[NSG 261 ATI Comp Test A]
NSG 261 ATI Comp Test A
Study online at https://quizlet.com/_ehr1br
1. A nurse is caring for a client The nurse should first address the client's
who is in the spinal cord in- oxygen saturation
jury (SCI) unit. followed by the client's
urinary output
CORRECT
2. The nurse should first ad- Fiber
dress the client's
oxygen saturation The nurse should instruct the client who has Crohn's disease and
followed by the client's an enteroenteric fistula to consume a low-fiber diet to reduce
urinary output diarrhea and inflammation.
.
3. A nurse is caring for a When analyzing cues, the nurse should identify that manifes-
school-age child. tations of ADHD include losing necessary things, interrupting
others, intellectual impairment, and hyper reactivity to sensory
input. In ADHD, the client often loses necessary things in daily life,
such as pencils, erasers, and books. The client often interrupts
others and has difficulty waiting for their turn in conversation.
The client might have an intellectual impairment, which can lead
to poor academic performance and difficulties with socialization.
The client might exhibit hyperreactivity or hyporeactivity to stim-
uli.
4. Teaching home wound care Double bag
to a family with large wound The client should double-bag soiled dressings in plastic bags
to prevent the spread of micro-organisms to other household
members.
5. A nurse is caring for a Upon recognizing and analyzing the client cues of hypoactive
68-year-old client who is 2 bowel sounds in all quadrants, abdominal distention, change
days postoperative following in pain from intermittent to constant, and last bowel movement
4/16/2026, 4:58:38 PM 4/16/2026,:58:36 PM 4/16/2026, 4:58:34 PM
, [NSG 261 ATI Comp Test A]
NSG 261 ATI Comp Test A
Study online at https://quizlet.com/_ehr1br
surgical repair of a left hip 5 days ago, the nurse's primary hypothesis should be that the
fracture. client is most likely experiencing intestinal obstruction. It is im-
portant to generate solutions and actions that relieve the pres-
sure from abdominal distention to promote lung expansion and
to reduce the risk of developing fluid and electrolyte imbalances
because the client is NPO. Therefore, the nurse should assist
the client to semi-Fowler's position and prepare to administer
IV fluids as prescribed. The nurse should assess bowel sounds
at least twice daily for the return of peristalsis and monitor urine
output because the client is receiving IV fluids. A manifestation
of intestinal obstruction is dehydration.
6. A nurse is caring for a When recognizing cues, the nurse should identify that the child
3-year-old child who has a is at risk for developing skin breakdown and infection due to the
gastrostomy tube. gastrostomy tube site. The gastrostomy tube site is red and there
is drainage from the site, which could lead to skin breakdown.
The child has also developed a fever, which could indicate infec-
tion.
7. A nurse is caring for a new- The nurse should plan to first assess the newborn's
born. respiratory rate
, followed by the newborn's
heart rate
.
When generating solutions, the nurse should identify that ex-
piratory grunting and nasal flaring are unexpected findings in
a newborn and indicate respiratory distress. The presence of
meconium-stained amniotic fluid increases the risk that the new-
born will develop meconium aspiration syndrome. Therefore, the
first action the nurse should take is to assess the newborn's res-
piratory rate, followed by the heart rate. The nurse should per-
4/16/2026, 4:58:38 PM 4/16/2026,:58:36 PM 4/16/2026, 4:58:34 PM
, [NSG 261 ATI Comp Test A]
NSG 261 ATI Comp Test A
Study online at https://quizlet.com/_ehr1br
form noninvasive assessments, such as observing the respiratory
rate, before more invasive assessments that might stimulate the
newborn, such as auscultating the heart rate, to avoid alteration
of data.
8. A nurse is caring for a client in When generating solutions and planning care for a client who
the emergency department is experiencing alcohol withdrawal, the nurse should plan inter-
(ED). ventions that keep the client safe and treat the physical manifes-
tations of alcohol withdrawal. The nurse should use the CIWA-Ar
Client presents with acute al- screening tool to determine the severity of withdrawal. With-
tered mental status. Client drawal seizures can occur 12 to 24 hr after cessation of alcohol
has a history of frequent ED use; therefore, the nurse should initiate seizure precautions to
visits for alcohol intoxication. prevent client injury. The nurse should plan to administer chlor-
Client states that they had diazepoxide, a benzodiazepine, to decrease agitation, hallucina-
an episode of binge drinking tions, and tremors. The nurse should place the client in a quiet
yesterday afternoon. Client environment with minimal stimuli to decrease agitation and the
awoke this morning on the risk for seizures. The nurse should administer thiamine to prevent
living room floor trembling Wernicke syndrome.
and flushed; remembers hav-
ing intense dreams and was
afraid they had a seizure so
they called a family mem-
ber to bring them to the
ED.Client reports their aver-
age alcohol intake has been
"two or three beers" after
work each day and "more
on the weekends" for the
past 6 months.Client reports
headache, nausea, agitation,
and is noted to be diaphoret-
ic.0800:
4/16/2026, 4:58:38 PM 4/16/2026,:58:36 PM 4/16/2026, 4:58:34 PM
NSG 261 ATI Comp Test A
Study online at https://quizlet.com/_ehr1br
1. A nurse is caring for a client The nurse should first address the client's
who is in the spinal cord in- oxygen saturation
jury (SCI) unit. followed by the client's
urinary output
CORRECT
2. The nurse should first ad- Fiber
dress the client's
oxygen saturation The nurse should instruct the client who has Crohn's disease and
followed by the client's an enteroenteric fistula to consume a low-fiber diet to reduce
urinary output diarrhea and inflammation.
