ATI

1.A nurse is reinforcing teaching about lowering fat and cholesterol in diet with a client who has atherosclerosis.
Which of the following responses by the client indicates an understand of the teaching?
-I will list baked goods to those containing trans-fat (my answer)
-I will limit meat portion to 3 ounces per meal (answer on the reviewer)
-I will use palm oil in my cooking
-I will increase my consumption of 2% milk

2. A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the
following statement by the client indicates the medication is effective?
-I have less oily skin
-I no longer take a stool softener
-I no longer feel nervous
-I continue to lose weight

3. A nurse is inserting an indwelling catheter for a client. The client reports pain when the nurse attempts to inflate
the balloon. Which of the following action should the nurse take?
-Continue to slowly inflate the balloon
-Aspirate the fluid before advancing the catheter
-Gently pull on the catheter to check for resistance
-Instruct the client to bear down as if to void.

4. A nurse is caring for a client who has Parkinson’s disease. The client displays difficulty using utensils while
eating mealtime. For which of the following interdisciplinary team members should the nurse recommend a
referral?
-Occupational therapist
-Physical therapist
-Recreational therapist
-Speech therapist

5. A nurse is reinforcing teaching with a client who is scheduled for colonoscopy. Which of the following client
statement indicates an understanding of the procedure?
-I will need arrangement for a ride home
-I should call the doctor if I feel bloated after the procedure
-I plan to eat light breakfast the morning of the procedure
-I can expect to have sore throat from the breathing tube.

6. A nurse is preparing to enter the room of a client who has tuberculosis. Which of the following personal
protective equipment should the nurse wear?
-Non breather mask
-Surgical mask
-Respirator mask
-venturi mask

7. A nurse is caring for an older adult client who has constipation. Which of the following action should the nurse
take?
-Instruct the client to limit activity
-Encourage a low residue diet (reviewer answer)
-Provide a glass of warm water before breakfast
-Offer foods high in potassium (my answer)

8. A nurse is collecting data from a client who has been admitted with suspected appendicitis. Which of the
following finding in the nurse’s priority to report to the provider?
-WBC count 15,000/mm3
-Loss of appetite
-Rigid board like abdomen
-Temperature of 37.8 C*

9. A nurse is collecting data from a client during an initial health assessment. Which of the following findings
should the nurse identify as a risk factor for osteoporosis?

-Uses a beclomethasone inhaler (my answer)

-Applies estrogen vaginal cream daily (reviewer answer)
-Walks 30 mins per day
-Includes canned of sardines in her diet

10. A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings
should the nurse report to the provider immediately?

-Dizziness
-Joint aches
-Metallic taste
-Lip swelling

11. A nurse is caring for an older adult client who has heart failure. Which of the following findings should the
nurse report to the provider?

-Chest X-ray showing cardiomegaly

-Potassium level 4.5 mEq/L
-Urinary output of 1000 ml in 12 hr.
-PaCo2 55 mmHg

12. An assistive personnel checks the blood glucose level of a client who has diabetes mellitus and reports a blood
glucose level of 42 mm/dL to a nurse. Which of the following action should the nurse take first?
-Validate when the client received the last dose of hypoglycemic medication
-Check the client’s blood pressure
-Review the client’s previous meal intake
-Determine if the client is able to swallow

13. A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforce teaching about the
use of automatic epinephrine injector, which of the following actions is the priority?
-Have a client perform the return demonstration of the equipment
-Instruct the client to store the injector at room temperature
-Inform the client to seek medical attention following administration of the injection
-Review the signs of anaphylaxis with the client.

14. A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the
following statement by the client indicates an understanding of the teaching?
-I’ll hold my cell phone against the ear opposite side of my body
-I’ll make sure I stay away from microwave ovens
-I should have MRI rather than a CAT scan if necessary
-I shouldn’t travel by plane because of airport security

15. A nurse is contributing to the plan of care for client who has neutropenia as a result of chemotherapy. Which of
the following interventions should nurse include in the plan of care? (SATA)

-Bathe daily with an antimicrobial soap

-Insert an indwelling urinary catheter
-Place the client in a private room
-Include fresh leafy greens in the client’s diet
-Restrict children under the age of 13 from visiting

16. A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following
values should the nurse report to the provider?

-Platelets 60,000/mm3
-Aspartate aminotransferase 34 units/L
-Bilirubin 1.0 mg/dL
-Ammonia 55 mg/dL

17. A nurse on the oncology unit is evaluating a client’s response after receiving a dose of aprepitant. Which of the
following therapeutic effects should the nurse expect?

