ATI CMS Nursing Exam 4 2024
A nurse is planning care for a client who has renal calculi. Which of the following
interventions should the nurse include to promote elimination of the calculi?
Maintain bedrest until calculi are expelled.
Withhold thiazide diuretics.
Encourage intake of at least 3 L of fluid each day.
Collect all urine for 24 hr in a collection container. - Encourage intake of at least 3 L
of fluid each day.
The nurse should encourage the client to consume at least 3 L of fluid each day.
Increased fluid intake increases urine production, promotes eliminiation of calculi,
and helps prevent recurrence.
A nurse is providing postoperative education for a client following a laparoscopic
cholecystectomy for cholelithiasis. Which of the following client statements indicates
an understanding of the teaching?
"The adhesive bandages on my incision will fall off as the incision heals."
"I will be able to take a shower in 1 week."
"I will need to follow a liquid diet for the first 3 days after surgery."
"I can begin to resume my normal activity level in 2 weeks." - "The adhesive
bandages on my incision will fall off as the incision heals."
The nurse should instruct the client that the small adhesive bandages will lose their
adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the
bandages to fall off over time as the incision heals.
A nurse is planning care to prevent hospital-acquired methicillin-resistant
Staphylococcus aureus (MRSA) infection for a client who is immunocompromised.
Which of the following interventions should the nurse include to prevent this
antibiotic-resistant infection?
Initiate contact precautions for this client.
Bathe the client with chlorhexidine wipes.
Administer ceftaroline to the client as a prophylactic measure.
Avoid using alcohol-based hand sanitizers after caring for the client - Bathe the client
with chlorhexidine wipes.
,The nurse should bathe a client who is immunocompromised with chlorhexidine
wipes to decrease the risk of contracting hospital-acquired MRSA.
A nurse is assessing a client who has developed type 1 herpes simplex virus. Which
of the following images should the nurse identify as this type of viral infection? -
Picture of lips.
Herpes simplex virus infection is a common viral infection in adults. The nurse
should identify that this image indicates the type 1 herpes simplex viral infection
because the infection causes a recurring cold sore.
A nurse is assessing a client who has Graves' disease. Which of the following
findings should the nurse expect?
Somnolence
Cold intolerance
Exophthalmos
Dry, scaly skin - Exophthalmos
The nurse should expect a client who has Graves' disease, an autoimmune form of
hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs.
A nurse is teaching an older adult client who has peripheral neuropathy about a new
prescription for duloxetine. Which of the following client statements indicates an
understanding of the teaching?
"It might take several weeks to notice an improvement in my symptoms."
"I will need to take this medication on an empty stomach."
"I should take a daily ibuprofen for generalized aches."
"I will need to decrease my dietary sodium intake while taking this medication." - It
might take several weeks to notice an improvement in my symptoms."
The nurse should instruct the client that duloxetine can take several weeks to be
effective. This medication is an antidepressant that reduces the discomfort of
peripheral neuropathy.
A nurse is teaching a client who has scabies about a new prescription for lindane
lotion. Which of the following client statements indicates an understanding of the
treatment for this parasitic infection?
"I will apply the lotion once a day for 1 week."
"I will rub in the lotion thoroughly from my face to my toes."
"I will wash the lotion off 12 hours after I apply it."
,"I should avoid bathing for 6 hours prior to applying the lotion." - "I will wash the
lotion off 12 hours after I apply it."
The nurse should instruct the client to apply the lotion and leave it in place for 8 to 12
hr and then remove it by washing it off.
A nurse is assessing a client who has appendicitis. Which of the following findings
should the nurse report to the provider immediately?
WBC 16,000/mm³
Board-like abdomen
Nausea and vomiting
Temperature of 38° C (100.4° F) - Board-like abdomen
When using the urgent vs. nonurgent approach to client care, the nurse should
identify that a board-like abdomen is the priority finding indicating peritonitis. The
nurse should notify the provider immediately.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to
prevent reflux. Which of the following information should the nurse include in the
teaching?
Drink tomato juice with the breakfast meal.
Suck on peppermint when having indigestion.
Elevate the head of the bed 10 cm (4 in) using wooden blocks.
