ATI RN CONCEPT-BASED
ASSESSMENT LEVEL 1 ONLINE
PRACTICE A
The01nurse01should01instruct01the01parent01to01wash01the01child's01clothing01in01hot01wat
er01and01detergent01after01exposure01to01the01poison01ivy01plant.01This01will01remove01th
e01oil,01urushiol,01which01causes01the01skin01reaction.01-01answer--
1.01First,01the01nurse01should01assist01the01client01into01high01Fowler's01position01or01rais
e01the01head01of01the01bed01at01least0130°01to01help01prevent01aspiration.01
2.01Then,01the01nurse01should01verify01the01tube's01placement01by01aspirating01501mL01o
f01gastric01contents01and01then01testing01the01aspirate01pH.01
3.01Then,01the01nurse01should01check01for01gastric01residual01volume01(GRV).01
4.01Excessive01GRV01is01an01indication01of01delayed01gastric01emptying,01which01places
01the01client01at01risk01of01aspiration01if01additional01formula01is01given.01
5.01Finally,01the01nurse01should01flush01the01tubing01with013001mL01of01water01to01ensure
01the01tube01is01clear01and01patent.
A01nurse01is01providing01change-of-
shift01report01about01a01group01of01clients01to01the01oncoming01nurse01at01the01end01of01t
he01shift.01Which01of01the01following01statements01should01the01nurse01include?
1.01"The01client01received01a01PRN01dose01of01pain01medication01this01morning."
2.01"The01client01has01been01very01tearful01since01finding01out01he01has01diabetes01mellit
us."
3.01"The01client's01routine01vital01signs01were01obtained01at010700,011100,01and011500."
4.01"The01client's01husband01visited01during01lunch01as01he01has01done01each01day."01-
01answer--"The01client01has01been01very01tearful01since01finding01out01he01has01diabetes
01mellitus."
Rat:01The01nurse01should01include01significant01information01such01as01a01new01diagnos
is01in01the01change-of-
, shift01report.01The01nurse01should01also01identify01changes01in01the01client's01emotional0
1status01that01might01indicate01a01need01for01additional01client01support01and01teaching.
A01nurse01is01teaching01a01young01adult01female01clients01about01health01screening01for0
1breast01cancer.01Which01of01the01following01statements01by01the01client01indicates01an01
understanding01of01breast01self-examination01(BSE)?
1.01"I01should01perform01a01BSE01about01101week01before01my01period01each01month."
2.01"I01should01use01the01fingers01of01my01right01hand01to01feel01for01lumps01in01my01right
01breast."
3.01"I01should01report01a01lump01in01my01breast01if01it01remains01for01two01consecutive01B
SEs."
4.01"I01should01expect01to01feel01a01firm01ridge01along01the01bottom01curve01of01each01br
east."01-
01answer--"I01should01expect01to01feel01a01firm01ridge01along01the01bottom01curve01of01ea
ch01breast."
Rat:01The01nurse01should01instruct01the01client01that01a01firm01ridge01is01expected01along
01the01bottom01curve01of01each01breast.01The01client01should01be01able01to01feel01this01ar
ea01during01the01BSE.01Performing01a01BSE01promotes01breast01self-
awareness01so01that01the01client01knows01how01her01breasts01normally01feel.01This01awa
reness01increases01the01client's01ability01to01identify01changes01that01require01further01ev
aluation01and01treatment.
A01nurse01is01planning01to01implement01bladder01retraining01for01a01client01who01has01ur
ge01incontinence.01Which01of01the01following01actions01should01the01nurse01plan01to01tak
e?
1.01Assist01the01client01to01the01toilet01as01soon01as01the01urge01to01void01is01reported.
2.01Apply01an01adult01diaper01to01the01client01during01nighttime01hours.
3.01Gradually01lengthen01the01time01between01the01client's01scheduled01voids.
4.01Decrease01the01client's01fluid01intake01beginning01at012000.01-01answer--
Gradually01lengthen01the01time01between01the01client's01scheduled01voids.
Rat:01The01nurse01should01gradually01lengthen01the01time01between01scheduled01voids0
1when01implementing01bladder01retraining.01The01client01is01encouraged01and01taught01t
o01suppress01the01urge01to01void01between01scheduled01voids01through01the01use01of01p
elvic01exercises,01distraction,01and01abdominal01breathing.01When01the01client01is01succ
essfully01able01to01suppress01the01urge,01the01time01between01voids01is01slightly01increa
sed.01This01process01of01scheduled01voiding01promotes01retraining01of01the01bladder01a
nd01decreases01urge01incontinence.
A01nurse01is01administering01enoxaparin01subcutaneously01to01a01client01who01is01posto
perative01and01is01at01risk01of01thromboembolic01events.01What01following01actions01sho
uld01the01nurse01take?
