ATI Final Exam
A nurse is teaching a client and his family how to care for the client's
tracheostomy
home. Which ofatthe following instructions is appropriate for the client
and family?
1. Remove the outer cannula cautiously for routine
cleaning.
2. Use tracheostomy covers when
outdoors.
3. Use sterile technique when performing tracheostomy care
at Cleanse
4. home. irritated skin with full-strength hydrogen peroxide. correct
answers 2. Usecovers when
tracheostomy
outdoors.
A nurse is giving an end-of-shift report about a client admitted earlier
that day withWhich of the following pieces of information is most essential
pneumonia.
to provide?
1. Admitting
diagnosis
2. Diagnostic test
results
3. Body
temperature
4. Breath sounds correct answers 4. Breath
sounds
**ABCs*
*
A nurse is checking blood pressures at a community health screening.
Which of the
following clients is at high risk for primary
hypertension?
1. A client who is
pregnant
2. A client who has an elevated
LDL
3. A client who takes oral
4. A client who has kidney disease correct answers 2. A client who has
contraceptives
an elevated
LDL
A nurse is planning care for a client who has had a stroke resulting in
aphasia andWhich of the following tasks should the nurse assign to an AP?
dysphagia.
(Select all
that
apply.)
- Assist the client with a partial bed
bath.
- Measure the client's BP after the nurse administers an antihypertensive
medication.
- Test the client's swallowing ability by providing
-thickened liquids.
Use a communication board to ask what the client wants
-for lunch.the client's indwelling urinary catheter. correct answers - Assist
Irrigate
the
a clientbed
partial with
bath.
- Measure the client's BP after the nurse administers an antihypertensive
medication.
- Use a communication board to ask what the client wants
for lunch.
,A nurse is caring for a client who is combative in the emergency
department.
provider Thewrist restraints after the client attempts to assault the
orders
admitting
Which nurse.
of the following actions is appropriate for the nurse
to take?
1. Tie restraints to the lower edge of the
side
2. rail. each restraint one at a time
Remove
every
3. 2 hr.3 finger-widths of space between the restraint and the
Ensure
client's
4. Use awrist.
square knot to securely tie the restraints to the bed. correct
answers each
Remove 2. restraint one at a time
every 2 hr.
**To perform ROM exercises and neurovascular
checks**
A nurse is preparing to administer morphine 4 mg IV bolus to a client.
Available is
morphine 5mg/mL. Which of the following is an appropriate nursing
intervention?
1. Return the unused medication to the automatic
dispensing
2. Keep thesystem.
remaining medication at the client's bedside for
later
3. use.a second nurse witness the disposal of remaining
Have
medication.
4. Lock remaining medication in secure cabinet. correct answers 3. Have
a second
nurse witness the disposal of remaining
medication.
A nurse is caring for a client who asks about the purpose of advance
directives.
of Which
the following is an appropriate response by the
nurse?
1. "It allows the court to overrule an adult client's refusal of medical
treatment."
2. "It permits a client to withhold medical information from health care
personnel."
3. "It indicates the form of treatment a client is willing to accept in the event
of a serious
illness.
"4. "It allows health care personnel in the emergency department to
stabilize a client's
condition." correct answers 3. "It indicates the form of treatment a client
is willing
accept in to
the event of a serious
illness."
A nurse finds a client on the floor upon entering the client's room. The
roommate
that reports
the client was trying to get out of bed and fell over the bedrail onto the
floor.
of theWhich
following is correct documentation of this
incident?
1. Incident report
completed.
2. Client climbed over the
bedrails.
3. Client found lying on
floor.
4. Client was trying to get out of bed. correct answers 3. Client found
lying on floor.
**remember, be Objective in
documentation**
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0
to 10. understands
nurse The that the preoperative teaching regarding pain
control has
effective whenbeenthe client states which of the
following?
,1. "I think I should take my pain medication more often, since it is not
controlling my
pain.
"2. "Breathing faster will help me keep my mind off of
the"Itpain."
3. may help me to listen to music while I'm lying
in bed."
4. "I don't want to walk today, because I'm experiencing some pain." correct
answers
"It may help3. me to listen to music while I'm lying
in bed."
**nonpharmacological intervention to
pain**
A client demonstrates anger when the nurse does not respond within 5 min
of ringing
the nurse.for
Which of the following is an appropriate response by
the nurse?
1. "I'm sorry, but another client needed my
attention."
2. "I arrived as soon as I could. What can I do for
you?"
3. "It must be frustrating. I have a few
minutes
4. "We had now."
an emergency on the unit, but now I'm here." correct answers 3.
"It must be I have a few minutes
frustrating.
now."
**therapeutic by acknowledging client's
feelings**
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 discharge
planning?
1. During the admission
process
2. As soon as the client's condition is
stable
3. During the initial team
conference
4. After consulting with the client's family correct answers 1. During the
admission
proces
s
**discharge planning starts at admission (patient needs for during and
after hospital)**
A nurse manager is overseeing the care of a unit. Which of the following
shouldmanager
nurse the identify as a violation of HIPPA
guidelines?