-Decreased dysrhythmias
-Absence of dizziness
-Absence of nausea
-Decreased incisional pain

18. A nurse is collecting data about the status of a client’s advance directives. Which of the following statement by
the client indicate he has advance directives?

-My attorney has copy of my trust on file

-I have a copy of my living will for my medical records
-I have restored to be an organ donor
-My kids know my wishes for when the time is right

19. A nurse is collecting admission history data form a client who is in a semiprivate room. Which of the following
data is the priority for the nurse to address?

-Recent exposure to tuberculosis

-History of generalized anxiety disorder
-Experiences nocturia
-Reports periodic migraine headaches

20. A charge nurses reinforcing teaching about infection control with a newly licensed nurse. Which of the
following actions by the newly licensed nurse indicates an understanding of teaching?

-The nurse performs hand hygiene with soap and water for 15 seconds. (reviewer answer)
-The nurse cleans a blood spill with chlorine bleach
-The nurse uses an electric thermometer for a client who is in contrast isolation (my answer)
-The nurse empties a urinal holding it at waist level.

21. A nurse in the long-term care facility is assigning tasks to assistive personnel. Which of the following tasks
should the nurse delegate to the AP?
-Taking a phone prescription from a provider
-Providing postmortem care
-Determining a client’s need for PRN pain medication
-Instructing a client about the use of an incentive spirometer

22. A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the
nurse anticipate?
-Orange-colored urine
-Referred pain in the right shoulder
-Confusion
-Hypothermia

23. A nurse is performing tracheostomy care for a client who has chronic tracheostomy. Which of the following
action should the nurse take?
-Suction the client for 20 seconds with each pass
-Allow space for one finger to be placed under the tube ties
-Apply suction pressure while inserting the catheter into the trachea
-Sanitize around the stoma with povidone iodine

24. A nurse is reinforcing teaching with a client who is schedule for cardiac catheterization. Which of the following
should the nurse tell the client?

-Numbness in the fingertips

-Feeling of heat
-Urge to urinate
-Pain in the jawline

25. A nurse is assisting in teaching a group of nurses about pain management for older clients. Which of the
following information should the nurse include in the teaching?
-Reassess the effectiveness of the pain relief measures every 3 hours.
-Recognize that a cognitively impaired older adult client can identify the intensity of pain
-Withhold pain medication until the client reports a pain level of 6 or higher on a scale from 0 to 10
-Use nonpharmacological measure as a substitute for pain medication.

26. A nurse is receiving change of shift report for a client who had an open reduction internal fixation of the right
femur 8 hrs. ago. Which of the following information should the nurse report to the provider?
-Tingling distal to the fracture
-A temperature of 37.8 C*
-A capillary refill of 4 seconds.
-Sanguineous drainage of 30 ml in the surgical drain at the incisional site

(28)27. A nurse is reinforcing teaching with a client who has a new diagnosis of celiac disease a prescription for a
gluten-free diet. Which of the following food choices should the nurse recommend in the reaching?
-Vegetable barley soup
-Baked chicken with brown rice
-Spaghetti made with wheat pasta

(35)28. A nurse is reviewing the results of a client’s fecal occult blood screening test. Which of the following
findings from the client’s history should the nurse identify as potentially causing a false-positive result?
-The client take ibuprofen for headaches
-The client has a history of breast cancer
-The client has a hemorrhoidectomy 1 year ago
-The client consumed citrus juice 3 days before the test.

29. A nurse is caring for a client who has a double-lumen NG tube set to low continuous suction as a treatment for a
small bowel obstruction. The client reports nausea. Which of the following actions should the nurse take?
-Place the client in the lateral sims position?
-Set the pressure gauge on the suction apparatus at 140 mmHg
-Verify the patency of the tube
-Clamp the antireflux valve of the tube

30. A nurse is preparing to administer ceftriaxone using the Z-track technique to a client who has gonorrhea. After
performing hand hygiene and reconstituting the medication. What order should the nurse use to administer the
medication?
-Put on gloves and cleanse the site with antiseptic swab
-use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 inch) laterally.
-Insert the needle into the muscle
-Aspirate by pulling back on the plunger and inject the medication.
-Remove the needle and release the tissue.

31. A nurse is reinforcing teaching with a female client about expected body changes during menopause. Which of
the following statements by the client indicates an understanding of the teaching?
-The use of herbal supplements will decrease vaginal bleeding
-I should expect to have an increased risk for breast cancer
-I will need hormone replacement therapy for the rest of my life
-I should use a vaginal douche to prevent dryness.

