NURS 251 ATI PROCTORED 2024 UPDATE ACTUAL EXAM ALL
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
A nurse is performing chest physiotherapy for a client who needs help mobilizing and
expectorating thick pulmonary secretions. To increase the turbulence of the air the client
exhales, the nurse should use which of the following techniques?
1) Vibration
2) Percussion
3) Nebulization
4) Postural Drainage - Vibration
---> used during or after percussion to increase the turbulence of exhaled air and loosen
secretions
A nurse is caring for a client who has a trach tube in place. During trach care, which of
the following should the nurse place underneath the flange of the outer cannula?
1) Commercially prepared transparent dressing
2) Cotton-filled gauze square
3) Commercially prepared fenestrated dressing
4) Twill tape - Commercially prepared fenestrated dressing
---> made of material that does not unravel and has a fenestration slit designed to fit
around the trach tube under flanges
A nurse is caring for a client who has a cuffed endotracheal tube in place. Which of the
following actions should the nurse plan to take?
1) Repositioning the ET tube in the client's mouth every 12 hr
2) providing oral care every 24 hour
3) Applying the securing tape over the client's ears
4) Maintaining a cuff pressure of 35 mm Hg - Repositioning the ET tube in the client's
mouth every 12 hr
---> helps prevent irritation to the oral mucous membranes
A nurse started a transfusion of packed RBCs for a client 1 hr ago. The client has
suddenly developed shaking chills, muscle stiffness, and a temperature of 101.5 F. The
client appears flushed and reports a headache and "nervousness". The nurse should
identify that the client has most likely developed which of the following types of
transfusion reaction?
1) Septic
2) Acute hemolytic
3) allergic
4) Febrile nonhemolytic - Febrile nonhemolytic
---> fever usually develops within 2 hrs after the transfusion has started. Other classic
symptoms include chills, headache, flushing, anxiety, and muscle pain
,A platelet transfusion is indicated for a patient who
1) has a systemic infection
2) has thrombocytopenia
3) is in hypovolemic shock
4) has hemolytic anemia - Has thrombocytopenia
---> low platelet count (drops below 20,000)
A nurse is providing education to a client who has a prescription for a blood transfusion.
Which of the following statements should the nurse include in the teaching?
1) "I will check your vitals every 15 min throughout the blood transfusion"
2) "I might have a nursing assistant check on you periodically during transfusion"
3) "If you have no adverse effects in the first 15-30 min, you will not have any adverse
effects later"
4) "You must immediately report any symptoms like chills, nausea, or itching" - You
must immediately report any symptoms like chills, nausea, or itching
A nurse is preparing a blood transfusion for a client who has type A blood. The nurse
should know that the client can safely receive blood from blood group O because
1) type O blood contains no A antigens
2) Type A blood contains O antibodies
3) Type O blood contains no A antibodies
4) type A blood contains O antigens - Type O blood contains no A antigens
A nurse is preparing to initiate the transfusion of a unit of packed RBCs to a client. After
the unit of blood has arrived, which of the following procedures will help the nurse
protect the client against the possibility of a blood-group incompatability?
1) Comparing the ID numbers on the blood unit with those on the order form and the
client's wrist band
2) Obtaining a blood sample from the client for typing and crossmatching
3) Giving a prescribed pre-med 30 min prior to starting the transfusion
4) observing the client 15-30 min after the transfusion is initiated - Comparing the ID
numbers on the blood unit with those on the order form and the client's wrist band
A nurse is suctioning a client's airway using in-line suctioning. Which of the following
actions should the nurse plan to take?
1) Hyperoxygenate the client before disconnecting the ventilator
2) Apply suction pressure while advancing the catheter
3) Wear a face shield during the procedure
4) Reuse the catheter repeatedly - 4) Reuse the catheter repeatedly
---> with in-line suctioning, the catheter attaches to the ventilator tubing and does not
need to be replaced until the system is replaced. It can be used repeatedly
A nurse is preparing to suction a client's tracheostomy. Which of the following actions
should the nurse take?
