ATI Exit Exam 180 Questions & Answers

1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? a. “You don’t have to go through with the treatment.” b. “Most people who have this procedure feel better following the treatment.” c. “It’s okay to be nervous before this treatment.” d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.” 2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM device. Which of the following actions should the nurse take first? a. Report the defect to the equipment maintenance staff. b. Ensure the device inspection sticker is current c. Remove the device from the room d. Initiate a requisition for a replacement CPM device 3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? a. Document administration of the medication upon removal from the medication dispensing system b. Withhold the medication if the client does not appear to be in pain. c. Count the current number of unit doses available in the medication dispensing system d. Withhold the medication if the client has a fever 4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding? a. Type 2 DM and a blood glucose of 250 mg/dL b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F) c. 2 hr. post cast placement and has 2+ pitting edema and pallor d. First-degree heart block and a heart rate of 62/min 5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram.” b. “I will avoid foods containing tyramine while taking fluoexetine.” c. “I will take the sustained-release methylphenidate every morning.” d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will help decrease GI distress) 6. A nurse in the emergency department is assessing client who has major depressive disorder. Which of the following actions should the nurse take first? [View Exhibit] a. Administer Zofran to the client for nausea b. Implement seizure precautions for the client c. Encourage the client to verbalize feelings d. Obtain the client’s weight 7. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder. Which of the following should the nurse expect? a. Suspicious of others b. Exhibits separation anxiety c. Ritualistic behavior d. Preoccupied with aging lOMoARcPSD| 8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein per day should the nurse include in the client’s dietary plan? 9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following actions should the nurse take first to manage her time effectively? a. Develop an hourly time frame for tasks b. Schedule daily activities c. Determine goals of the day d. Delegate tasks to the AP 10. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Restrict the client’s total fluid intake to 250 mL/hr. b. Measure the client’s urine output every hour c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium gluconate) d. Monitor the FHR via Doppler every 30 min 11. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? a. Infected laceration b. Stage II pressure ulcer c. Approximated surgical incision d. Partial-thickness burn 12. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. Client taking clozapine to treat schizophrenia and reports sore throat (pharm pg. 72: monitor for infection [fever, sore throat, etc.]) b. Client has OCD and is upset about a change in daily routine c. Client has narcissistic personality disorder and is mocking others during group therapy d. Client who has depressive disorder and requires assistance with ADLs 13. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to assess the port? a. An angiocatheter b. A butterfly needle c. A noncoring needle d. A 25 gauge needle 14. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test? a. PT and INR b. 12 lead ECG c. Chest X-ray d. Serum potassium 15. A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions should the nurse ask the parent to determine if the child is exhibiting typical developmental expectations? a. “Can your child draw a stick figure?” b. “Can your child catch and throw a small ball?” lOMoARcPSD| c. “Can your child ride a tricycle?” d. “Can your child name five colors?” 16. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Measure the fundal height to determine the placement of the ultrasound stethoscope b. Perform Leopold maneuvers prior to auscultating the FHR c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR d. Place the client in a side-lying position prior to assessing the FHR 17. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. There is a loop of tubing below the drainage system b. The system is working properly (medsurg pg. 104: tidaling in the water seal chamber and continuous bubbling only in the suction chamber) c. The lung has re-expanded d. The tubing is partially obstructed by clots 18. A charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who is receiving heparin for DVT b. A client who is 1 day postoperative following a vertebroplasty c. A client who has COPD and a respiratory rate of 44/min d. A client who has cancer with a sealed implant for radiation therapy 19. A nurse is caring for a client who has ESRD. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Osteoarthritis b. HTN c. Amputation d. Primary glaucoma 20. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (SATA) a. Foul perineal odor b. Fundus displaced to the right c. Lochia serosa d. Fundus 4 cm (1.6 in) below the umbilicus e. Postpartum chill 21. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure twice a day b. Hold hand to perform percussions on the child c. Administer a bronchodilator after the procedure d. Perform the procedure prior to meals 22. A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following action should the nurse take? lOMoARcPSD| a. Ensure that the client checks the gauge weekly b. Store the oxygen tank wrench in a locked cabinet c. Have the client store smaller tanks under his bed d. Place the oxygen tank away from curtains or drapes Location of crackles [IMAGE] 23. A nurse is caring for a newly client who has bacterial meningitis. Which of the following actions should the nurse take? (medsurg pg. 31) a. Implement seizure precautions b. Place the client in high-Fowler’s position c. Perform ROM exercises once per shift d. Monitor the client for hypoglycemia 24. A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? a. Na 142 mEq/L b. Blood glucose 80 mg/dL c. K 3.3 mEq/L d. PT 11.5 seconds 25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? a. Reset the vacuum by compressing the container b. Secure the drain to the bedding c. Position the affected extremity below the level of the client’s heart d. Maintain the client in a supine position for the first 24 hr. 26. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse assess first? a. DM and HbA1c of 5.2% b. Leukemia and platelet level of 95,000/mm3 c. Received IV Lasix and K of 3.6 mEq/L d. Hepatitis B and total bilirubin of 1.2 mg/dL 27. A nurse is developing plan of care for a newborn mother tested positive for heroin during pregnancy. Newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Minimize noise in the newborn’s environment b. Swaddle the newborn with his legs extended c. Administer naloxone to the newborn d. Maintain eye contact with the newborn during feedings 28. Nutritional teaching for an adult client who has seizure disorder and a new prescription for phenytoin. Which of the following instructions by the nurse is appropriate? a. “You should expect a change in the color of your stool while taking this medication.” b. “Increase your intake of vitamin D while taking this medication.” (pharm pg. 96: consume adequate amounts of calcium and vitamin D) c. “Plan to take this medication with antacids.” d. “Limit foods that contain folic acid while taking this medication.” 29. A nurse is assessing a client who presents to the L&D unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? lOMoARcPSD| a. Presence of bloody show b. Contraction intensity increased by ambulation c. Slow change in dilation and effacement d. Intermittent, painless contractions 30. A nurse is caring for a client who has Cdif. Which of the following actions should the nurse take? (SATA) a. Wash hands with alcohol based b. Wear N95 c. Remove thermometer from client’s room for use on another client d. Change gloves after contact with infectious material e. Wear a gown when providing care 31. A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. DM and HbA1C of 6.8% b. Hip fracture and a new onset of tachypnea c. Epidural analgesia and weakness in lower extremities d. Sinus arrhythmia and is receiving cardiac monitoring 32. Nurse accidently punctures IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a bio hazardous material spill? a. Phenytoin b. Doxorubicin hydrochloride c. Metronidazole d. Ampicillin sodium 33. Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication? a. Respiratory rate 22/min b. Hgb 8.7 g/dL c. 2+ pitting edema of the ankles d. Creatinine 2.3 mg/dL (pharm pg. 365: nephrotoxicity) 34. Which of the following clients should the nurse recommend referral to a dietitian? a. Older adult who has BMI of 24 b. Client with albumin of 3.7 g/dL c. Older adult who has presbyopia d. Client who has a nonhealing leg ulcer 35. Support group for clients whose family have committed suicide. Which of the following should the nurse plan to use during the group session? a. Encourage clients to establish a timeline for their grieving process b. Assist clients in identifying ways suicide could have been prevented c. Discourage clients from sharing negative aspects of their relationship with the deceased persons d. Initiate a discussion with clients about ways to cope with changes in family dynamics 36. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. A history of being in prison c. Male gender d. Previous violent behavior 37. Arial fibrillation places the client at risk for which of the following conditions? lOMoARcPSD| a. Pulmonary emboli b. Cardiac tamponade c. Widened pulse pressure d. Hemothorax 38. Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan? a. Refer to the hallucinations as if they are real b. Encourage the client to lie down in a quiet room c. Ask the client directly what he is hearing d. Avoid eye contact with the client 39. Circumcised newborn. Which of the following instructions should the nurse include in the teaching? a. “Wrap sterile gauze around the penis if bleeding occurs.” b. “Use soap to cleanse the site.” c. “Apply petroleum jelly to the glans with diaper changes.” d. “Remove yellow exudate around the penis.” 40. Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? a. Schilling test (medsurg pg. 254) b. Oral glucose tolerance test c. D-dimer test d. Thyroid scan 41. A nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? a. Administer atropine to the client if tachycardia is present b. Maintain the indwelling urinary catheter until the client is ready for discharge c. Prepare for fluid volume replacement if the central venous pressure steadily increases d. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr (medsurg pg. 185: volume exceeding 150 mL/hr could be a sign of hemorrhage) 42. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing? a. Morphine b. Digoxin c. Prednisone d. Omeprazole 43. Client becomes unconscious and monitor displays v-tach. Which action should the nurse take first after determining the client does not have a palpable pulse? a. Establish IV access b. Administer epinephrine c. Defibrillate d. Assess heart sounds 44. A nurse is caring for several clients on a med surg unit. For which of the following nursing activities is it required that the nurse use sterile gloves? a. Initiating IV assess lOMoARcPSD| b. Performing tracheostomy care c. Inserting an NG tube d. Administering total parenteral nutrition through a central venous assess device 45. Lab results s/p surgery. Which should be reported to the provider? a. Na 160 mEq/L b. Cl 100 mEq/L c. Bicarbonate 26 mEq/L d. K 3.8 mEq/L 46. Nurse is developing care plan for client on Buck’s traction and is schedules for surgery for a fractured femur of the right leg. Which should the nurse delegate