32. A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the
nurse report to the provider?
-Urine negative for bilirubin
-Fasting blood glucose 70mg/dL
-Urine positive for ketone
-Glycosylate hemoglobin 5.2%

33. A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statement by the
client indicates an understanding of the teaching?
-I will use an electric razor for shaving
-I will use ibuprofen when I have headache
-I will massage the site after injection
-I will avoid the use of stool softener

34. A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke.
Which of the following statements by the client indicates an understanding of the teaching?

-My risk for stroke increases if my HbA1c level is 6 % or less

-My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke
-Having a total cholesterol level below 200 mg/dL increases my risk for a stroke
-I can decrease my risk for a stroke by losing excess weight.

35. A nurse is preparing to transfer a client from a bed to a stretcher. Which of the following actions should the
nurse take?
-Shift weight to the front foot when pulling the client onto the stretcher
-Position the bed slightly lower than the stretcher
-Instruct the client to cross his arms over his chest
-Ensure the wheels of the bed are unlocked before moving the client.

36. A nurse is caring for a client who has leukemia. Which of the following findings is the highest priority for the
nurse to report to the provider?
-Dysuria
-Weight loss
-Fatigue
-Elevated temperature

37. A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which
of the following foods should the nurse recommend?

-Broccoli
-Bananas
-Asparagus
-Grapes

38. A nurse is reviewing the laboratory data of a client who is 1 day postoperative following an abdominal
hysterectomy. Which of the following findings should the nurse report to the provider?

-Hematocrit 41%
-Creatinine 2.3 mg/dL
-BUN 20 mg/dL
-WBC count 10000/mm3

39. A nurse is reinforcing teaching with a client who has a new prescription for finasteride to treat benign prostatic
hyperplasia. Which of the following information should the nurse include?

-Take his medication for at least 6 months

-Expect the medication’s effects within 2 to 4 weeks
-Avoid foods high in carbohydrates
-Understand that this medication can decrease libido
40. A nurse is reinforcing dietary teaching about reduced sodium intake with a client who has chronic kidney
disease. Which of the following foods should the nurse recommend?

-8 oz. cottage cheese

-1 cup canned carrots
-1 medium baked potato
-2 oz. cheddar cheese with crackers.

41. A nurse in an urgent care facility is obtaining information form a client who was stung by a wasp. Which of the
following findings indicates the client is experiencing anaphylaxis?

-Difficulty swallowing
-Extensive swelling of the limb
-Bilateral tinnitus
-Petechial rash on the abdomen

42. A nurse is assisting with the care of plan for a client who has osteoarthritis. The client reports knee stiffness
upon ambulation. Which of the following intervention should the nurse include in plan of care?

-apply moist heat prior to ambulation

-Rest in a soft chair
-Use continuous passive motion machine
-Delay ambulation until the next day

43. A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the
nurse is appropriate regarding breast-self-examination?

-Perform breast self-examination during the middle of your cycle

-Use small, circular motion working vertically up and down across the breast
-Use the palm of your hands to detect the presence of any large masses under the skin
-Perform breast self-examination while lying on you side

44. A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following
actions should the nurse take to prevent the development of lymphedema?

-Use the client’s left arm to obtain blood samples

-Obtain blood pressure readings using the client’s right arm
-Limit range-of-motion exercises with the effected arm
-Keep both arms below the level of the client’s heart.

45. A client who is taking furosemide is experiencing generalize weakness. The nurse should recommend
consuming which of the following?

-Cucumber slices (reviewer answer)

-Cup of applesauce (my answer)
-Iceberg lettuce
-Cantaloupe wedges

(54)46. A nurse is reinforcing dietary teaching with a client who has a stage III pressure ulcer. Which of the
following foods should the nurse include in the teaching?

-Avocados
-Tuna
-Whole grain
-Carrots.

(55)47. A nurse is caring for a client who has a hearing impairment. Which of the following interventions should
the nurse take to facilitate communication?

-Repeat sentences for clarification

-Increase speaking volume
-Use a low voice pitch
-Speak directly into the client’s ear.

48. A nurse is caring for a client who was admitted with suspected meningitis. Which of the following precautions
should the nurse implement?

-Airborne precaution
-Contact precaution
-Droplet precaution
-Reverse precaution

49. A nurse is collecting data from a client who is 2 days postoperative following a colon resection. Which of the
following findings indicates the need for nursing intervention?

-Oxygen saturated 95%

-Dark brown drainage in NG tube
-Serosanguineous drainage on the wound dressing
-Mild abdominal pain when coughing 3) mins. After receiving pain medication.

