ATI practice assessment A questions and solutions
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/mi
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
to 110/min and becomes irregular. Which of the following actions should the nurse take?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Obtain a cardiology consult.
mi mi mi mi
B. Suction the client less frequently.
mi mi mi mi mi
C. Administer an antidysrhythmic medication.
mi mi mi mi
D. Perform pre-oxygenation prior to suctioning. - answersD. Perform pre-oxygenation prior to suctioning
mi mi mi mi mi mi mi mi mi mi mi mi
Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
accumulated secretions from the airways.
mi mi mi mi mi
Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue
mi mi mi mi mi mi mi mi mi mi mi mi mi
injury.. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
resuscitator bag set at 100% oxygen.
mi mi mi mi mi mi
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. BP mi
B. Heart rate mi mi
C. Urine output mi mi
D. Weight - answersB. Heart rate
mi mi mi mi mi
When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore,
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team wi
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Epinephrine mi
B. Magnesium mi
C. Atropine mi
D. Sodium bicarbonate - answersC. Atropine
mi mi mi mi mi
The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
- The team administers epinephrine during CPR to clients who have systole or pulseless electrical activity.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
- The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
ventricular tachycardia.
mi mi
- The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
following clients?
mi mi
A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
B. A client who has terminal cancer and needs assistance with pain management
mi mi mi mi mi mi mi mi mi mi mi mi
C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
D. A client who has dementia and needs help with activities of daily living - answersB. A client who has terminal cancer a
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
needs assistance with pain management
mi mi mi mi mi
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10
,A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
Hospice care provides the client with physical and psychological support, which includes management of symptoms,
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
such as pain and dyspnea.
mi mi mi mi mi
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
reliable measure of fluid retention?
mi mi mi mi mi
A. Daily weight mi mi
B. Sodium level mi mi
C. Tissue turgor mi mi
D. Intake and output - answersA. Daily weight
mi mi mi mi mi mi mi
Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
volume over time.
mi mi mi
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
should the nurse expect?
mi mi mi mi
A. Frothy sputum mi mi
B. Dependent edema mi mi
C. Nocturnal polyuria mi mi
D. Jugular distention - answersA. Frothy sputum
mi mi mi mi mi mi
Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking
mi mi mi mi mi mi mi mi mi mi mi mi mi
cough, frothy sputum, wheezing, fatigue, and weakness. All the other options are signs of right-sided heart failure.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliab
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
indicator of central cyanosis?
mi mi mi mi
A. Oral mucosa mi mi
B. Conjunctivae mi
C. Ear lobes mi mi
D. Soles of the feet - answersA. Oral mucosa
mi mi mi mi mi mi mi mi
According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
central cyanosis because cyanosis is most evident in areas with minimal pigmentation.
mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for th
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
client?
mi
A. Short peripheral catheter
mi mi mi
B. Implanted infusion port
mi mi mi
C. Peripherally inserted central catheter
mi mi mi mi
D. Arteriovenous fistula - answersC. Peripherally inserted central catheter
mi mi mi mi mi mi mi mi
A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months. PICC lines
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
can also be used to draw blood samples without the need for additional venipunctures.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
should wear a gown as personal protective equipment when taking which of the following actions?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Talking to the client at the bedside
mi mi mi mi mi mi mi
B. Administering an intermittent IV bolus medication
mi mi mi mi mi mi
C. Completing a dressing change
mi mi mi mi
2/ mimimimi mimimimi
10
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/mi
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
to 110/min and becomes irregular. Which of the following actions should the nurse take?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Obtain a cardiology consult.
mi mi mi mi
B. Suction the client less frequently.
mi mi mi mi mi
C. Administer an antidysrhythmic medication.
mi mi mi mi
D. Perform pre-oxygenation prior to suctioning. - answersD. Perform pre-oxygenation prior to suctioning
mi mi mi mi mi mi mi mi mi mi mi mi
Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
accumulated secretions from the airways.
mi mi mi mi mi
Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue
mi mi mi mi mi mi mi mi mi mi mi mi mi
injury.. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
resuscitator bag set at 100% oxygen.
mi mi mi mi mi mi
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. BP mi
B. Heart rate mi mi
C. Urine output mi mi
D. Weight - answersB. Heart rate
mi mi mi mi mi
When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore,
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team wi
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Epinephrine mi
B. Magnesium mi
C. Atropine mi
D. Sodium bicarbonate - answersC. Atropine
mi mi mi mi mi
The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
- The team administers epinephrine during CPR to clients who have systole or pulseless electrical activity.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
- The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
ventricular tachycardia.
mi mi
- The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
following clients?
mi mi
A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
B. A client who has terminal cancer and needs assistance with pain management
mi mi mi mi mi mi mi mi mi mi mi mi
C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
D. A client who has dementia and needs help with activities of daily living - answersB. A client who has terminal cancer a
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
needs assistance with pain management
mi mi mi mi mi
1/ mimimimi mimimimi
10
,A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
Hospice care provides the client with physical and psychological support, which includes management of symptoms,
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
such as pain and dyspnea.
mi mi mi mi mi
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
reliable measure of fluid retention?
mi mi mi mi mi
A. Daily weight mi mi
B. Sodium level mi mi
C. Tissue turgor mi mi
D. Intake and output - answersA. Daily weight
mi mi mi mi mi mi mi
Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
volume over time.
mi mi mi
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
should the nurse expect?
mi mi mi mi
A. Frothy sputum mi mi
B. Dependent edema mi mi
C. Nocturnal polyuria mi mi
D. Jugular distention - answersA. Frothy sputum
mi mi mi mi mi mi
Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking
mi mi mi mi mi mi mi mi mi mi mi mi mi
cough, frothy sputum, wheezing, fatigue, and weakness. All the other options are signs of right-sided heart failure.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliab
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
indicator of central cyanosis?
mi mi mi mi
A. Oral mucosa mi mi
B. Conjunctivae mi
C. Ear lobes mi mi
D. Soles of the feet - answersA. Oral mucosa
mi mi mi mi mi mi mi mi
According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
central cyanosis because cyanosis is most evident in areas with minimal pigmentation.
mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for th
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
client?
mi
A. Short peripheral catheter
mi mi mi
B. Implanted infusion port
mi mi mi
C. Peripherally inserted central catheter
mi mi mi mi
D. Arteriovenous fistula - answersC. Peripherally inserted central catheter
mi mi mi mi mi mi mi mi
A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months. PICC lines
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
can also be used to draw blood samples without the need for additional venipunctures.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
should wear a gown as personal protective equipment when taking which of the following actions?
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Talking to the client at the bedside
mi mi mi mi mi mi mi
B. Administering an intermittent IV bolus medication
mi mi mi mi mi mi
C. Completing a dressing change
mi mi mi mi
2/ mimimimi mimimimi
10