.
3. A nurse is caring for a When analyzing cues, the nurse should identify that manifes-
school-age child. tations of ADHD include losing necessary things, interrupting
others, intellectual impairment, and hyper reactivity to sensory
input. In ADHD, the client often loses necessary things in daily life,
such as pencils, erasers, and books. The client often interrupts
others and has difficulty waiting for their turn in conversation.
The client might have an intellectual impairment, which can lead
to poor academic performance and difficulties with socialization.
The client might exhibit hyperreactivity or hyporeactivity to stim-
uli.
4. Teaching home wound care Double bag
to a family with large wound The client should double-bag soiled dressings in plastic bags
to prevent the spread of micro-organisms to other household
members.
5. A nurse is caring for a Upon recognizing and analyzing the client cues of hypoactive
68-year-old client who is 2 bowel sounds in all quadrants, abdominal distention, change
days postoperative following in pain from intermittent to constant, and last bowel movement
4/16/2026, 4:58:38 PM 4/16/2026,:58:36 PM 4/16/2026, 4:58:34 PM
, [NSG 261 ATI Comp Test A]
NSG 261 ATI Comp Test A
Study online at https://quizlet.com/_ehr1br
surgical repair of a left hip 5 days ago, the nurse's primary hypothesis should be that the
fracture. client is most likely experiencing intestinal obstruction. It is im-
portant to generate solutions and actions that relieve the pres-
sure from abdominal distention to promote lung expansion and
to reduce the risk of developing fluid and electrolyte imbalances
because the client is NPO. Therefore, the nurse should assist
the client to semi-Fowler's position and prepare to administer
IV fluids as prescribed. The nurse should assess bowel sounds
at least twice daily for the return of peristalsis and monitor urine
output because the client is receiving IV fluids. A manifestation
of intestinal obstruction is dehydration.
6. A nurse is caring for a When recognizing cues, the nurse should identify that the child
3-year-old child who has a is at risk for developing skin breakdown and infection due to the
gastrostomy tube. gastrostomy tube site. The gastrostomy tube site is red and there
is drainage from the site, which could lead to skin breakdown.
The child has also developed a fever, which could indicate infec-
tion.
7. A nurse is caring for a new- The nurse should plan to first assess the newborn's
born. respiratory rate
, followed by the newborn's
heart rate
.
When generating solutions, the nurse should identify that ex-
piratory grunting and nasal flaring are unexpected findings in
a newborn and indicate respiratory distress. The presence of
meconium-stained amniotic fluid increases the risk that the new-
born will develop meconium aspiration syndrome. Therefore, the
first action the nurse should take is to assess the newborn's res-
piratory rate, followed by the heart rate. The nurse should per-
4/16/2026, 4:58:38 PM 4/16/2026,:58:36 PM 4/16/2026, 4:58:34 PM
, [NSG 261 ATI Comp Test A]
NSG 261 ATI Comp Test A
Study online at https://quizlet.com/_ehr1br
form noninvasive assessments, such as observing the respiratory
rate, before more invasive assessments that might stimulate the
newborn, such as auscultating the heart rate, to avoid alteration
of data.
8. A nurse is caring for a client in When generating solutions and planning care for a client who
the emergency department is experiencing alcohol withdrawal, the nurse should plan inter-
(ED). ventions that keep the client safe and treat the physical manifes-
tations of alcohol withdrawal. The nurse should use the CIWA-Ar
Client presents with acute al- screening tool to determine the severity of withdrawal. With-
tered mental status. Client drawal seizures can occur 12 to 24 hr after cessation of alcohol
has a history of frequent ED use; therefore, the nurse should initiate seizure precautions to
visits for alcohol intoxication. prevent client injury. The nurse should plan to administer chlor-
Client states that they had diazepoxide, a benzodiazepine, to decrease agitation, hallucina-
an episode of binge drinking tions, and tremors. The nurse should place the client in a quiet
yesterday afternoon. Client environment with minimal stimuli to decrease agitation and the
awoke this morning on the risk for seizures. The nurse should administer thiamine to prevent
living room floor trembling Wernicke syndrome.
and flushed; remembers hav-
ing intense dreams and was
afraid they had a seizure so
they called a family mem-
ber to bring them to the
ED.Client reports their aver-
age alcohol intake has been
"two or three beers" after
work each day and "more
on the weekends" for the
past 6 months.Client reports
headache, nausea, agitation,
and is noted to be diaphoret-
ic.0800:
4/16/2026, 4:58:38 PM 4/16/2026,:58:36 PM 4/16/2026, 4:58:34 PM