, 1) Suction for 30 seconds with each pass
2) allow 2 min in between suctioning to reoxygenate the lungs
3) Use a rotating motion when inserting the catheter from the trach
4) Set the suction pressure to 180 mmHg - 2) Allow 2 min in between suctioning to
reoxygenate the lungs
---> allow the client to cough and deep breathe and allow the lungs to reoxygenate
a nurse is preparing to suction a client's oral airway. Which of the following devices or
methods should the nurse use?
1) in-line suctioning
2) Yankauer catheter
3) Bulb syringe
4) Open suctioning - Yankauer Catheter
---> helps clear secretions from the mouth. This is the appropriate device to use for
clients who can cough effectively but cannot swallow or expectorate secretions
A nurse is caring for a client who has a trach tube with an inner cannula in place. Which
of the following supplies should the nurse use to dry the inner cannula of the client's
trach tube after cleaning it?
1) Paper towels
2) cotton-tipped applicators
3) Folded pipe cleaners
4) Facial tissues - Folded pipe cleaners
---> they remain intact without leaving any particulate matter the client could aspirate
A nurse is caring for a client who sustained trauma to their head and neck and will
require long-term airway support. Which of the following pieces of equipment will be
required for home health care for this client?
1) Nasopharyngeal airway device
2) Oropharyngeal airway device
3) Endotracheal tube
4) Trach Tube - Trach Tube
When administering a transfusion of packed red blood cells, it is important to
1) allow the blood to warm to room temp for 1 hr
2) make sure the entire unit is transfused within 4 hr
3) begin the blood transfusion at a rate of 10 mL/hr
4) change the blood tubing after every unit infused - make sure the entire is transfused
within 4 hr
A nurse is caring for a client who is receiving a blood transfusion and reports itching.
The nurse observes areas of urticaria on the client's skin. Which of the following actions
should the nurse take?
1) Administer prescribed antipyretic
2) stop the blood transfusion
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
A nurse is performing chest physiotherapy for a client who needs help mobilizing and
expectorating thick pulmonary secretions. To increase the turbulence of the air the client
exhales, the nurse should use which of the following techniques?
1) Vibration
2) Percussion
3) Nebulization
4) Postural Drainage - Vibration
---> used during or after percussion to increase the turbulence of exhaled air and loosen
secretions
A nurse is caring for a client who has a trach tube in place. During trach care, which of
the following should the nurse place underneath the flange of the outer cannula?
1) Commercially prepared transparent dressing
2) Cotton-filled gauze square
3) Commercially prepared fenestrated dressing
4) Twill tape - Commercially prepared fenestrated dressing
---> made of material that does not unravel and has a fenestration slit designed to fit
around the trach tube under flanges
A nurse is caring for a client who has a cuffed endotracheal tube in place. Which of the
following actions should the nurse plan to take?
1) Repositioning the ET tube in the client's mouth every 12 hr
2) providing oral care every 24 hour
3) Applying the securing tape over the client's ears
4) Maintaining a cuff pressure of 35 mm Hg - Repositioning the ET tube in the client's
mouth every 12 hr
---> helps prevent irritation to the oral mucous membranes
A nurse started a transfusion of packed RBCs for a client 1 hr ago. The client has
suddenly developed shaking chills, muscle stiffness, and a temperature of 101.5 F. The
client appears flushed and reports a headache and "nervousness". The nurse should
identify that the client has most likely developed which of the following types of
transfusion reaction?
1) Septic
2) Acute hemolytic
3) allergic
4) Febrile nonhemolytic - Febrile nonhemolytic
---> fever usually develops within 2 hrs after the transfusion has started. Other classic
symptoms include chills, headache, flushing, anxiety, and muscle pain
,A platelet transfusion is indicated for a patient who
1) has a systemic infection
2) has thrombocytopenia
3) is in hypovolemic shock
4) has hemolytic anemia - Has thrombocytopenia
---> low platelet count (drops below 20,000)
A nurse is providing education to a client who has a prescription for a blood transfusion.
