ATI testing level 2 proctored exam
A community health nurse is teaching a group of older adult clients about interventions
to prevent pneumonia. Which of the following instructions should the nurse include in
the teaching?
"Obtain a pneumococcal vaccination every 2 years."
"Contact your provider if you have a fever that lasts 18 hours."
"Wash your hands when you return home from running errands."
"Avoid exposure to cold air by shopping inside enclosed malls." - ANS -"Wash your
hands when you return home from running errands."
The nurse should instruct clients that handwashing is one way to avoid organisms that
can cause pneumonia. Handwashing after using the restroom or being in public areas
can minimize the risk of developing pneumonia.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's
parents tells the nurse that it is too difficult to cope any longer and has decided to move
out of the house. Which of the following responses should the nurse make?
"Let's talk about a few ways you have dealt with stress in the past."
"I believe that you will regret that decision. Your family needs your support."
"I agree that you have to do what is best for your well-being at this time."
"I think you should try to put your feelings aside and focus solely on your child." - ANS
-"Let's talk about a few ways you have dealt with stress in the past."
This statement by the nurse combines two therapeutic responses, active listening and
focusing. Used together, these techniques facilitate communication by letting the parent
know one's feelings are heard and taken seriously, which conveys acceptance and
respect. Therefore, the parent feels the nurse validates the concerns and becomes
comfortable asking the nurse sensitive questions about the child.
,A nurse has arrived at the site of an accident where a client has sustained a traumatic
amputation of the big toe. Identify the sequence of steps the nurse should take to treat
the musculoskeletal trauma. (Move the steps into the box on the right, placing them in
the order of performance. Use all the steps.) - ANS -The nurse should first call 911 and
examine the amputation site. Next, the nurse should apply direct pressure with layers of
dry cloth to slow or stop the bleeding. Then, the nurse should elevate the affected
extremity above the client's heart to slow the bleeding. Next, the nurse should find the
toe and wrap it in sterile gauze or a clean cloth to decrease contamination for possible
surgical reattachment. Finally, the nurse should place the wrapped toe in a bag and
place the bag in 1 part ice and 3 parts water to maintain tissue integrity for possible
reattachment.
A nurse in a provider's office is assessing a preschooler who has developed contact
dermatitis following exposure to poison ivy. Which of the following statements should
the nurse make to the child's parent regarding disease management?
"Wash your child's exposed clothing in cold water using powder detergent."
"Keep your child away from other children for 10 days after lesions
appear."
"Scrub your child's affected areas with an antibacterial soap every other day."
"Place your child in an oatmeal bath using tepid water for 15 minutes." - ANS -"Place
your child in an oatmeal bath using tepid water for 15 minutes."
The nurse should instruct the parent that tepid baths containing oatmeal or mineral oil
can decrease itching and evenly disperse the antipruritic solution. The parent should not
place the child in a hot bath as this can aggravate the child's condition and increase
itching.
A nurse in a provider's office is completing a preoperative screening for a client who is
scheduled for a knee arthroplasty later that week. Which of the following findings
requires the nurse's intervention? (Click on the exhibit button for additional information
about the client. There are three tabs that contain separate categories of data.) - ANS
-Coagulation time
The nurse should report the client's coagulation time, or INR, to the provider
immediately because it is above the expected reference range, which predisposes the
,client to intraoperative and/or postoperative hemorrhage. The nurse should expect the
provider to postpone the joint arthroplasty until the client's clotting time is within the
expected reference range.
A nurse in an emergency department is assessing a client who has hyperthermia.
Which of the following findings should the nurse identify as an indication that the client
has heat exhaustion?
Hallucinations
Vomiting
Bradycardia
Seizures - ANS -Vomiting
The nurse should identify that heat exhaustion is usually the result of excess sweating,
leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness,
fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F).
A nurse in an emergency department is assessing a client who has type 1 diabetes
mellitus. Which of the following findings should the nurse identify as an indication that
the client has diabetic ketoacidosis?
Seizure activity
Nervousness
Blood glucose 396 mg/dL
Serum pH 7.52 - ANS -Blood glucose 396 mg/dL
A client who has diabetic ketoacidosis will have a blood glucose level above 300 mg/dL
A nurse in an emergency department is assessing a client who is experiencing mild
hypothermia. Which of the following manifestations should the nurse expect?
Stupor
Decreased pulse
, Slurred speech
Dysrhythmias - ANS -Slurred speech
The nurse should expect a client who is experiencing mild hypothermia to exhibit
manifestations such as slurred speech, shivering, decreased coordination, and diuresis.
A nurse in an emergency department is assessing a client who reports severe
constipation. The nurse should identify which of the following findings as an indication
that the client might have a small-bowel obstruction?
Peripheral edema
Minimal vomiting
Intermittent cramping in the lower abdomen
Visible peristaltic waves in the upper abdomen - ANS -Visible peristaltic waves in the
upper abdomen
The nurse should identify that visible peristaltic waves in the upper and middle abdomen
are a manifestation of a small-bowel obstruction. The client might also have abdominal
discomfort or pain.
A nurse in an emergency department is assessing a preschooler who has severe
dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the
following findings should the nurse identify as an indication that the treatment is
effective?
Urine output 0.5 mL/kg/hr
Capillary refill 3 seconds
Heart rate 148/min
Brisk skin turgor - ANS -Brisk skin turgor
The nurse should expect the child to have brisk skin turgor if fluid replacement therapy
is effective.