1. The assigned nurse reviews the medical chart with a nursing
2. A nursing student discusses a client's status with the assigned nurse at
student.
theThe
3. bedside.
assigned nurse returns a call to a client's Power of Attorney to
discuss the
client's
care.
4. A nursing student consults a former classmate to assist with her
documentation.
correct answers 4. A nursing student consults a former classmate to
assist with her
documentatio
n.
**only those in direct
care**
, A nurse is teaching a client about self-administering NPH insulin. Which of
the following
actions by the client indicates a need for further
teaching?
1. The client inserts the needle at a 30°-
angle.
2. The client rolls the vial between both
hands.
3. The client holds the syringe in place for 5 seconds following
injection.
4. The client uses her anterior thigh as the injection site. correct answers
1. The client
inserts the needle at a 30°-
angle.
**Insert needle at 45° to 90° (depending on adipose/fat
tissue)**
A nurse is reviewing a client's fluid and electrolyte status. Which of the
following
should thefindings
nurse report to the
provider?
1. BUN 15
mg/dL
2. Creatinine 0.8
mg/dL
3. Sodium 143
mEq/L
4. Potassium 5.4 mEq/L correct answers 4. Potassium 5.4
mEq/L
**Electrolytes
(ranges):**
Sodium ~ 135-145
mEq/L
Chloride ~ 95-105
mEq/L
Potassium ~ 3.5-5.0
mEq/L
Bicarbonate ~ 22-28
mEq/L
Magnesium ~ 1.5-2.0
mEq/L
A nurse contacts the facility's interpreter to explain a therapeutic
procedure
who does notfor speak
a clientEnglish. Which of the following guidelines should the
nurse working
when follow with the
interpreter?
1. Speak slowly to allow the interpreter to interpret
each
2. word.the purpose of the communication to the
Explain
interpreter.
3. Address the interpreter when explaining the procedure
information.
4. Supplement words with gestures and nonverbal reinforcement. correct
answersthe
Explain 2. purpose of the communication to the
interpreter.
A nurse is preparing to perform nasopharyngeal suctioning for a client who
is unable
cough up to
excessive secretions. Which of the following actions is
appropriate?
1. Use the clean technique throughout the
procedure.
2. Insert the catheter as the client
exhales.
3. Apply suction for up the 20
seconds.
4. Perform suctioning while removing the catheter. correct answers
4. Perform while removing the
suctioning
catheter.
A nurse is teaching a client and his family how to care for the client's
tracheostomy
home. Which ofatthe following instructions is appropriate for the client
and family?
1. Remove the outer cannula cautiously for routine
cleaning.
2. Use tracheostomy covers when
outdoors.
3. Use sterile technique when performing tracheostomy care
at Cleanse
4. home. irritated skin with full-strength hydrogen peroxide. correct
answers 2. Usecovers when
tracheostomy
outdoors.
A nurse is giving an end-of-shift report about a client admitted earlier
that day withWhich of the following pieces of information is most essential
pneumonia.
to provide?
1. Admitting
diagnosis
2. Diagnostic test
results
3. Body
temperature
4. Breath sounds correct answers 4. Breath
sounds
**ABCs*
*
A nurse is checking blood pressures at a community health screening.
Which of the
following clients is at high risk for primary
hypertension?
1. A client who is
pregnant
2. A client who has an elevated
LDL
3. A client who takes oral
4. A client who has kidney disease correct answers 2. A client who has
contraceptives
an elevated
LDL
A nurse is planning care for a client who has had a stroke resulting in
aphasia andWhich of the following tasks should the nurse assign to an AP?
dysphagia.
(Select all
that
apply.)
- Assist the client with a partial bed
bath.
- Measure the client's BP after the nurse administers an antihypertensive
medication.
- Test the client's swallowing ability by providing
-thickened liquids.
Use a communication board to ask what the client wants
-for lunch.the client's indwelling urinary catheter. correct answers - Assist
Irrigate
the
a clientbed
partial with
bath.
- Measure the client's BP after the nurse administers an antihypertensive
medication.
- Use a communication board to ask what the client wants
for lunch.
,A nurse is caring for a client who is combative in the emergency
department.
provider Thewrist restraints after the client attempts to assault the
orders
admitting
Which nurse.
of the following actions is appropriate for the nurse
to take?
1. Tie restraints to the lower edge of the
side
2. rail. each restraint one at a time
Remove
every
3. 2 hr.3 finger-widths of space between the restraint and the
Ensure
client's
4. Use awrist.
square knot to securely tie the restraints to the bed. correct
answers each
Remove 2. restraint one at a time
every 2 hr.
**To perform ROM exercises and neurovascular
checks**
A nurse is preparing to administer morphine 4 mg IV bolus to a client.
Available is
morphine 5mg/mL. Which of the following is an appropriate nursing
intervention?