ASSESSMENT LEVEL 1 ONLINE
PRACTICE A
The01nurse01should01instruct01the01parent01to01wash01the01child's01clothing01in01hot01wat
er01and01detergent01after01exposure01to01the01poison01ivy01plant.01This01will01remove01th
e01oil,01urushiol,01which01causes01the01skin01reaction.01-01answer--
1.01First,01the01nurse01should01assist01the01client01into01high01Fowler's01position01or01rais
e01the01head01of01the01bed01at01least0130°01to01help01prevent01aspiration.01
2.01Then,01the01nurse01should01verify01the01tube's01placement01by01aspirating01501mL01o
f01gastric01contents01and01then01testing01the01aspirate01pH.01
3.01Then,01the01nurse01should01check01for01gastric01residual01volume01(GRV).01
4.01Excessive01GRV01is01an01indication01of01delayed01gastric01emptying,01which01places
01the01client01at01risk01of01aspiration01if01additional01formula01is01given.01
5.01Finally,01the01nurse01should01flush01the01tubing01with013001mL01of01water01to01ensure
01the01tube01is01clear01and01patent.
A01nurse01is01providing01change-of-
shift01report01about01a01group01of01clients01to01the01oncoming01nurse01at01the01end01of01t
he01shift.01Which01of01the01following01statements01should01the01nurse01include?
1.01"The01client01received01a01PRN01dose01of01pain01medication01this01morning."
2.01"The01client01has01been01very01tearful01since01finding01out01he01has01diabetes01mellit
us."
3.01"The01client's01routine01vital01signs01were01obtained01at010700,011100,01and011500."
4.01"The01client's01husband01visited01during01lunch01as01he01has01done01each01day."01-
01answer--"The01client01has01been01very01tearful01since01finding01out01he01has01diabetes
01mellitus."
Rat:01The01nurse01should01include01significant01information01such01as01a01new01diagnos
is01in01the01change-of-
, shift01report.01The01nurse01should01also01identify01changes01in01the01client's01emotional0
1status01that01might01indicate01a01need01for01additional01client01support01and01teaching.
A01nurse01is01teaching01a01young01adult01female01clients01about01health01screening01for0
1breast01cancer.01Which01of01the01following01statements01by01the01client01indicates01an01
understanding01of01breast01self-examination01(BSE)?
1.01"I01should01perform01a01BSE01about01101week01before01my01period01each01month."
2.01"I01should01use01the01fingers01of01my01right01hand01to01feel01for01lumps01in01my01right
01breast."
3.01"I01should01report01a01lump01in01my01breast01if01it01remains01for01two01consecutive01B
SEs."
4.01"I01should01expect01to01feel01a01firm01ridge01along01the01bottom01curve01of01each01br
east."01-
01answer--"I01should01expect01to01feel01a01firm01ridge01along01the01bottom01curve01of01ea
ch01breast."
Rat:01The01nurse01should01instruct01the01client01that01a01firm01ridge01is01expected01along
01the01bottom01curve01of01each01breast.01The01client01should01be01able01to01feel01this01ar
ea01during01the01BSE.01Performing01a01BSE01promotes01breast01self-
awareness01so01that01the01client01knows01how01her01breasts01normally01feel.01This01awa
reness01increases01the01client's01ability01to01identify01changes01that01require01further01ev
aluation01and01treatment.
A01nurse01is01planning01to01implement01bladder01retraining01for01a01client01who01has01ur
ge01incontinence.01Which01of01the01following01actions01should01the01nurse01plan01to01tak
e?
1.01Assist01the01client01to01the01toilet01as01soon01as01the01urge01to01void01is01reported.
2.01Apply01an01adult01diaper01to01the01client01during01nighttime01hours.
3.01Gradually01lengthen01the01time01between01the01client's01scheduled01voids.
4.01Decrease01the01client's01fluid01intake01beginning01at012000.01-01answer--
Gradually01lengthen01the01time01between01the01client's01scheduled01voids.
Rat:01The01nurse01should01gradually01lengthen01the01time01between01scheduled01voids0
1when01implementing01bladder01retraining.01The01client01is01encouraged01and01taught01t
o01suppress01the01urge01to01void01between01scheduled01voids01through01the01use01of01p
elvic01exercises,01distraction,01and01abdominal01breathing.01When01the01client01is01succ
essfully01able01to01suppress01the01urge,01the01time01between01voids01is01slightly01increa
sed.01This01process01of01scheduled01voiding01promotes01retraining01of01the01bladder01a
nd01decreases01urge01incontinence.
A01nurse01is01administering01enoxaparin01subcutaneously01to01a01client01who01is01posto
perative01and01is01at01risk01of01thromboembolic01events.01What01following01actions01sho
uld01the01nurse01take?
