ATI Final Exam ~ Review Questions and solutions
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
instructions is appropriate for the client and family?
mi mi mi mi mi mi mi mi
1. Remove the outer cannula cautiously for routine cleaning.
mi mi mi mi mi mi mi mi
2. Use tracheostomy covers when outdoors.
mi mi mi mi mi
3. Use sterile technique when performing tracheostomy care at home.
mi mi mi mi mi mi mi mi mi
4. Cleanse irritated skin with full-strength hydrogen peroxide. - answers2. Use tracheostomy covers when outdoors.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which of the following
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
pieces of information is most essential to provide?
mi mi mi mi mi mi mi mi
1. Admitting diagnosis
mi mi
2. Diagnostic test results
mi mi mi
3. Body temperature
mi mi
4. Breath sounds - answers4. Breath sounds
mi mi mi mi mi mi
**ABCs**
A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
primary hypertension?
mi mi
1. A client who is pregnant
mi mi mi mi mi
2. A client who has an elevated LDL
mi mi mi mi mi mi mi
3. A client who takes oral contraceptives
mi mi mi mi mi mi
4. A client who has kidney disease - answers2. A client who has an elevated LDL
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following task
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
should the nurse assign to an AP? (Select all that apply.)
mi mi mi mi mi mi mi mi mi mi mi
- Assist the client with a partial bed bath.
mi mi mi mi mi mi mi mi
- Measure the client's BP after the nurse administers an antihypertensive medication.
mi mi mi mi mi mi mi mi mi mi mi
- Test the client's swallowing ability by providing thickened liquids.
mi mi mi mi mi mi mi mi mi
- Use a communication board to ask what the client wants for lunch.
mi mi mi mi mi mi mi mi mi mi mi mi
- Irrigate the client's indwelling urinary catheter. - answers- Assist the client with a partial bed bath.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
- Measure the client's BP after the nurse administers an antihypertensive medication.
mi mi mi mi mi mi mi mi mi mi mi
- Use a communication board to ask what the client wants for lunch.
mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after th
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
1. Tie restraints to the lower edge of the side rail.
mi mi mi mi mi mi mi mi mi mi
2. Remove each restraint one at a time every 2 hr.
mi mi mi mi mi mi mi mi mi mi
3. Ensure 3 finger-widths of space between the restraint and the client's wrist.
mi mi mi mi mi mi mi mi mi mi mi mi
4. Use a square knot to securely tie the restraints to the bed. - answers2. Remove each restraint one at a time every 2 hr.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
mimimimimimimimi mimimimimimimimi
,**To perform ROM exercises and neurovascular checks**
mi mi mi mi mi mi
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
following is an appropriate nursing intervention?
mi mi mi mi mi mi
1. Return the unused medication to the automatic dispensing system.
mi mi mi mi mi mi mi mi mi
2. Keep the remaining medication at the client's bedside for later use.
mi mi mi mi mi mi mi mi mi mi mi
3. Have a second nurse witness the disposal of remaining medication.
mi mi mi mi mi mi mi mi mi mi
4. Lock remaining medication in secure cabinet. - answers3. Have a second nurse witness the disposal of remaining
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
medication.
mi
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
response by the nurse?
mi mi mi mi
1. "It allows the court to overrule an adult client's refusal of medical treatment."
mi mi mi mi mi mi mi mi mi mi mi mi mi
2. "It permits a client to withhold medical information from health care personnel."
mi mi mi mi mi mi mi mi mi mi mi mi
3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
4. "It allows health care personnel in the emergency department to stabilize a client's condition." - answers3. "It indicate
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
the form of treatment a client is willing to accept in the event of a serious illness."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get o
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
1. Incident report completed.
mi mi mi
2. Client climbed over the bedrails.
mi mi mi mi mi
3. Client found lying on floor.
mi mi mi mi mi
4. Client was trying to get out of bed. - answers3. Client found lying on floor.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
**remember, be Objective in documentation** mi mi mi mi
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
preoperative teaching regarding pain control has been effective when the client states which of the following?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
1. "I think I should take my pain medication more often, since it is not controlling my pain."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
2. "Breathing faster will help me keep my mind off of the pain."
mi mi mi mi mi mi mi mi mi mi mi mi
3. "It may help me to listen to music while I'm lying in bed."
mi mi mi mi mi mi mi mi mi mi mi mi mi
4. "I don't want to walk today, because I'm experiencing some pain." - answers3. "It may help me to listen to music while I
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
lying in bed."
mi mi mi
**nonpharmacological intervention to pain** mi mi mi
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the followin
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
is an appropriate response by the nurse?
mi mi mi mi mi mi mi
1. "I'm sorry, but another client needed my attention."
mi mi mi mi mi mi mi mi
2. "I arrived as soon as I could. What can I do for you?"
mi mi mi mi mi mi mi mi mi mi mi mi mi
3. "It must be frustrating. I have a few minutes now."