Which of the following statements should the nurse include in the teaching?
1) "I will check your vitals every 15 min throughout the blood transfusion"
2) "I might have a nursing assistant check on you periodically during transfusion"
3) "If you have no adverse effects in the first 15-30 min, you will not have any adverse
effects later"
4) "You must immediately report any symptoms like chills, nausea, or itching" - You
must immediately report any symptoms like chills, nausea, or itching
A nurse is preparing a blood transfusion for a client who has type A blood. The nurse
should know that the client can safely receive blood from blood group O because
1) type O blood contains no A antigens
2) Type A blood contains O antibodies
3) Type O blood contains no A antibodies
4) type A blood contains O antigens - Type O blood contains no A antigens
A nurse is preparing to initiate the transfusion of a unit of packed RBCs to a client. After
the unit of blood has arrived, which of the following procedures will help the nurse
protect the client against the possibility of a blood-group incompatability?
1) Comparing the ID numbers on the blood unit with those on the order form and the
client's wrist band
2) Obtaining a blood sample from the client for typing and crossmatching
3) Giving a prescribed pre-med 30 min prior to starting the transfusion
4) observing the client 15-30 min after the transfusion is initiated - Comparing the ID
numbers on the blood unit with those on the order form and the client's wrist band
A nurse is suctioning a client's airway using in-line suctioning. Which of the following
actions should the nurse plan to take?
1) Hyperoxygenate the client before disconnecting the ventilator
2) Apply suction pressure while advancing the catheter
3) Wear a face shield during the procedure
4) Reuse the catheter repeatedly - 4) Reuse the catheter repeatedly
---> with in-line suctioning, the catheter attaches to the ventilator tubing and does not
need to be replaced until the system is replaced. It can be used repeatedly
A nurse is preparing to suction a client's tracheostomy. Which of the following actions
should the nurse take?
, 1) Suction for 30 seconds with each pass
2) allow 2 min in between suctioning to reoxygenate the lungs
3) Use a rotating motion when inserting the catheter from the trach
4) Set the suction pressure to 180 mmHg - 2) Allow 2 min in between suctioning to
reoxygenate the lungs
---> allow the client to cough and deep breathe and allow the lungs to reoxygenate
a nurse is preparing to suction a client's oral airway. Which of the following devices or
methods should the nurse use?
1) in-line suctioning
2) Yankauer catheter
3) Bulb syringe
4) Open suctioning - Yankauer Catheter
---> helps clear secretions from the mouth. This is the appropriate device to use for
clients who can cough effectively but cannot swallow or expectorate secretions
A nurse is caring for a client who has a trach tube with an inner cannula in place. Which
of the following supplies should the nurse use to dry the inner cannula of the client's
trach tube after cleaning it?
1) Paper towels
2) cotton-tipped applicators
3) Folded pipe cleaners
4) Facial tissues - Folded pipe cleaners
---> they remain intact without leaving any particulate matter the client could aspirate
A nurse is caring for a client who sustained trauma to their head and neck and will
require long-term airway support. Which of the following pieces of equipment will be
required for home health care for this client?
1) Nasopharyngeal airway device
2) Oropharyngeal airway device
3) Endotracheal tube
4) Trach Tube - Trach Tube
When administering a transfusion of packed red blood cells, it is important to
1) allow the blood to warm to room temp for 1 hr
2) make sure the entire unit is transfused within 4 hr
3) begin the blood transfusion at a rate of 10 mL/hr
4) change the blood tubing after every unit infused - make sure the entire is transfused
within 4 hr
A nurse is caring for a client who is receiving a blood transfusion and reports itching.
The nurse observes areas of urticaria on the client's skin. Which of the following actions
should the nurse take?
1) Administer prescribed antipyretic
2) stop the blood transfusion