A community health nurse is teaching a group of older adult clients about interventions
to prevent pneumonia. Which of the following instructions should the nurse include in
the teaching?
"Obtain a pneumococcal vaccination every 2 years."
"Contact your provider if you have a fever that lasts 18 hours."
"Wash your hands when you return home from running errands."
"Avoid exposure to cold air by shopping inside enclosed malls." - ANS -"Wash your
hands when you return home from running errands."
The nurse should instruct clients that handwashing is one way to avoid organisms that
can cause pneumonia. Handwashing after using the restroom or being in public areas
can minimize the risk of developing pneumonia.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's
parents tells the nurse that it is too difficult to cope any longer and has decided to move
out of the house. Which of the following responses should the nurse make?
"Let's talk about a few ways you have dealt with stress in the past."
"I believe that you will regret that decision. Your family needs your support."
"I agree that you have to do what is best for your well-being at this time."
"I think you should try to put your feelings aside and focus solely on your child." - ANS
-"Let's talk about a few ways you have dealt with stress in the past."
This statement by the nurse combines two therapeutic responses, active listening and
focusing. Used together, these techniques facilitate communication by letting the parent
know one's feelings are heard and taken seriously, which conveys acceptance and
respect. Therefore, the parent feels the nurse validates the concerns and becomes
comfortable asking the nurse sensitive questions about the child.
,A nurse has arrived at the site of an accident where a client has sustained a traumatic
amputation of the big toe. Identify the sequence of steps the nurse should take to treat
the musculoskeletal trauma. (Move the steps into the box on the right, placing them in
the order of performance. Use all the steps.) - ANS -The nurse should first call 911 and
examine the amputation site. Next, the nurse should apply direct pressure with layers of
dry cloth to slow or stop the bleeding. Then, the nurse should elevate the affected
extremity above the client's heart to slow the bleeding. Next, the nurse should find the
toe and wrap it in sterile gauze or a clean cloth to decrease contamination for possible
surgical reattachment. Finally, the nurse should place the wrapped toe in a bag and
place the bag in 1 part ice and 3 parts water to maintain tissue integrity for possible
reattachment.
A nurse in a provider's office is assessing a preschooler who has developed contact
dermatitis following exposure to poison ivy. Which of the following statements should
the nurse make to the child's parent regarding disease management?
"Wash your child's exposed clothing in cold water using powder detergent."
"Keep your child away from other children for 10 days after lesions
appear."
"Scrub your child's affected areas with an antibacterial soap every other day."
"Place your child in an oatmeal bath using tepid water for 15 minutes." - ANS -"Place
your child in an oatmeal bath using tepid water for 15 minutes."
The nurse should instruct the parent that tepid baths containing oatmeal or mineral oil
can decrease itching and evenly disperse the antipruritic solution. The parent should not
place the child in a hot bath as this can aggravate the child's condition and increase
itching.
A nurse in a provider's office is completing a preoperative screening for a client who is
scheduled for a knee arthroplasty later that week. Which of the following findings
requires the nurse's intervention? (Click on the exhibit button for additional information
about the client. There are three tabs that contain separate categories of data.) - ANS
-Coagulation time
The nurse should report the client's coagulation time, or INR, to the provider
immediately because it is above the expected reference range, which predisposes the
,client to intraoperative and/or postoperative hemorrhage. The nurse should expect the
provider to postpone the joint arthroplasty until the client's clotting time is within the
expected reference range.
A nurse in an emergency department is assessing a client who has hyperthermia.
Which of the following findings should the nurse identify as an indication that the client
has heat exhaustion?
Hallucinations
Vomiting
Bradycardia
Seizures - ANS -Vomiting
The nurse should identify that heat exhaustion is usually the result of excess sweating,
leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness,
fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F).
A nurse in an emergency department is assessing a client who has type 1 diabetes
mellitus. Which of the following findings should the nurse identify as an indication that
the client has diabetic ketoacidosis?
Seizure activity
Nervousness
Blood glucose 396 mg/dL
Serum pH 7.52 - ANS -Blood glucose 396 mg/dL
A client who has diabetic ketoacidosis will have a blood glucose level above 300 mg/dL
A nurse in an emergency department is assessing a client who is experiencing mild
hypothermia. Which of the following manifestations should the nurse expect?
Stupor
Decreased pulse
, Slurred speech
Dysrhythmias - ANS -Slurred speech
The nurse should expect a client who is experiencing mild hypothermia to exhibit
manifestations such as slurred speech, shivering, decreased coordination, and diuresis.
A nurse in an emergency department is assessing a client who reports severe
constipation. The nurse should identify which of the following findings as an indication
that the client might have a small-bowel obstruction?
Peripheral edema
Minimal vomiting
Intermittent cramping in the lower abdomen
Visible peristaltic waves in the upper abdomen - ANS -Visible peristaltic waves in the
upper abdomen
The nurse should identify that visible peristaltic waves in the upper and middle abdomen
are a manifestation of a small-bowel obstruction. The client might also have abdominal
discomfort or pain.
A nurse in an emergency department is assessing a preschooler who has severe
dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the
following findings should the nurse identify as an indication that the treatment is
effective?
Urine output 0.5 mL/kg/hr
Capillary refill 3 seconds
Heart rate 148/min
Brisk skin turgor - ANS -Brisk skin turgor
The nurse should expect the child to have brisk skin turgor if fluid replacement therapy
is effective.
