on my bedroom dresser across the room." D. "I will replace the old throw rug in my kitchen with a new one." 9. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L 10. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1hr. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record. B. Complete an incident report. C. Consult the facility's risk manager. D. Notify the nursing manager. 11. A Nurse is caring for a client who has pancreatitis. Nurses' Notes - 1000: Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site.. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). SATA A. Document the client's vital signs. B. Measure the client's intake and output. C. Transfer the client from wheelchair to bed. D. Insert an NG tube for the client. E. Collect data about the client's pain level. 12. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Increase in hematocrit B. Increase in respiratory rate C. Decrease in heart rate D. Decrease in capillary refill time 13. A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. Combine client care tasks when caring for multiple clients. B. Wait until the end of the shift to document client care. C. Use the planning step of the nursing process to prioritize client care delivery. D. Allow for interruptions in tasks to discuss client care issues with colleagues. 14. A nurse is talking with the partner of a client how has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of roleperformance stress? A. Role ambiguity B. Sick role C. Role overload D. Role conflict 15. Nurses Notes - 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. lOMoARcPSD| Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed...The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? A. Wear an N95 mask when caring for the client. B. Place a container for soiled linens inside the client's room. C. Place the client in a negative airflow room. D. Remove mask after exiting the client's room. E. Wear a sterile, water-resistant gown if within 3 feet of the client. 16. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication. C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container. 17. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill 15 mL of irrigation fluid into the catheter with each flush. C. Subtract the amount of irrigant used from the client's urine output. D. Perform the irrigation using a 20-mL syringe. 18. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning. B. Use tracheostomy covers when outdoors. C. Use sterile technique when performing tracheostomy care at home. D. Cleanse irritated skin with full-strength hydrogen peroxide. 19. A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if i arrived at the emergency department and i had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your health care proxy to make decisions." B. "We would give you oxygen through a tube in your nose." C. "You would be unable to change your previous wishes about your care." D. "We would insert a breathing tube while we evaluate your condition." 20. Physical Examination 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids. Complete the following sentence by using the list of options. A. The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe. 21. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least six air exchanges per hour. B. Make sure the client wears a mask when outside her room if there is construction in the area. C. Place the client in a private room with negative-pressure airflow. D. Wear an N95 respirator when giving the client direct care. 22. A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole lOMoARcPSD| number) A. 107 mL/hr 23. A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? SATA A. "I have been weighing myself every other morning." B. "I am trying to decrease my intake of foods with potassium." C. "I am limiting my sodium intake to 2 grams daily." D. "I am eating fewer potato chips and more fruit for snacks." E. "I lie down and rest after meals." F. "I know to call my doctor if I gain 3 pounds or more in 2 days." 24. A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client holds the cane on the stronger side of her body. D. The client moves her stronger limb forward with the cane. 25. A Nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Have the client take sips of water to promote insertion of the NG tube into the esophagus. 26. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45° angle. B. Place the client's arm in a dependent position. C. Shave excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand. 27. A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Bend at the waist. B. Keep his feet close together. C. Use his back muscles for lifting. D. Stand close to the cabinet when lifting it. 28. A nurse is caring for a client who has terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. Turn the client every 2 hr. B. Administer an antiemetic every 6 hr. C. Hold oral care. D. Increase the room's temperature. 29. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. A. Increase intake of high-calcium foods. B. Eat probiotic foods, such as yogurt. C. Avoid alcohol while experiencing diarrhea. D. Eat raw vegetables. E. Eat three large meals a day. F. Avoid caffeine while experiencing diarrhea. G. Drink hot liquids several times a day. H. Drink carbonated beverages to replace lost fluids. lOMoARcPSD| I. Follow a low-fiber diet. 30. 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 in the discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family 31. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. "Use the complete name of the medication magnesium sulfate." B. "Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin." D. "Use the abbreviation SC when indicating an injection." 32. A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. A. The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer. 33. A nurse is auscultating the anterior chest of a client who was newly admitted to a medicalsurgical unit. listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. A. Crackles B. Rhonchi C. Friction rub D. Normal breath sounds 34. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. Pad the client's wrist before applying the restraints. B. Evaluate the client's circulation every 8 hr after application. C. Remove the restraints every 4 hr to evaluate the client's status. D. Secure the restraint ties to the bed's side rails. 