1. Return the unused medication to the automatic
dispensing
2. Keep thesystem.
remaining medication at the client's bedside for
later
3. use.a second nurse witness the disposal of remaining
Have
medication.
4. Lock remaining medication in secure cabinet. correct answers 3. Have
a second
nurse witness the disposal of remaining
medication.
A nurse is caring for a client who asks about the purpose of advance
directives.
of Which
the following is an appropriate response by the
nurse?
1. "It allows the court to overrule an adult client's refusal of medical
treatment."
2. "It permits a client to withhold medical information from health care
personnel."
3. "It indicates the form of treatment a client is willing to accept in the event
of a serious
illness.
"4. "It allows health care personnel in the emergency department to
stabilize a client's
condition." correct answers 3. "It indicates the form of treatment a client
is willing
accept in to
the event of a serious
illness."
A nurse finds a client on the floor upon entering the client's room. The
roommate
that reports
the client was trying to get out of bed and fell over the bedrail onto the
floor.
of theWhich
following is correct documentation of this
incident?
1. Incident report
completed.
2. Client climbed over the
bedrails.
3. Client found lying on
floor.
4. Client was trying to get out of bed. correct answers 3. Client found
lying on floor.
**remember, be Objective in
documentation**
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0
to 10. understands
nurse The that the preoperative teaching regarding pain
control has
effective whenbeenthe client states which of the
following?
,1. "I think I should take my pain medication more often, since it is not
controlling my
pain.
"2. "Breathing faster will help me keep my mind off of
the"Itpain."
3. may help me to listen to music while I'm lying
in bed."
4. "I don't want to walk today, because I'm experiencing some pain." correct
answers
"It may help3. me to listen to music while I'm lying
in bed."
**nonpharmacological intervention to
pain**
A client demonstrates anger when the nurse does not respond within 5 min
of ringing
the nurse.for
Which of the following is an appropriate response by
the nurse?
1. "I'm sorry, but another client needed my
attention."
2. "I arrived as soon as I could. What can I do for
you?"
3. "It must be frustrating. I have a few
minutes
4. "We had now."
an emergency on the unit, but now I'm here." correct answers 3.
"It must be I have a few minutes
frustrating.
now."
**therapeutic by acknowledging client's
feelings**
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 discharge
planning?
1. During the admission
process
2. As soon as the client's condition is
stable
3. During the initial team
conference
4. After consulting with the client's family correct answers 1. During the
admission
proces
s
**discharge planning starts at admission (patient needs for during and
after hospital)**
A nurse manager is overseeing the care of a unit. Which of the following
shouldmanager
nurse the identify as a violation of HIPPA
guidelines?
1. The assigned nurse reviews the medical chart with a nursing
2. A nursing student discusses a client's status with the assigned nurse at
student.
theThe
3. bedside.
assigned nurse returns a call to a client's Power of Attorney to
discuss the
client's
care.
4. A nursing student consults a former classmate to assist with her
documentation.
correct answers 4. A nursing student consults a former classmate to
assist with her
documentatio
n.
**only those in direct
care**
, A nurse is teaching a client about self-administering NPH insulin. Which of
the following
actions by the client indicates a need for further
teaching?
1. The client inserts the needle at a 30°-
angle.
2. The client rolls the vial between both
hands.
3. The client holds the syringe in place for 5 seconds following
injection.
4. The client uses her anterior thigh as the injection site. correct answers
1. The client
inserts the needle at a 30°-
angle.
**Insert needle at 45° to 90° (depending on adipose/fat
tissue)**
A nurse is reviewing a client's fluid and electrolyte status. Which of the
following
should thefindings
nurse report to the
provider?
1. BUN 15
mg/dL
2. Creatinine 0.8
mg/dL
3. Sodium 143
mEq/L
4. Potassium 5.4 mEq/L correct answers 4. Potassium 5.4
mEq/L
**Electrolytes
(ranges):**
Sodium ~ 135-145
mEq/L
Chloride ~ 95-105
mEq/L
Potassium ~ 3.5-5.0
mEq/L
Bicarbonate ~ 22-28
mEq/L
Magnesium ~ 1.5-2.0
mEq/L
A nurse contacts the facility's interpreter to explain a therapeutic
procedure
who does notfor speak
a clientEnglish. Which of the following guidelines should the
nurse working
when follow with the
interpreter?
1. Speak slowly to allow the interpreter to interpret
each
2. word.the purpose of the communication to the
Explain
interpreter.
3. Address the interpreter when explaining the procedure
information.
4. Supplement words with gestures and nonverbal reinforcement. correct
answersthe
Explain 2. purpose of the communication to the
interpreter.
A nurse is preparing to perform nasopharyngeal suctioning for a client who
is unable
cough up to
excessive secretions. Which of the following actions is
appropriate?
1. Use the clean technique throughout the
procedure.
2. Insert the catheter as the client
exhales.
3. Apply suction for up the 20
seconds.
4. Perform suctioning while removing the catheter. correct answers
4. Perform while removing the
suctioning
catheter.
