With Correct Verified Answers/Graded A+
1. A nurse is planning care to prevent a catheter-re- b. Perform hand hy-
lated blood stream infection for a client who is giene before touch-
receiving IV fluid therapy. Which of the following ing IV tubing
interventions should the nurse include in the plan?
a. Change bags of IV solution every 72 hours. Explanation: The
b. Perform hand hygiene before touching IV tubing. nurse should per-
c. use hydrogen peroxide to cleanse IV insertion form thorough hand
site. hygiene before
d. Assess the IV insertion site every 12 hr for touching any part
redness. of the infusion sys-
tem or the client
to reduce the risk
of catheter-related
blood stream infec-
tions.
2. A newly licensed nurse asks a charge nurse where b. "The state board of
to find information about scope of practice for reg- nursing can provide
istered nurses. Which of the following responses this information."
should the charge nurse make?
a. "The National Institutes of Health website con- explanation: Each
tains this information." state develops a
b. "The state board of nursing can provide this nurse practice act,
information." which defines scope
c. The facility's legal department write a summary of practice for nurs-
of scope of practice." es in that state. This
d. "The Nurse Licensure Compact defines a practice act is avail-
nurse's scope of practice." able on the board of
nursing website for
each state.
3. A nurse is caring for a client who is 2 days post- b. administer a
operative following an above-the-knee amputation. beta-blocking med-
The client states he is experiencing a dull, burning ication to the client.
pain in the leg that was amputated. Which of the
following actions should the nurse take to treat the explanation: The
client's neuropathic pain? nurse should admin-
a. inform the client that phantom limb pain is not ister a beta-block-
real. ing medication to the
, ATI Proctored Exam
b. administer a beta-blocking medication to the client. This classifi-
client. cation of medication
c. place the client on a soft mattress. has been shown to
d. loosen the bandage on the client's residual limb. relieve the phantom
limb pain manifes-
tations of constant
dull and burning type
pain.
4. A nurse is creating a plan of care for a client who d. offer the client a
is non-ambulatory and has bladder and bowel in- glass of water every
continence. Which of the following interventions 2 hr when re-posi-
should the nurse include to prevent skin break- tioning.
down?
a. use a sheepskin device to pad the client's pres- explanation: The
sure points. nurse should offer
b. apply cornstarch to the perineal area after the client a glass
bathing the client. of water every 2 hr
c. massage the client's skin and pressure points on the client's re-po-
every 12 hr. sitioning schedule.
d. offer the client a glass of water every 2 hr when This helps prevent
re-positioning. dehydration, which
increases the risk of
skin breakdown.
5. a nurse is teaching a young adult female client d. "I should ex-
about health screening for breast cancer. Which of pect to feel a firm
the following statements by the client indicates an ridge along the bot-
understanding of breast self-examination (BSE)? tom curve of each
a. "I should perform a BSE about 1 week before my breast."
period each month."
b. "I should use the fingers of my right hand to feel explanation: The
for lumps in my right breast." nurse should instruct
c. "I should report a lump in my breast if it remains the client that a
for two consecutive BSEs." firm ridge is expect-
d. "I should expect to feel a firm ridge along the ed along the bot-
bottom curve of each breast." tom curve of each
breast. The client
should be able to
, ATI Proctored Exam
feel this area during
the BSE. Perform-
ing a BSE promotes
breast self-aware-
ness so that the
client knows how
her breasts normal-
ly feel. This aware-
ness increases the
client's ability to
identify changes that
require further evalu-
ation and treatment.
6. A nurse is caring for an adolescent client who is in b. inform the parent
critical condition following a motor vehicle crash that anger is a nat-
in which he is the passenger. The client's parent ural response when
shouts at the nurse, asking why her son is dying dealing with loss.
instead of the driver. Which of the following actions
should the nurse take to provide emotional support explanation: The
to the parent? nurse should iden-
a. encourage the parent to speak with the family of tify that the par-
the driver of the car. ent is in the anger
b. inform the parent that anger is a natural re- stage of grief. The
sponse when dealing with loss. nurse should assist
c. ask the parent to leave and come back later after the parent to under-
she has calmed down. stand that anger is a
d. contact a clergy member to come and speak with natural response to
the parent. loss and encourage
her to talk about her
feelings.
7. A nurse is teaching an older adult client about ac- c. "Websites ending
cessing electronic resources for health care infor- in 'dot-gov' are re-
mation on the internet. Which of the following state- liable sites for ob-
ments should the nurse include in the teaching? taining health infor-
a. "websites that are evidence-based avoid placing mation from govern-
direct links to other evidence-based websites on ment agencies."
their home pages."
, ATI Proctored Exam
Study online at https://quizlet.com/_getrvz
b. "Websites that market products are credible as explanation: The
long as the products are beneficial for health care." nurse should teach
c. "Websites ending in 'dot-gov' are reliable sites the client how to
for obtaining health information from government select reliable inter-
agencies." net websites when
d. "Website forums with the opinions of other researching health
clients provide factual and trustworthy informa- care information.
tion." The nurse should
identify that web-
sites ending in ".gov"
(government agen-
cies) and ".edu" (ed-
ucational organiza-
tions) are consid-
ered reliable and
credible sources for
health information.
Websites ending in
".com" should not be
used for researching
credible health care
information.
8. A nurse enters a client's room and finds the client c. check the client for
lying on the floor. The client states that on the way injuries.
to the bathroom her "knee locked," causing her to
fall. Which of the following actions should the nurse explanation: The first
take first? action the nurse
a. ask an assistive personnel to help return the should take when
client to her bed. using the nursing
b. complete an incident report. process is to assess
c. check the client for injuries. the client. The nurse
d. document objective detail about the client's con- should first check
dition in the medical record. the client for injuries
and measure vital
signs to help de-
termine physiologic
stability. The nurse
should also inform