NSG 212- ATI Exam Questions With Complete Solutions
1. second intercostal space at the left sternal border
2. fourth intercostal space at the life sternal border
3. second intercostal space at the right sternal border Correct
Answer 1. pulmonary valve
2. tricuspid valve
3. aortic valve
25,00 units of heparin in 250 ml of 0.9% sodium chloride to
infuse at 800 units/hr. What should you set infusion pump for
ml/hr? Correct Answer 800x250/25000
8 ml/hr
4 oz Correct Answer 120 ml
A nurse finds a client on the floor upon entering the client's
room. Roommate reports the client was trying to get out of bed
and fell over the bedrail onto the floor. What is correct
documentation of this incident? Correct Answer - An incident
report is an internal document that is part of a facility's risk
management system. The nurse should not document completion
of an incident report in the client's medical record for the
facility's protection in the event of litigation.
- Unless the nurse witnessed the client climbing over the
bedrails or that the client was trying to get out of bed, these
statements are not objective.
- Documentation must contain descriptive, objective info. about
what the nurse actually observes, without any opinions or
,judgment about motive or cause. So document "Client found
lying on floor."
A nurse i caring for a client who is combative. The provider
orders wrist restraints. What actions are appropriate for the nurse
to take? Correct Answer - The nurse should not tie the
restraints to a stationary portion of the bed, but rather to a part of
the bed frame that will move when raising or lowering the bed.
- The nurse should remove each restraint one at a time every 2
hr to allow the client to perform ROM exercises and the nurse to
perform neurovascular checks.
- The nurse should ensure there are only 2 finger-widths of
space between the restraint and the client's wrist to prevent the
client from slipping her hand out of the restraint.
- The nurse should use a quick-release tie to secure the restraints
to the bed.
A nurse is caring for a client who asks about the purpose of
advance directives. Which is the appropriate response? Correct
Answer - A court may only overrule an adult client's refusal of
medical treatment if the client is deemed incompetent.
- The Americans of Disabilities Act, not advance directives,
protects the privacy of a client who chooses not to disclose a
medical disability.
- Advance directives include living will, which permits the client
to direct treatment in the event of a terminal illness.
- The Emergency Medical Treatment and Active Labor Act, not
advance directives, permits emergency personnel to provide care
in the event of an emergency medical situation.
, A nurse is checking BP at a community health screening. Which
of the following clients is at high risk for primary hypertension?
Correct Answer - The client who is pregnant, takes oral
contraceptives, and has kidney disease is at risk for secondary
hypertension.
- The client who has an elevated LDL is at risk for primary
hypertension.
A nurse is giving an end-of-shift report about a client admitted
earlier that day with pneumonia. Which of the following pieces
of information is most essential to provide? Correct Answer -
Although the admitting diagnosis, diagnostic tests, and body
temp. are important info. for the nurse to provide in order to plan
care, they are not highest priority.
- When using the airway, breathing, circulation approach to
client care the nurse determines the priority info. to provide are
the client's breath sounds.
A nurse is preparing to administer oral medications to a client
who has dysphagia. What are appropriate actions? Correct
Answer - Instruct client to avoid use of straws, this could
increase aspiration.
- Instruct the client to place his chin in downward position when
swallowing to prevent aspiration.
- Administer medication one at a time.
- Encourage client to self-administer medications.
A nurse is teaching a client and his family how to care for the
client's tracheostomy at home. Which of the following
instructions is appropriate for the client and family? Correct
1. second intercostal space at the left sternal border
2. fourth intercostal space at the life sternal border
3. second intercostal space at the right sternal border Correct
Answer 1. pulmonary valve
2. tricuspid valve
3. aortic valve
25,00 units of heparin in 250 ml of 0.9% sodium chloride to
infuse at 800 units/hr. What should you set infusion pump for
ml/hr? Correct Answer 800x250/25000
8 ml/hr
4 oz Correct Answer 120 ml
A nurse finds a client on the floor upon entering the client's
room. Roommate reports the client was trying to get out of bed
and fell over the bedrail onto the floor. What is correct
documentation of this incident? Correct Answer - An incident
report is an internal document that is part of a facility's risk
management system. The nurse should not document completion
of an incident report in the client's medical record for the
facility's protection in the event of litigation.
- Unless the nurse witnessed the client climbing over the
bedrails or that the client was trying to get out of bed, these
statements are not objective.
- Documentation must contain descriptive, objective info. about
what the nurse actually observes, without any opinions or
,judgment about motive or cause. So document "Client found
lying on floor."
A nurse i caring for a client who is combative. The provider
orders wrist restraints. What actions are appropriate for the nurse
to take? Correct Answer - The nurse should not tie the
restraints to a stationary portion of the bed, but rather to a part of
the bed frame that will move when raising or lowering the bed.
- The nurse should remove each restraint one at a time every 2
hr to allow the client to perform ROM exercises and the nurse to
perform neurovascular checks.
- The nurse should ensure there are only 2 finger-widths of
space between the restraint and the client's wrist to prevent the
client from slipping her hand out of the restraint.
- The nurse should use a quick-release tie to secure the restraints
to the bed.
A nurse is caring for a client who asks about the purpose of
advance directives. Which is the appropriate response? Correct
Answer - A court may only overrule an adult client's refusal of
medical treatment if the client is deemed incompetent.
- The Americans of Disabilities Act, not advance directives,
protects the privacy of a client who chooses not to disclose a
medical disability.
- Advance directives include living will, which permits the client
to direct treatment in the event of a terminal illness.
- The Emergency Medical Treatment and Active Labor Act, not
advance directives, permits emergency personnel to provide care
in the event of an emergency medical situation.
, A nurse is checking BP at a community health screening. Which
of the following clients is at high risk for primary hypertension?
Correct Answer - The client who is pregnant, takes oral
contraceptives, and has kidney disease is at risk for secondary
hypertension.
- The client who has an elevated LDL is at risk for primary
hypertension.
A nurse is giving an end-of-shift report about a client admitted
earlier that day with pneumonia. Which of the following pieces
of information is most essential to provide? Correct Answer -
Although the admitting diagnosis, diagnostic tests, and body
temp. are important info. for the nurse to provide in order to plan
care, they are not highest priority.
- When using the airway, breathing, circulation approach to
client care the nurse determines the priority info. to provide are
the client's breath sounds.
A nurse is preparing to administer oral medications to a client
who has dysphagia. What are appropriate actions? Correct
Answer - Instruct client to avoid use of straws, this could
increase aspiration.
- Instruct the client to place his chin in downward position when
swallowing to prevent aspiration.
- Administer medication one at a time.
- Encourage client to self-administer medications.
A nurse is teaching a client and his family how to care for the
client's tracheostomy at home. Which of the following
instructions is appropriate for the client and family? Correct