mi mi mi mi mi mi mi mi mi mi
4. "We had an emergency on the unit, but now I'm here." - answers3. "It must be frustrating. I have a few minutes now."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
mimimimimimimimi mimimimimimimimi
,**therapeutic by acknowledging client's feelings** mi mi mi mi
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
nurse initiate discharge planning?
mi mi mi mi
1. During the admission process
mi mi mi mi
2. As soon as the client's condition is stable
mi mi mi mi mi mi mi mi
3. During the initial team conference
mi mi mi mi mi
4. After consulting with the client's family - answers1. During the admission process
mi mi mi mi mi mi mi mi mi mi mi mi
**discharge planning starts at admission (patient needs for during and after hospital)** mi mi mi mi mi mi mi mi mi mi mi
A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
HIPPA guidelines?
mi mi
1. The assigned nurse reviews the medical chart with a nursing student.
mi mi mi mi mi mi mi mi mi mi mi
2. A nursing student discusses a client's status with the assigned nurse at the bedside.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
3. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
4. A nursing student consults a former classmate to assist with her documentation. - answers4. A nursing student consu
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
a former classmate to assist with her documentation.
mi mi mi mi mi mi mi mi
**only those in direct care** mi mi mi mi
A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
need for further teaching?
mi mi mi mi
1. The client inserts the needle at a 30°-angle.
mi mi mi mi mi mi mi mi
2. The client rolls the vial between both hands.
mi mi mi mi mi mi mi mi
3. The client holds the syringe in place for 5 seconds following injection.
mi mi mi mi mi mi mi mi mi mi mi mi
4. The client uses her anterior thigh as the injection site. - answers1. The client inserts the needle at a 30°-angle.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
**Insert needle at 45° to 90° (depending on adipose/fat tissue)** mi mi mi mi mi mi mi mi mi
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
provider?
mi
1. BUN 15 mg/dL mi mi mi
2. Creatinine 0.8 mg/dL
mi mi mi
3. Sodium 143 mEq/L mi mi mi
4. Potassium 5.4 mEq/L - answers4. Potassium 5.4 mEq/L
mi mi mi mi mi mi mi mi
**Electrolytes (ranges):** mi
Sodium ~ 135-145 mEq/L mi mi mi
Chloride ~ 95-105 mEq/L mi mi mi
Potassium ~ 3.5-5.0 mEq/L mi mi mi
Bicarbonate ~ 22-28 mEq/L mi mi mi
Magnesium ~ 1.5-2.0 mEq/L mi mi mi
A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. Wh
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
of the following guidelines should the nurse follow when working with the interpreter?
mi mi mi mi mi mi mi mi mi mi mi mi mi
mimimimimimimimi mimimimimimimimi
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
instructions is appropriate for the client and family?
mi mi mi mi mi mi mi mi
1. Remove the outer cannula cautiously for routine cleaning.
mi mi mi mi mi mi mi mi
2. Use tracheostomy covers when outdoors.
mi mi mi mi mi
3. Use sterile technique when performing tracheostomy care at home.
mi mi mi mi mi mi mi mi mi
4. Cleanse irritated skin with full-strength hydrogen peroxide. - answers2. Use tracheostomy covers when outdoors.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which of the following
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
pieces of information is most essential to provide?
mi mi mi mi mi mi mi mi
1. Admitting diagnosis
mi mi
2. Diagnostic test results
mi mi mi
3. Body temperature
mi mi
4. Breath sounds - answers4. Breath sounds
mi mi mi mi mi mi
**ABCs**
A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
primary hypertension?
mi mi
1. A client who is pregnant
mi mi mi mi mi
2. A client who has an elevated LDL
mi mi mi mi mi mi mi
3. A client who takes oral contraceptives
mi mi mi mi mi mi
4. A client who has kidney disease - answers2. A client who has an elevated LDL
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following task
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
should the nurse assign to an AP? (Select all that apply.)
mi mi mi mi mi mi mi mi mi mi mi
- Assist the client with a partial bed bath.
mi mi mi mi mi mi mi mi
- Measure the client's BP after the nurse administers an antihypertensive medication.
mi mi mi mi mi mi mi mi mi mi mi
- Test the client's swallowing ability by providing thickened liquids.
mi mi mi mi mi mi mi mi mi
- Use a communication board to ask what the client wants for lunch.
mi mi mi mi mi mi mi mi mi mi mi mi
- Irrigate the client's indwelling urinary catheter. - answers- Assist the client with a partial bed bath.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
- Measure the client's BP after the nurse administers an antihypertensive medication.
mi mi mi mi mi mi mi mi mi mi mi
- Use a communication board to ask what the client wants for lunch.
mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after th
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
1. Tie restraints to the lower edge of the side rail.
mi mi mi mi mi mi mi mi mi mi
2. Remove each restraint one at a time every 2 hr.
mi mi mi mi mi mi mi mi mi mi
3. Ensure 3 finger-widths of space between the restraint and the client's wrist.
mi mi mi mi mi mi mi mi mi mi mi mi
4. Use a square knot to securely tie the restraints to the bed. - answers2. Remove each restraint one at a time every 2 hr.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
mimimimimimimimi mimimimimimimimi
,**To perform ROM exercises and neurovascular checks**
mi mi mi mi mi mi
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
following is an appropriate nursing intervention?
