ATI practice assessment A questions and solutions

ATI practice assessment A questions and solutions

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/mi
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to 110/min and becomes irregular. Which of the following actions should the nurse take?
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A. Obtain a cardiology consult.
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B. Suction the client less frequently.
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C. Administer an antidysrhythmic medication.
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D. Perform pre-oxygenation prior to suctioning. - answersD. Perform pre-oxygenation prior to suctioning
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Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove
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accumulated secretions from the airways.
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Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue
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injury.. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual
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resuscitator bag set at 100% oxygen.
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A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy.
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The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
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A. BP mi




B. Heart rate mi mi




C. Urine output mi mi




D. Weight - answersB. Heart rate
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When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore,
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the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
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A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team wi
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administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
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A. Epinephrine mi




B. Magnesium mi




C. Atropine mi




D. Sodium bicarbonate - answersC. Atropine
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The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable.
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- The team administers epinephrine during CPR to clients who have systole or pulseless electrical activity.
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- The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of
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ventricular tachycardia.
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- The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR.
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A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the
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following clients?
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A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
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B. A client who has terminal cancer and needs assistance with pain management
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C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
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D. A client who has dementia and needs help with activities of daily living - answersB. A client who has terminal cancer a
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needs assistance with pain management
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,A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services.
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Hospice care provides the client with physical and psychological support, which includes management of symptoms,
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such as pain and dyspnea.
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A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a
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reliable measure of fluid retention?
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A. Daily weight mi mi




B. Sodium level mi mi




C. Tissue turgor mi mi




D. Intake and output - answersA. Daily weight
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Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid
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volume over time.
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A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings
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should the nurse expect?
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A. Frothy sputum mi mi




B. Dependent edema mi mi




C. Nocturnal polyuria mi mi




D. Jugular distention - answersA. Frothy sputum
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Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking
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cough, frothy sputum, wheezing, fatigue, and weakness. All the other options are signs of right-sided heart failure.
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A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliab
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indicator of central cyanosis?
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A. Oral mucosa mi mi




B. Conjunctivae mi




C. Ear lobes mi mi




D. Soles of the feet - answersA. Oral mucosa
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According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of
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central cyanosis because cyanosis is most evident in areas with minimal pigmentation.
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A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12
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weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for th
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client?
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A. Short peripheral catheter
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B. Implanted infusion port
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C. Peripherally inserted central catheter
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D. Arteriovenous fistula - answersC. Peripherally inserted central catheter
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A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs
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extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months. PICC lines
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can also be used to draw blood samples without the need for additional venipunctures.
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A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse
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should wear a gown as personal protective equipment when taking which of the following actions?
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A. Talking to the client at the bedside
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B. Administering an intermittent IV bolus medication
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C. Completing a dressing change
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