ATI Exams A and B - 220
Study online at https://quizlet.com/_alzpqg
1. A nurse in a clinic is interviewing a client who will undergo diagnostic testing.
The nurse should ask about a client's potential allergies during which phase
of the nursing process?: Assessment
The assessment phase includes asking the client about her health history, physical concerns and health care
expectations. A review of possible allergies is included in the assessment phase.
2. A charge nurse is anticipating the admission of four clients and planning
their room assignments. Which of the following clients should the nurse
assign to the room closest to the nurses' station?: A client who sustained a head injury
and is having periods of confusion
A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room
near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs
3. A nurse is caring for a client who refuses treatment and asks to be dis-
charged from the hospital against medical advice. The nurse notifies the
client's provider, who tells the nurse to restrain the client, if necessary, to
keep her from leaving the hospital. The nurse understands that restraining
this client would be considered which type of civil action by the nurse?: False
imprisonment
False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment
against medical advice and leave the hospital.
4. A nurse is performing tracheostomy care for a client and suctioning to
remove copious secretions. Which of the following actions should the nurse
take?: Suction two to three times with a 60-second pause between passes.
Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed
between passes to prevent hypoxia.
5. A nurse is preparing a client for outpatient surgery. After the nurse inserts
the IV catheter, the client reports pain in the insertion area. Which of the
following actions should the nurse take?: Remove the catheter and insert another into a different
site.
, ATI Exams A and B - 220
Study online at https://quizlet.com/_alzpqg
It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter
insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.
6. A nurse is caring for a client who has fallen while getting out of bed and
states, "I'm okay! I guess I should have called for help to the bathroom." After
assessing the client, the nurse notifies the provider. Which of the following
documentation should the nurse include in the client's medical record?: "The
provider was notified."
Nursing interventions that support factual information should be documented in the health record.
7. A nurse is caring for a client who experienced a lacerated spleen and has
been on bedrest for several days. The nurse auscultates decreased breath
sounds in the lower lobes of both lungs. The nurse should realize that this
finding is most likely an indication of which of the following conditions?: Atelec-
tasis
Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by
hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease
are risk factors for the development of atelectasis.
8. A nurse is assisting with transferring a client from the bed to a wheelchair.
Which of the following actions should the nurse take?: Lock the wheels of the bed and
the wheelchair.
The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving
when transferring a client.
9. A nurse is planning care for a client who has a decreased level of conscious-
ness. The client is receiving continuous enteral feedings via a gastrostomy
tube due to an inability to swallow. Which of the following is the priority action
by the nurse?: Elevate the head of the client's bed 30° to 45°.
A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also
increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote
gastric emptying and reduce the risk of aspiration.
, ATI Exams A and B - 220
Study online at https://quizlet.com/_alzpqg
10. A nurse is reviewing information about the Health Insurance Portability
and Accountability Act (HIPAA) with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates a need for further
teaching?: "Information about a client can be disclosed to family members at any time."
This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of
his or her own personal health information.
11. A nurse is caring for a client who has an NG tube. The nurse tests the pH
of the secretions to determine if the tube is correctly placed. Which of the
following readings should the nurse expect?: 4.0
This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.
12. A nurse at an extended-care facility is instructing a class of assistive person-
nel (AP) about client use of assistive devices during ambulation. Which of the
following instructions should the nurse give the APs about the clients' use of
a cane?: "When the client moves, he should move the cane forward first."
When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak
leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.
13. A nurse enters an older adult client's room to insert a saline lock. The client
asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of
the following responses should the nurse provide?: "Your provider has prescribed antibiotic
therapy to be administered intravenously every 6 hours."
Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate
between medication administrations, enhances client safety and promotes comfort. The response addresses the
client's concern.
14. A nurse is working with a licensed practical nurse (LPN) to care for a client
who is receiving a continuous IV infusion. Which of the following findings
reported by the LPN indicates to the nurse the client has phlebitis at the IV
insertion site?: "The area surrounding the insertion site feels warm to the touch."