mi mi mi mi mi mi
1. Return the unused medication to the automatic dispensing system.
mi mi mi mi mi mi mi mi mi
2. Keep the remaining medication at the client's bedside for later use.
mi mi mi mi mi mi mi mi mi mi mi
3. Have a second nurse witness the disposal of remaining medication.
mi mi mi mi mi mi mi mi mi mi
4. Lock remaining medication in secure cabinet. - answers3. Have a second nurse witness the disposal of remaining
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
medication.
mi
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
response by the nurse?
mi mi mi mi
1. "It allows the court to overrule an adult client's refusal of medical treatment."
mi mi mi mi mi mi mi mi mi mi mi mi mi
2. "It permits a client to withhold medical information from health care personnel."
mi mi mi mi mi mi mi mi mi mi mi mi
3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
4. "It allows health care personnel in the emergency department to stabilize a client's condition." - answers3. "It indicate
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
the form of treatment a client is willing to accept in the event of a serious illness."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get o
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
1. Incident report completed.
mi mi mi
2. Client climbed over the bedrails.
mi mi mi mi mi
3. Client found lying on floor.
mi mi mi mi mi
4. Client was trying to get out of bed. - answers3. Client found lying on floor.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
**remember, be Objective in documentation** mi mi mi mi
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
preoperative teaching regarding pain control has been effective when the client states which of the following?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
1. "I think I should take my pain medication more often, since it is not controlling my pain."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
2. "Breathing faster will help me keep my mind off of the pain."
mi mi mi mi mi mi mi mi mi mi mi mi
3. "It may help me to listen to music while I'm lying in bed."
mi mi mi mi mi mi mi mi mi mi mi mi mi
4. "I don't want to walk today, because I'm experiencing some pain." - answers3. "It may help me to listen to music while I
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
lying in bed."
mi mi mi
**nonpharmacological intervention to pain** mi mi mi
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the followin
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
is an appropriate response by the nurse?
mi mi mi mi mi mi mi
1. "I'm sorry, but another client needed my attention."
mi mi mi mi mi mi mi mi
2. "I arrived as soon as I could. What can I do for you?"
mi mi mi mi mi mi mi mi mi mi mi mi mi
3. "It must be frustrating. I have a few minutes now."
mi mi mi mi mi mi mi mi mi mi
4. "We had an emergency on the unit, but now I'm here." - answers3. "It must be frustrating. I have a few minutes now."
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
mimimimimimimimi mimimimimimimimi
,**therapeutic by acknowledging client's feelings** mi mi mi mi
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
nurse initiate discharge planning?
mi mi mi mi
1. During the admission process
mi mi mi mi
2. As soon as the client's condition is stable
mi mi mi mi mi mi mi mi
3. During the initial team conference
mi mi mi mi mi
4. After consulting with the client's family - answers1. During the admission process
mi mi mi mi mi mi mi mi mi mi mi mi
**discharge planning starts at admission (patient needs for during and after hospital)** mi mi mi mi mi mi mi mi mi mi mi
A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
HIPPA guidelines?
mi mi
1. The assigned nurse reviews the medical chart with a nursing student.
mi mi mi mi mi mi mi mi mi mi mi
2. A nursing student discusses a client's status with the assigned nurse at the bedside.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
3. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
4. A nursing student consults a former classmate to assist with her documentation. - answers4. A nursing student consu
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
a former classmate to assist with her documentation.
mi mi mi mi mi mi mi mi
**only those in direct care** mi mi mi mi
A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
need for further teaching?
mi mi mi mi
1. The client inserts the needle at a 30°-angle.
mi mi mi mi mi mi mi mi
2. The client rolls the vial between both hands.
mi mi mi mi mi mi mi mi
3. The client holds the syringe in place for 5 seconds following injection.
mi mi mi mi mi mi mi mi mi mi mi mi
4. The client uses her anterior thigh as the injection site. - answers1. The client inserts the needle at a 30°-angle.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
**Insert needle at 45° to 90° (depending on adipose/fat tissue)** mi mi mi mi mi mi mi mi mi
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
provider?
mi
1. BUN 15 mg/dL mi mi mi
2. Creatinine 0.8 mg/dL
mi mi mi
3. Sodium 143 mEq/L mi mi mi
4. Potassium 5.4 mEq/L - answers4. Potassium 5.4 mEq/L
mi mi mi mi mi mi mi mi
**Electrolytes (ranges):** mi
Sodium ~ 135-145 mEq/L mi mi mi
Chloride ~ 95-105 mEq/L mi mi mi
Potassium ~ 3.5-5.0 mEq/L mi mi mi
Bicarbonate ~ 22-28 mEq/L mi mi mi
Magnesium ~ 1.5-2.0 mEq/L mi mi mi
A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. Wh
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
of the following guidelines should the nurse follow when working with the interpreter?
mi mi mi mi mi mi mi mi mi mi mi mi mi
mimimimimimimimi mimimimimimimimi