Plan to finish eating at least 3 hr before bedtime. - Plan to finish eating at least 3 hr
before bedtime.
The nurse should encourage the client not to eat anything at least 3 hr before
bedtime to prevent reflux.
A nurse is teaching a client who has a deep-vein thrombosis about a new
prescription for warfarin. Which of the following client statements indicates an
understanding of the teaching?
"I will stop taking the medication immediately if I experience nausea."
"I should contact my provider if I notice a pink-tinged color to my urine."
"I will increase my dietary intake of spinach."
"I will not be able to use an electric razor while I am taking this medication." - "I
should contact my provider if I notice a pink-tinged color to my urine."
, The nurse should instruct the client to monitor for blood in the urine. The client
should report a pink-tinged urine color to the provider.
A nurse is reviewing the urinalysis results of a client who has completed a 14-day
course of ciprofloxacin to treat pyelonephritis. Which of the following values should
indicate to the nurse that the client has a continuing infection?
Negative nitrites
RBCs < 2
Positive leukocyte esterase
Amber-colored urine - Positive leukocyte esterase
The nurse should identify that a positive leukocyte esterase test is an indication of
the presence of WBCs in the urine and the presence of continued infection.
A nurse is assessing a client for manifestations of grief after having a colostomy for
removal of colon cancer. Which of the following findings indicates to the nurse that
the client has accepted the loss?
Becomes angry when it is time to perform colostomy care
Touches the colostomy stoma when the bag is changed
Looks away as the nurse empties the colostomy bag
Tells others that it will be nice to have a normal bowel movement again - Touches
the colostomy stoma when the bag is changed
The client touching the colostomy stoma when the bag is changed should indicate to
the nurse that the client is accepting and coping with the alteration of body image
and has gone through the stages of grief.
A nurse is assessing a school-age child who has appendicitis with possible
perforation. Which of the following findings should the nurse identify as a
manifestation of peritonitis?
Abdominal distention
Bradycardia
Hyperactive bowel sounds
Slow, deep breathing - Abdominal distention
The nurse should identify that peritonitis is an inflammation of the lining of the
abdominal wall. This inflammation, along with the ileus that develops, causes
A nurse is planning care for a client who has renal calculi. Which of the following
interventions should the nurse include to promote elimination of the calculi?
Maintain bedrest until calculi are expelled.
Withhold thiazide diuretics.
Encourage intake of at least 3 L of fluid each day.
Collect all urine for 24 hr in a collection container. - Encourage intake of at least 3 L
of fluid each day.
The nurse should encourage the client to consume at least 3 L of fluid each day.
Increased fluid intake increases urine production, promotes eliminiation of calculi,
and helps prevent recurrence.
A nurse is providing postoperative education for a client following a laparoscopic
cholecystectomy for cholelithiasis. Which of the following client statements indicates
an understanding of the teaching?
"The adhesive bandages on my incision will fall off as the incision heals."
"I will be able to take a shower in 1 week."
"I will need to follow a liquid diet for the first 3 days after surgery."
"I can begin to resume my normal activity level in 2 weeks." - "The adhesive
bandages on my incision will fall off as the incision heals."
The nurse should instruct the client that the small adhesive bandages will lose their
adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the
bandages to fall off over time as the incision heals.
A nurse is planning care to prevent hospital-acquired methicillin-resistant
Staphylococcus aureus (MRSA) infection for a client who is immunocompromised.
Which of the following interventions should the nurse include to prevent this
antibiotic-resistant infection?
Initiate contact precautions for this client.
Bathe the client with chlorhexidine wipes.
Administer ceftaroline to the client as a prophylactic measure.
Avoid using alcohol-based hand sanitizers after caring for the client - Bathe the client
with chlorhexidine wipes.
,The nurse should bathe a client who is immunocompromised with chlorhexidine
wipes to decrease the risk of contracting hospital-acquired MRSA.
A nurse is assessing a client who has developed type 1 herpes simplex virus. Which
of the following images should the nurse identify as this type of viral infection? -
Picture of lips.
Herpes simplex virus infection is a common viral infection in adults. The nurse
should identify that this image indicates the type 1 herpes simplex viral infection
because the infection causes a recurring cold sore.