Study online at https://quizlet.com/_alzpqg
1. A nurse in a clinic is interviewing a client who will undergo diagnostic testing.
The nurse should ask about a client's potential allergies during which phase
of the nursing process?: Assessment
The assessment phase includes asking the client about her health history, physical concerns and health care
expectations. A review of possible allergies is included in the assessment phase.
2. A charge nurse is anticipating the admission of four clients and planning
their room assignments. Which of the following clients should the nurse
assign to the room closest to the nurses' station?: A client who sustained a head injury
and is having periods of confusion
A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room
near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs
3. A nurse is caring for a client who refuses treatment and asks to be dis-
charged from the hospital against medical advice. The nurse notifies the
client's provider, who tells the nurse to restrain the client, if necessary, to
keep her from leaving the hospital. The nurse understands that restraining
this client would be considered which type of civil action by the nurse?: False
imprisonment
False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment
against medical advice and leave the hospital.
4. A nurse is performing tracheostomy care for a client and suctioning to
remove copious secretions. Which of the following actions should the nurse
take?: Suction two to three times with a 60-second pause between passes.
Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed
between passes to prevent hypoxia.
5. A nurse is preparing a client for outpatient surgery. After the nurse inserts
the IV catheter, the client reports pain in the insertion area. Which of the
following actions should the nurse take?: Remove the catheter and insert another into a different
site.
, ATI Exams A and B - 220
Study online at https://quizlet.com/_alzpqg
It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter
insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.
6. A nurse is caring for a client who has fallen while getting out of bed and
states, "I'm okay! I guess I should have called for help to the bathroom." After
assessing the client, the nurse notifies the provider. Which of the following
documentation should the nurse include in the client's medical record?: "The
provider was notified."
Nursing interventions that support factual information should be documented in the health record.
7. A nurse is caring for a client who experienced a lacerated spleen and has
been on bedrest for several days. The nurse auscultates decreased breath
sounds in the lower lobes of both lungs. The nurse should realize that this
finding is most likely an indication of which of the following conditions?: Atelec-
tasis
Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by
hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease
are risk factors for the development of atelectasis.
8. A nurse is assisting with transferring a client from the bed to a wheelchair.
Which of the following actions should the nurse take?: Lock the wheels of the bed and
the wheelchair.
The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving
when transferring a client.
9. A nurse is planning care for a client who has a decreased level of conscious-
ness. The client is receiving continuous enteral feedings via a gastrostomy
tube due to an inability to swallow. Which of the following is the priority action
by the nurse?: Elevate the head of the client's bed 30° to 45°.
A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also
increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote
gastric emptying and reduce the risk of aspiration.
, ATI Exams A and B - 220
Study online at https://quizlet.com/_alzpqg
10. A nurse is reviewing information about the Health Insurance Portability
and Accountability Act (HIPAA) with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates a need for further
teaching?: "Information about a client can be disclosed to family members at any time."
This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of
his or her own personal health information.
11. A nurse is caring for a client who has an NG tube. The nurse tests the pH
of the secretions to determine if the tube is correctly placed. Which of the
following readings should the nurse expect?: 4.0
This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.
12. A nurse at an extended-care facility is instructing a class of assistive person-
nel (AP) about client use of assistive devices during ambulation. Which of the
following instructions should the nurse give the APs about the clients' use of
a cane?: "When the client moves, he should move the cane forward first."
When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak
leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.
13. A nurse enters an older adult client's room to insert a saline lock. The client
asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of
the following responses should the nurse provide?: "Your provider has prescribed antibiotic
therapy to be administered intravenously every 6 hours."
Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate
between medication administrations, enhances client safety and promotes comfort. The response addresses the
client's concern.
14. A nurse is working with a licensed practical nurse (LPN) to care for a client
who is receiving a continuous IV infusion. Which of the following findings
reported by the LPN indicates to the nurse the client has phlebitis at the IV
insertion site?: "The area surrounding the insertion site feels warm to the touch."
