TEST BANK; ATI RN CONCEPT BASED
ASSESMENT LEVEL 1-4 |RATED A+|
1. A nurse is caring for a client who is 2 days postoperative following an above-the-
knee amputation. The client states he is experiencing a dull, burning pain in the
leg that was amputated. Which of the following actions should the nurse take to
treat the client's neuropathic pain? ...ANSWER...Administer a beta-blocking
medication to the client.
(The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.)
2. A newly licensed nurse asks a charge nurse where to find information about
scope of practice for registered nurses. Which of the following responses should
the charge nurse make? ...ANSWER..."The state board of nursing can provide
this information"
(each state develops a nurse practice act, which defines scope of practice for
nurses in that state. This practice act is available on the board of nursing website
for each state.)
3. A nurse is planning care to prevent a catheter-related bloodstream infection for a
client who is receiving IV fluid therapy. Which of the following interventions
should the nurse include in the plan? ...ANSWER...Perform hand hygiene before
touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part of
the infusion system or the client to reduce the risk of catheter-related blood
stream infections.)
4. A nurse is creating a plan of care for a client who is non-ambulatory and has
bladder and bowel incontinence. Which of the following interventions should the
nurse include to prevent skin breakdown? ...ANSWER...Offer the client a glass of
water every two hour when repositioning.
(The nurse should offer the client a glass of water every two hours on the clients
repositioning schedule. This helps prevent dehydration, which increases the risk
of skin breakdown.)
,5. A nurse is teaching a young adult female client about health screening for breast
cancer. Which of the following statements by the client indicates an
understanding of breast self-examination (BSE)? ...ANSWER..."I should expect
to feel a firm ridge along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom
curve of each breast. The client should be able to feel this area during the BSE.
Performing a BSE promotes breast self awareness so that the client knows how
her breast normally feel. The awareness increases the clients ability to identify
changes that require further evaluation.)
6. A nurse is caring for an adolescent who is in critical condition following a motor
vehicle crash which he was the passenger. The clients parent shout at the nurse,
asking why her son is dying instead of the driver. Which of the following actions
should the nurse take to provide emotional support to the
parent? ...ANSWER...Inform the parent that anger is a natural response when
dealing with loss.
(The nurse should identify that the parent is in the anger stage of grief. The nurse
should assist the parent to understand that anger is a natural response to loss
and encourage her to talk about her feelings.)
7. A nurse is teaching an older adult client about accessing electronic resources for
healthcare information on the internet. Which of the following statements should
the nurse include in the teaching? ...ANSWER..."Websites ending in '.gov' are
reliable sites for obtaining health information from government agencies."
(The nurse should teach the client how to select reliable internet websites when
researching health care information. The nurse should identify that websites
ending in '.gov' and '.edu' are considered reliable and credible sources for health
information. Websites ending in '.com' should not be used for researching
credible healthcare information.)
8. A nurse enters a clients room and finds the client lying on the floor. The client
states that on the way to the bathroom her "knee locked," causing her to fall.
Which of the following actions should the nurse take first? ...ANSWER...Check
the client for injuries.
(The first action the nurse should take when using the nursing process is to
assess the client. The nurse should first check the client for injuries and measure
vital signs to help determine physiologic stability. The nurse should also inform
the provider of the clients fall and of the assessment findings.)
9. A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates an
understanding of the teaching? ...ANSWER..."I should use a warm paraffin dip
for my hands and feet."
(The nurse should instruct the client to dip her hands and feet in warm paraffin to
alleviate pain and stiffness. The client can more easily perform hand and finger
exercises following the treatment.)
, 10. A community health nurse is planning prevention strategies for hypertension
among members of her community. The nurse should identify that which of the
following ethnic groups in the community is at greatest risk of developing
hypertension? ...ANSWER...African American
(Evidence-based practice indicates that individuals of AA ethnicity have the highest
prevalence of hypertension. Therefore, the nurse should identify community
members of this ethnicity are at greatest risk of developing hypertension.)
11. A nurse is preparing to extinguish a small fire in a clients room. Which of the
following actions should the nurse take when using the fire
extinguisher? ...ANSWER...Slide the pin on top of the fire extinguisher straight
out.
(The nurse should pull the pin on top of the fire extinguisher to allow for use to
extinguish the fire.)
12. A nurse is preparing to administer intermittent external nutrition via a clients NG
tube. In which order should the nurse take the following actions? ...ANSWER...1.
Assist the client to an upright position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.
(First, the nurse should assist the client into high Fowler's position or raise the
HOB at least 30 degrees to help prevent aspiration. Then, the nurse should verify
the tubes placement by aspirating 5 mL of gastric contents and then testing the
pH. Then, the nurse should check for gastric residual volume. Excessive GRV is
an indication of delayed gastric emptying, which places the client at risk of
aspiration if additional formula is given. Finally, the nurse should flush the tubing
with 30 mL of water to ensure the tube is clear and patent.)
13. A nurse is caring for a 47-year-old female client who had urinary incontinence.
Which of the following actions should the nurse take first? ...ANSWER...Obtain a
specimen from the client for culture.
(The first action the nurse should take when using the nursing process is
assessment. The nurse should obtain a urine specimen from the client to rule out
a UTI. If it is a determined the client has RBC's and WBC's in the urine, the
specimen will require a culture. If it is determined that the client has a UTI, this
will require treatment before any further assessment of incontinence would be
indicated.)
14. A nurse is talking with a client who has a major depressive disorder. The client
states, "Nobody cares if I'm around or not." Which of the following responses
should the nurse make? ...ANSWER..."It sounds as though you're feeling
hopeless."