A nurse is assessing a client who has Graves' disease. Which of the following
findings should the nurse expect?
Somnolence
Cold intolerance
Exophthalmos
Dry, scaly skin - Exophthalmos
The nurse should expect a client who has Graves' disease, an autoimmune form of
hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs.
A nurse is teaching an older adult client who has peripheral neuropathy about a new
prescription for duloxetine. Which of the following client statements indicates an
understanding of the teaching?
"It might take several weeks to notice an improvement in my symptoms."
"I will need to take this medication on an empty stomach."
"I should take a daily ibuprofen for generalized aches."
"I will need to decrease my dietary sodium intake while taking this medication." - It
might take several weeks to notice an improvement in my symptoms."
The nurse should instruct the client that duloxetine can take several weeks to be
effective. This medication is an antidepressant that reduces the discomfort of
peripheral neuropathy.
A nurse is teaching a client who has scabies about a new prescription for lindane
lotion. Which of the following client statements indicates an understanding of the
treatment for this parasitic infection?
"I will apply the lotion once a day for 1 week."
"I will rub in the lotion thoroughly from my face to my toes."
"I will wash the lotion off 12 hours after I apply it."
,"I should avoid bathing for 6 hours prior to applying the lotion." - "I will wash the
lotion off 12 hours after I apply it."
The nurse should instruct the client to apply the lotion and leave it in place for 8 to 12
hr and then remove it by washing it off.
A nurse is assessing a client who has appendicitis. Which of the following findings
should the nurse report to the provider immediately?
WBC 16,000/mm³
Board-like abdomen
Nausea and vomiting
Temperature of 38° C (100.4° F) - Board-like abdomen
When using the urgent vs. nonurgent approach to client care, the nurse should
identify that a board-like abdomen is the priority finding indicating peritonitis. The
nurse should notify the provider immediately.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to
prevent reflux. Which of the following information should the nurse include in the
teaching?
Drink tomato juice with the breakfast meal.
Suck on peppermint when having indigestion.
Elevate the head of the bed 10 cm (4 in) using wooden blocks.
Plan to finish eating at least 3 hr before bedtime. - Plan to finish eating at least 3 hr
before bedtime.
The nurse should encourage the client not to eat anything at least 3 hr before
bedtime to prevent reflux.
A nurse is teaching a client who has a deep-vein thrombosis about a new
prescription for warfarin. Which of the following client statements indicates an
understanding of the teaching?
"I will stop taking the medication immediately if I experience nausea."
"I should contact my provider if I notice a pink-tinged color to my urine."
"I will increase my dietary intake of spinach."
"I will not be able to use an electric razor while I am taking this medication." - "I
should contact my provider if I notice a pink-tinged color to my urine."
, The nurse should instruct the client to monitor for blood in the urine. The client
should report a pink-tinged urine color to the provider.
A nurse is reviewing the urinalysis results of a client who has completed a 14-day
course of ciprofloxacin to treat pyelonephritis. Which of the following values should
indicate to the nurse that the client has a continuing infection?
Negative nitrites
RBCs < 2
Positive leukocyte esterase
Amber-colored urine - Positive leukocyte esterase
The nurse should identify that a positive leukocyte esterase test is an indication of
the presence of WBCs in the urine and the presence of continued infection.
A nurse is assessing a client for manifestations of grief after having a colostomy for
removal of colon cancer. Which of the following findings indicates to the nurse that
the client has accepted the loss?
Becomes angry when it is time to perform colostomy care
Touches the colostomy stoma when the bag is changed
Looks away as the nurse empties the colostomy bag
Tells others that it will be nice to have a normal bowel movement again - Touches
the colostomy stoma when the bag is changed
The client touching the colostomy stoma when the bag is changed should indicate to
the nurse that the client is accepting and coping with the alteration of body image
and has gone through the stages of grief.
A nurse is assessing a school-age child who has appendicitis with possible
perforation. Which of the following findings should the nurse identify as a
manifestation of peritonitis?
Abdominal distention
Bradycardia
Hyperactive bowel sounds
Slow, deep breathing - Abdominal distention
The nurse should identify that peritonitis is an inflammation of the lining of the
abdominal wall. This inflammation, along with the ileus that develops, causes
