ATI
COMPREHENSIVE 2.0
1. Following abdominal surgery, a client's abdominal wound edges are
separating, and the wound is draining a large amount of serous drainage. The nurse should place
the client:
Incorrect: This position is incorrect because it can increase tension on the suture line, and cause
further wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it
can increase tension on the suture line, and cause further wound separation and tearing
(dehiscence).
Correct: The semi-Fowler's position decreases tension on the wound, and it may prevent
further separation and tearing of the wound(dehiscence). Incorrect: This position is incorrect
because it can increase tension on the suture line, and cause further wound separation and tearing
(dehiscence).
flat on the back with legs straight.
in high-Fowler's position with legs straight.
in semi-Fowler's position with the knees slightly bent.
on the left side with knees bent .
2. The PN is preparing to administer an enteral feeding to a client. To prevent
gastric cramping and discomfort due to the feeding, the nurse should:
Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via
gastrostomy tube, the formula reaches the stomach quickly, with little or no opportunity to be
warmed, as oral feedings would as they pass through the mouth and esophagus.Incorrect: Tube
placement is confirmed prior to beginning each feeding. This action does not prevent gastric
discomfort. However, checking tube placement does help prevent the infusion of the formula
into the lungs.
Incorrect: To prevent gastric discomfort, the concentration of the tube feeding formula needs to
,be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the
first few feedings areadministered.Incorrect: The head of the bed should be elevated at least 30°
during the feeding and for at least 30
minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent
cramping and discomfort.
allow time for the formula to reach room temperature prior to administration.
determine tube placement once every 24 hours.
prepare to administer full-strength rather than diluted formula.
elevate the head of the bed during and after feedings.
3. The nurse is caring for a child with cystic fibrosis (CF). Which intervention willhelp to
prevent respiratory complications?
Incorrect: Clients with CF should not receive cough suppressant syrups. These children need to
cough
frequently to clear lung secretions.
Correct: Nebulization with mist or aerosol therapy followed by chest physiotherapy helps to keep
secretions free-flowing. The pulmonary effects of CF are progressive, and bronchial secretions
must be kept moist.
Incorrect: The child should change positions frequently to promote drainage from the lungs, and
promote
aeration of the lungs.
Incorrect: Children with CF can safely receive the pertussis vaccine. These children need
protection from pertussis because this infection causes severe respiratory complications.
Encourage the use of cough suppressant syrup.
Give frequent nebulization treatments.
Limit changing the child's position to conserve the child's need for oxygen.
Withhold the vaccine for pertussis.
,4. The nurse is caring for a client following insertion of a pacemaker. The client isplaced on
continuous ECG monitoring because it will:
Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time
of insertion.
Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker
insertion.
Correct: The heart rate may change following pacemaker insertion because the pacemaker fails
to maintain the pre-set heartrate. This problem can be detected immediately with continuous
ECG monitoring.
Incorrect: Fluoroscopy is used to determine dislodgement of pacer leads after a pacemaker
insertion. Dislodgement can be prevented with bedrest and minimal arm and shoulder activity.
allow the primary care provider to adjust voltage settings. check placement of the pacer wires.
detect a dramatic change in heart rate.
, determine dislodgement of pacer leads.
5. The nurse is administering eye drops to a client. To prevent injury, the nurse
should:
Incorrect: The nurse should ask the client to "look up" before instilling the eye drops. This action
reduces stimulation of the corneal reflex and injury to the eye, should the client jerk away.
Incorrect: Eye drops should never bedropped directly onto the cornea as this action may injure
the cornea. The nurse should deposit the medication onto the lower conjunctiva.
Correct: As a safety precaution, the nurse administering eye drops should rest his hand on the
client's forehead. In case the client moves, the nurse's hand will move at the same time, lowering
the risk that the dropper will hit the client's eye.
Incorrect: When administering eye drops, it is essential to have an adequate amount of light.
However, the nurse should not shine a bright light directly into the client's eye. ask the client to
"look down" before instilling the eye drops. drop the eye drops directly onto the client's cornea.
rest his hand on the client's forehead. shine a bright light into the client's eye.
6. Which statement is true regarding the behavior of clients who are in pain?
Incorrect: Many clients avoid conversation and social contacts when they are experiencing pain.
Clients with chronic pain may become withdrawn and isolated.
Incorrect: Clients' reactions to pain are often influenced by their cultural and ethnic background.
The nurse needs to consider each client's cultural background when assessing a client's pain.
Incorrect: Clients often place their hands over the painful area as a self-protective or guarding
mechanism to prevent further pain.
Correct: Many clients fail to report or discuss their pain or discomfort with nurses and other
caretakers. Thus, the PN needs to assess clients for pain on a routine basis. Clients experiencing
pain may engage in social activities for distraction. Clients from different cultures react to pain in
the same way. Clients in pain usually avoid touching the painful area. Clients who are in pain
may not report their pain to the nurse or other caretakers.
7. A client is being discharged from same-day surgery following cataract
extraction from the right eye. The nurse will instruct the client to:
Correct: Lifting requires straining, which increases pressure in the eye and may disrupt suture
lines.
