ATI_Practice_Test_B

1. A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? a. Talk directly to the client, instead of the interpreter, when speaking. b. Use a family member as the client's interpreter. c. Make sure that the interpreter has a college degree. d. Avoid asking the client personal questions through the interpreter. 2. A nurse is reviewing evidence-based practice principle about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. b. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. c. Make sure the reservoir bag of a partial rebreathing mask remains deflated. d. Use petroleum jelly to lubricate the client's nares, face, and lips. 3. A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? a. Loss of skin turgor on the back of the hands b. Varicosities on the lower extremities c. Thick, discolored nails with ridges d. Bruises on the arms in various stages of healing 4. A nurse is calculating a client’s fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client’s intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips – 4 oz of water = 120 mL of fluid. The nurse should ½ the volume of ice when calculating fluid intake to account for the air between the chips. d. 6 oz of tea 5. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? a. Reduce dietary sodium. b. Administer a loop diuretic. c. Evaluate electrolytes. d. Restrict intake of oral fluids. 6. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the client was trying to get out of a bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident? a. "Incident report completed." b. "Client climbed over the bedrails." c. "Client found lying on floor." d. "Client was trying to get out of bed." 7. A nurse in a provider’s office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client? a. "Rashes are very common, especially if you have dry skin. Did it go away on its own?" b. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic." c. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash." d. "We need to document the exact medication you were taking because you might be allergic to it." 8. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to the chair/ After securing a safe environment, which of the following actions should the nurse take next? a. Rock the client up to a standing position. b. Pivot on the foot that is the farthest from the chair. c. Assess the client for orthostatic hypotension. d. Apply a gait belt to the client. 9. A nurse receives report about a client who has 0.9% NaCl infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first? a. Reposition the client. b. Document the client's IV intake in the medical record. c. Request a new IV fluid prescription. d. Check the IV tubing for obstruction. 10. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client’s plan of care? a. Wrap blankets around all four sides of the bed. b. Apply restraints during seizure activity. c. Place the client in a supine position during seizure activity. - side This study source doHwanvloeadaedtobny g10u0e00d0e8p03r7e3s8s4o17r farot mthCeocurliseeHnet'dsonid0e6.-2–9-d20o2n1’t11in:1s7e:1r9t aGnMyTth-0in5g:00in mouth 11. A nurse working in the emergency dept is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals’ signatures may the nurse legally witness? a. A teacher who brings in a 7-year-old student is incorrect. Only a parent, legal guardian, or, in emergency situations, a grandparent or adult sibling, can legally give consent for medical treatment of a young child. b. A 16-year-old client who is married is correct. A minor who is married is emancipated and can give consent for his own treatment. c. A 27-year-old client who has schizophrenia is correct. An adult client who requires psychiatric care can give consent for her own care unless the court has determined the client to be incompetent. d. An adoptive parent who brings in his 8-year-old son is correct. The adoptive parent of a child is a parent and legal guardian and can sign to give consent for the child's care. e. A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor can legally give consent for the medical treatment of her child. 12. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? a. Albumin level of 3 g/dL - An albumin level below 3.5 g/dL indicates protein deficiency, placing the client at risk for pressure ulcer formation and poor wound healing. b. HDL level of 90 mg/dL - A high-density lipoprotein level above 60 mg/dL indicates a desirable level of protection against coronary artery disease. c. Norton scale score of 18 - The Norton scale measures pressure ulcer risk based on physical condition, mental condition, activity, mobility, and incontinence. A score of 16 or less indicates pressure ulcer risk. d. Braden scale score of 20 - The Braden scale measures pressure ulcer risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A score below 18 indicates pressure ulcer risk. 13. A nurse is caring for a client who is postop and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client’s vital sins every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? a. Document the provider's statement in the medical record. b. Notify the nursing manager. - The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care is provided to the client. c. Consult the facility's risk manager. d. Complete an incident report. ........................................................................................CONTINUED