35. A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A. Critical pathway B. Situation, background, assessment, and recommendation (SBAR) C. Transfer report D. Medication administration record (MAR) 36. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. A. Neurological assessment B. Incisional drainage C. Urinary output D. Reported pain level E. Gastrointestinal assessment F. Vital signs 37. A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. The client uses a wool blanket on their bed. B. The client identifies the location of a fire extinguisher. C. The client stores an extra oxygen tank on its side under their bed. lOMoARcPSD| D. The client has a weekly inspection checklist for oxygen equipment. 38. A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. D. Palpate the client's abdomen before auscultating bowel sounds. 39. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A. On the Knee 40. A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. Insert the needle at a 15° angle. B. Aspirate for blood return prior to administration. C. Administer the medication into the abdomen. D. Massage the site following the injection. 41. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? A. Use a bed exit alarm system. B. Raise four side rails while the client is in bed. C. Apply one soft wrist restraint. D. Dim the lights in the client's room. 42. Complete the following sentence by using the list of options. A. A client has manifestations of allergic reaction as evidence by the client's itching. 43. A nurse is performing a skin assessment for a lcient who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. A lesion with uniform pigmentation B. New appearance of petechiae C. A mole with an asymmetrical appearance D. The presence of a papule 44. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective 45. A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? A. "You would have so much more time to spend with your family." B. "You should consider getting a part-time job or doing volunteer work." C. "Let's talk about how the change in your job status will affect you." D. "Why wouldn't you want to retire and relax?" 46. The nurse is assessing the client. Which of the following actions should the nurse take? SATA A. Stop the IV infusion. B. Elevate the client's left arm. C. Apply heat to the client's left hand. D. Place a pressure dressing over the IV site. E. Start a new IV in the client's left hand. lOMoARcPSD| 47. A nurse is caring for a client who is post-op and refuses to use an incentive spirometer following a major abdominal surgery. Which of the following actions is the nurse's priority? A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. B. Determine the reasons why the client is refusing to use the incentive spirometer. C. Document the client's refusal to participate in health restorative activities. D. Administer a pain medication to the client. 48. A nurse is caring for a client who ask about the purpose of advance directives. Which of the following statements should the nurse make? A. "They allow the court to overrule an adult client's refusal of medical treatment." B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." C. "They permit a client to withhold medical information from health care personnel." D. "They allow health care personnel in the emergency department to stabilize a client's condition." 49. A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? A. I am not worried because I still have hope that he will be okay." B. "I am relying on support from our family during this time." C. "We can plan our family reunion once he recovers and comes home." D. "We don't see any reason to start discussing funeral arrangements right now." 50. Complete the following sentence by using the list of options. A. The nurse should identify that the client might be experiencing extravasation as evidenced by the client's IV catheter site. 51. A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? A. "I will return shortly after I document this in your record." B. "Most men live a long time with prostate cancer." C. "I am available to talk if you should change your mind." D. "I will make a referral to a cancer support group for you." 52. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries. B. Move hazardous objects away from the client. C. Notify the provider. D. Ask the client to describe how she felt prior to the fall. 53. A nurse is caring for a client who has herpes zoster and ask the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A. Biofeedback B. Aloe C. Feverfew D. Acupuncture 54. Complete the following sentence by using the list of options. A. The nurse should first address the client's physical safety followed by the client's positioning. 55. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. lOMoARcPSD| B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. C. Make sure the reservoir bag of a partial rebreathing mask remains deflated. D. Use petroleum jelly to lubricate the client's nares, face, and lips. 56. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? A. Administer the medication with the needle at a 45° angle. B. Administer the medication into the client's nondominant arm. C. Pull the client's skin laterally or downward prior to administration. D. Massage the injection site after administration. 57. A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 0 to 10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?" 58. A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions sould hte nurse take? A. Examine personal values about the issue. B. Tell the parents that this is a necessary procedure. C. Inform the parents that the staff does not require their consent. D. Contact a spiritual support person to explain the importance of the procedure. 59. Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Select the 3 findings that require follow-up. A. Breath sounds B. Blood pressure C. Oxygen saturation D. Temperature E. Heart rate 60. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management. A. "I think I should take my pain medication more often, since it is not controlling my pain." B. "Breathing faster will help me keep my mind off of the pain." C. "It might help me to listen to music while I'm lying in bed." D. "I don't want to walk today because I have some pain."