COMPREHENSIVE 2.0
1. Following abdominal surgery, a client's abdominal wound edges are
separating, and the wound is draining a large amount of serous drainage. The nurse should place
the client:
Incorrect: This position is incorrect because it can increase tension on the suture line, and cause
further wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it
can increase tension on the suture line, and cause further wound separation and tearing
(dehiscence).
Correct: The semi-Fowler's position decreases tension on the wound, and it may prevent
further separation and tearing of the wound(dehiscence). Incorrect: This position is incorrect
because it can increase tension on the suture line, and cause further wound separation and tearing
(dehiscence).
flat on the back with legs straight.
in high-Fowler's position with legs straight.
in semi-Fowler's position with the knees slightly bent.
on the left side with knees bent .
2. The PN is preparing to administer an enteral feeding to a client. To prevent
gastric cramping and discomfort due to the feeding, the nurse should:
Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via
gastrostomy tube, the formula reaches the stomach quickly, with little or no opportunity to be
warmed, as oral feedings would as they pass through the mouth and esophagus.Incorrect: Tube
placement is confirmed prior to beginning each feeding. This action does not prevent gastric
discomfort. However, checking tube placement does help prevent the infusion of the formula
into the lungs.
Incorrect: To prevent gastric discomfort, the concentration of the tube feeding formula needs to
,be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the
first few feedings areadministered.Incorrect: The head of the bed should be elevated at least 30°
during the feeding and for at least 30
minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent
cramping and discomfort.
allow time for the formula to reach room temperature prior to administration.
determine tube placement once every 24 hours.
prepare to administer full-strength rather than diluted formula.
elevate the head of the bed during and after feedings.
3. The nurse is caring for a child with cystic fibrosis (CF). Which intervention willhelp to
prevent respiratory complications?
Incorrect: Clients with CF should not receive cough suppressant syrups. These children need to
cough
frequently to clear lung secretions.
Correct: Nebulization with mist or aerosol therapy followed by chest physiotherapy helps to keep
secretions free-flowing. The pulmonary effects of CF are progressive, and bronchial secretions
must be kept moist.
Incorrect: The child should change positions frequently to promote drainage from the lungs, and
promote
aeration of the lungs.
Incorrect: Children with CF can safely receive the pertussis vaccine. These children need
protection from pertussis because this infection causes severe respiratory complications.
Encourage the use of cough suppressant syrup.
Give frequent nebulization treatments.
Limit changing the child's position to conserve the child's need for oxygen.
Withhold the vaccine for pertussis.
,4. The nurse is caring for a client following insertion of a pacemaker. The client isplaced on
continuous ECG monitoring because it will:
Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time
of insertion.
Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker
insertion.
Correct: The heart rate may change following pacemaker insertion because the pacemaker fails
to maintain the pre-set heartrate. This problem can be detected immediately with continuous
ECG monitoring.
Incorrect: Fluoroscopy is used to determine dislodgement of pacer leads after a pacemaker
insertion. Dislodgement can be prevented with bedrest and minimal arm and shoulder activity.
allow the primary care provider to adjust voltage settings. check placement of the pacer wires.
detect a dramatic change in heart rate.
, determine dislodgement of pacer leads.
5. The nurse is administering eye drops to a client. To prevent injury, the nurse
should:
Incorrect: The nurse should ask the client to "look up" before instilling the eye drops. This action
reduces stimulation of the corneal reflex and injury to the eye, should the client jerk away.
Incorrect: Eye drops should never bedropped directly onto the cornea as this action may injure
the cornea. The nurse should deposit the medication onto the lower conjunctiva.
Correct: As a safety precaution, the nurse administering eye drops should rest his hand on the
client's forehead. In case the client moves, the nurse's hand will move at the same time, lowering
the risk that the dropper will hit the client's eye.
Incorrect: When administering eye drops, it is essential to have an adequate amount of light.
However, the nurse should not shine a bright light directly into the client's eye. ask the client to
"look down" before instilling the eye drops. drop the eye drops directly onto the client's cornea.
rest his hand on the client's forehead. shine a bright light into the client's eye.
6. Which statement is true regarding the behavior of clients who are in pain?
Incorrect: Many clients avoid conversation and social contacts when they are experiencing pain.
Clients with chronic pain may become withdrawn and isolated.
Incorrect: Clients' reactions to pain are often influenced by their cultural and ethnic background.
The nurse needs to consider each client's cultural background when assessing a client's pain.
Incorrect: Clients often place their hands over the painful area as a self-protective or guarding
mechanism to prevent further pain.
Correct: Many clients fail to report or discuss their pain or discomfort with nurses and other
caretakers. Thus, the PN needs to assess clients for pain on a routine basis. Clients experiencing
pain may engage in social activities for distraction. Clients from different cultures react to pain in
the same way. Clients in pain usually avoid touching the painful area. Clients who are in pain
may not report their pain to the nurse or other caretakers.
7. A client is being discharged from same-day surgery following cataract
extraction from the right eye. The nurse will instruct the client to:
Correct: Lifting requires straining, which increases pressure in the eye and may disrupt suture
lines.