ASSESMENT LEVEL 1-4 |RATED A+|
1. A nurse is caring for a client who is 2 days postoperative following an above-the-
knee amputation. The client states he is experiencing a dull, burning pain in the
leg that was amputated. Which of the following actions should the nurse take to
treat the client's neuropathic pain? ...ANSWER...Administer a beta-blocking
medication to the client.
(The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.)
2. A newly licensed nurse asks a charge nurse where to find information about
scope of practice for registered nurses. Which of the following responses should
the charge nurse make? ...ANSWER..."The state board of nursing can provide
this information"
(each state develops a nurse practice act, which defines scope of practice for
nurses in that state. This practice act is available on the board of nursing website
for each state.)
3. A nurse is planning care to prevent a catheter-related bloodstream infection for a
client who is receiving IV fluid therapy. Which of the following interventions
should the nurse include in the plan? ...ANSWER...Perform hand hygiene before
touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part of
the infusion system or the client to reduce the risk of catheter-related blood
stream infections.)
4. A nurse is creating a plan of care for a client who is non-ambulatory and has
bladder and bowel incontinence. Which of the following interventions should the
nurse include to prevent skin breakdown? ...ANSWER...Offer the client a glass of
water every two hour when repositioning.
(The nurse should offer the client a glass of water every two hours on the clients
repositioning schedule. This helps prevent dehydration, which increases the risk
of skin breakdown.)
,5. A nurse is teaching a young adult female client about health screening for breast
cancer. Which of the following statements by the client indicates an
understanding of breast self-examination (BSE)? ...ANSWER..."I should expect
to feel a firm ridge along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom
curve of each breast. The client should be able to feel this area during the BSE.
Performing a BSE promotes breast self awareness so that the client knows how
her breast normally feel. The awareness increases the clients ability to identify
changes that require further evaluation.)
6. A nurse is caring for an adolescent who is in critical condition following a motor
vehicle crash which he was the passenger. The clients parent shout at the nurse,
asking why her son is dying instead of the driver. Which of the following actions
should the nurse take to provide emotional support to the
parent? ...ANSWER...Inform the parent that anger is a natural response when
dealing with loss.
(The nurse should identify that the parent is in the anger stage of grief. The nurse
should assist the parent to understand that anger is a natural response to loss
and encourage her to talk about her feelings.)
7. A nurse is teaching an older adult client about accessing electronic resources for
healthcare information on the internet. Which of the following statements should
the nurse include in the teaching? ...ANSWER..."Websites ending in '.gov' are
reliable sites for obtaining health information from government agencies."
(The nurse should teach the client how to select reliable internet websites when
researching health care information. The nurse should identify that websites
ending in '.gov' and '.edu' are considered reliable and credible sources for health
information. Websites ending in '.com' should not be used for researching
credible healthcare information.)
8. A nurse enters a clients room and finds the client lying on the floor. The client
states that on the way to the bathroom her "knee locked," causing her to fall.
Which of the following actions should the nurse take first? ...ANSWER...Check
the client for injuries.
(The first action the nurse should take when using the nursing process is to
assess the client. The nurse should first check the client for injuries and measure
vital signs to help determine physiologic stability. The nurse should also inform
the provider of the clients fall and of the assessment findings.)
9. A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates an
understanding of the teaching? ...ANSWER..."I should use a warm paraffin dip
for my hands and feet."
(The nurse should instruct the client to dip her hands and feet in warm paraffin to
alleviate pain and stiffness. The client can more easily perform hand and finger
exercises following the treatment.)
, 10. A community health nurse is planning prevention strategies for hypertension
among members of her community. The nurse should identify that which of the
following ethnic groups in the community is at greatest risk of developing
hypertension? ...ANSWER...African American
(Evidence-based practice indicates that individuals of AA ethnicity have the highest
prevalence of hypertension. Therefore, the nurse should identify community
members of this ethnicity are at greatest risk of developing hypertension.)
11. A nurse is preparing to extinguish a small fire in a clients room. Which of the
following actions should the nurse take when using the fire
extinguisher? ...ANSWER...Slide the pin on top of the fire extinguisher straight
out.
(The nurse should pull the pin on top of the fire extinguisher to allow for use to
extinguish the fire.)
12. A nurse is preparing to administer intermittent external nutrition via a clients NG
tube. In which order should the nurse take the following actions? ...ANSWER...1.
Assist the client to an upright position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.
(First, the nurse should assist the client into high Fowler's position or raise the
HOB at least 30 degrees to help prevent aspiration. Then, the nurse should verify
the tubes placement by aspirating 5 mL of gastric contents and then testing the
pH. Then, the nurse should check for gastric residual volume. Excessive GRV is
an indication of delayed gastric emptying, which places the client at risk of
aspiration if additional formula is given. Finally, the nurse should flush the tubing
with 30 mL of water to ensure the tube is clear and patent.)
13. A nurse is caring for a 47-year-old female client who had urinary incontinence.
Which of the following actions should the nurse take first? ...ANSWER...Obtain a
specimen from the client for culture.
(The first action the nurse should take when using the nursing process is
assessment. The nurse should obtain a urine specimen from the client to rule out
a UTI. If it is a determined the client has RBC's and WBC's in the urine, the
specimen will require a culture. If it is determined that the client has a UTI, this
will require treatment before any further assessment of incontinence would be
indicated.)
14. A nurse is talking with a client who has a major depressive disorder. The client
states, "Nobody cares if I'm around or not." Which of the following responses
should the nurse make? ...ANSWER..."It sounds as though you're feeling
hopeless."