to an AP? a. Observe the position of the suspended weight b. Remind the client to use the incentive spirometer c. Check the client’s pedal pulse on the right leg d. Ask client to describe her pain 47. Client in ER experiencing stimulant withdrawal. Which finding should the nurse expect? a. Decreased appetite b. Runny nose c. Muscle spasms d. Fatigue 48. Postpartum client with a language barrier. Which of the following actions should the nurse take to gather the client’s admission data? a. Allow client’s partner to translate b. Request female interpreter through the facility c. Have client’s child translate d. Ask nursing student who speaks the same language as the client to translate 49. Operating fire extinguisher [arrange] 1) Unlock the handle by pulling on the pin 2) Point the hose at the base of the fire 3) Squeeze the handle by pulling on the pin 4) Sweep the extinguisher from side to side 50. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy obtain a copy of the therapist’s notes. Which of the following responses should the nurse make? a. “Are you not happy with your treatment?” b. “Why are you interested in seeing your therapist’s notes?” c. “I don’t think you will benefit from reviewing your therapist’s notes right now.” d. “We can provide a copy of your records, but the therapist’s notes are not included.” 51. A nurse is assessing a client who has hypervolemia. Which of the findings should the nurse expect? a. Urinary frequency b. Decreased BP c. Bounding pulse (medsurg pg. 267) d. Bradycardia 52. Inserting indwelling urinary catheter to a male client. Which of the following actions should the nurse take? lOMoARcPSD| a. Cleanse the tip of the penis in a side to side motion b. Pick up the catheter 13 cm (5 in) from its tip c. Perform the cleansing procedure with a fresh swab two times d. Lift the penis so that it is perpendicular to the client’s body 53. A nurse is caring for a client who is febrile. To reduce fever, the nurse applies a cooling blanket. Which of the findings indicates the client is having an adverse reaction to the cooling? a. Tachycardia b. Flushing c. Shivering d. Restlessness 54. Teaching for misoprostol. Which information should be included in the teaching? a. “You will have a urinary catheter inserted prior to the placement of the medication.” b. “You will lie on your side for 30 min after the medication is inserted.” c. “You will have oxytocin initiated within 3 hours of administration of the medication.” d. “You will have intermittent fetal monitoring while you receive the medication.” 55. Client in psychiatric unit. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? a. “That can’t be true. The only voices in this room are yours and mine.” b. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” c. “I understand the voices are frightening you, but I do not hear any voices.” d. “Do you recognize the voices as belonging to anyone you know?” 56. Teaching the parent of an infant who has positional plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? a. “I should place my baby in the left side-lying position at night when using the helmet.” b. “I should avoid tummy time when my baby is wearing the helmet.” c. “I should expect to have my baby wear this helmet for 10 months.” d. “I should keep the helmet on my baby for 23 hours a day.” 57. Which of the following lab findings should the nurse recognize as indicative of rheumatic fever? a. Decreased hgb and platelet count b. Decreased myoglobin and antinuclear antibody titer c. Elevated sedimentation rate and C-reactive protein d. Elevated creatine kinase and troponin 58. Client with pneumonia gained 4.2 (9.3 lb.) over the last 5 days. Lab values this morning are: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? a. Nephrologist b. Cardiologist c. Infectious control nurse d. Dietitian 59. A nurse received change of shift report. Which of the following actions should the nurse take to manage time effectively? a. Focus on several client tasks at a time lOMoARcPSD| b. Document client care at the end of the shift c. Skip breaks until client tasks are completed d. Make a client to-do list for the day 60. Protocols for belt restraints. Which of the following guidelines should the nurse include? a. Remove the client’s restraint every 4 hr. b. Request a PRN restraint prescription for clients who are aggressive c. Attach the restraint to the bed’s side rails d. Document the client’s condition every 15 min 61. Assessing client in ER. Which of the following actions should the nurse take first? [View Exhibit] a. Obtain ABG levels b. Elevate the head of the client’s bed to 30° c. Place client on a coating blanket d. Administer an analgesic 62. Client who has depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicators an understanding of the teaching? a. “I can continue to take St. John’s wort while taking this medication.” b. “I know it will be a couple of weeks before the medication helps me feel better.” (pharm pg. 56: it can take 10-14 days or longer) c. “I expect this medication to raise my blood pressure.” d. “I should take this medication on an empty stomach.” 63. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing b. Sit at or below the client’s eye level during feedings c. Talk with the client during her feeding d. Discourage the client from coughing during feedings 64. Child with sickle cell anemia. The nurse should emphasize the importance of which of the following factors to prevent sickle cell crisis? a. A low-protein diet b. Adequate hydration c. Calorie restriction d. Increased iron intake 65. Client with indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? a. Provide perineal hygiene after defecation b. Empty the collected urine once every 24 hr. c. Hang the drainage bag on a bed rail d. Change the indwelling catheter every 8 hr. 66. Client experiencing acute mania. Which of the foods should the nurse provide for this client? a. Peanut butter sandwich b. Chicken noodle soup c. Celery sticks d. Oatmeal with butter 68. ??????????