50. A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should
the nurse have at the client’s bedside at all times?

-Wrist restraints
-Suction equipment (my answer)
-Back board (reviewer answer)
-Padded tongue blades

51. A nurse is assisting with the care of a client who has closed-chest tube drainage system. Which of the following
actions should the nurse take?

-Monitor for at least 150 ml of drainage every hour

-Clamp the tube for 20 min every 8 hrs.
-Pin the tubing to the client’s bed sheets (reviewer answer)
-Replace the unit when the drainage chamber is full (my answer)

52. A nurse is reinforcing dietary teaching with a client who has a family history of colon cancer. Which of the
following images indicates the type of food the nurse should recommend to the client to minimize his risk of
developing cancer?

-Eat lots of vegetables, fruits and fish. Decrease consumption of red meat (beef, lamb, or pork) and
processed meat.

53. A nurse is reinforcing teaching about foot care for a client who has diabetes. Which of the following statements
indicates an understanding of the teaching?

-I should round the corners of my toenails when trimming them

-I can apply lotion between my toes after shower
-I can wear open-toe shoes
-I should wear cotton socks

54. A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the
following findings indicates the colostomy is functioning properly?

-Passing flatus
-Absent bowel sound
-Stoma is pinkish red
-Tolerating a clear liquid diet

55. A nurse is providing care to a client who has sustained deep partial-thickness burns to the back of both legs.
Which of the following actions should the nurse anticipate taking?

-Restrict the client’s calorie intake to no more than 2000 calories per day
-Administer a diuretic if the client’s urine output falls below 30 mL/hr.
-Limit movement or bending of the clients’ affected extremities
-Change sterile gloves between caring for wounds on different areas of the body.

56. A nurse is caring for a client who has manifestation of an aortic aneurysm. Which of the following diagnostic
test should the nurse expect the provider to prescribed?

-Abdominal ultrasound, Abdominal CT scan, Abdominal MRI

57. A nurse is caring for a client who has a newly applied lower-leg plaster cast. Which of the following is an
appropriate nursing intervention?

-Handle the cast with the palms of the hands instead of the fingers.
-Place the leg in a dependence position until the cast is dry.
-Use a plastic-covered pillow to elevate the extremity
-Ask the client to bear weight to ensure that no pressure points exist.
58. A nurse is assisting with the care of a young adult client who has diabetic ketoacidosis. The client has three
episodes of emesis and reports abdominal pain of 4 on a scale of 0 to 10. Which of the following actions should the
nurse take?
-NO CHOICES

59. A pregnant women visits a clinic during her 21st week of pregnancy. The nurse identifies edema, lip and
oliguria. What condition does the nurse suspects?
-Gestational hypertension
60. A pregnant patient who has type 2 diabetes may require insulin. Why is insulin necessary?
-Oral hypoglycemic agents may be teratogenic

61. The nurse is assessing the newborn and discovers a yellowing of the skin what is true for jaundice that appears
at birth?

-Pathologic

62. A nursery nurse is implementing photography for a jaundice infant. What is the purpose of the phototherapy?
-Converts bilirubin to a water-soluble form to be excreted in the urine

63. Antidote for magnesium sulphate toxicity?

-Calcium gluconate

64. A nurse has just received morning change-of-shift report for four clients. Which of the following clients has the
highest priority need?

-A client who returned 1 hr. ago from lithotripsy and reporting nausea
-A client who has a total abdominal hysterectomy 2 days ago and reporting pain level of 3 on a scale of 0-10
-A client who has a serum potassium level of 5 mEq/L and is schedule for dialysis in the afternoon.
-A client who has an indwelling urinary catheter and has a total urine output of 80 mL over the past 8 hr

65. A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions
should the nurse take?

-Weight the client before and after the treatment

-Monitor the client for diarrhea
-Chill the dialysate prior to infusion
-Use clean gloves when?????

66. Nurse enters a client room and see smoke coming from the bathroom. Which of the following actions should the
nurse take first?

-Assist the client to a nearby common area

-Use a fire extinguisher at the source of the smoke
-Activate fire alarm
-Close the doors to the room and to the bedroom

67. A nurse is reviewing laboratory results for a client who was administer with nausea and vomiting. Which of the
following serum levels of the nurse report to the provider?

-Creatinine 0.8 mg/dL

-Potassium 4.6 mEq/L
-Blood urea nitrogen 15mg/dL
-Sodium 130 mEq/L

68. A nurse is reinforcing teaching with a client who is recovering from gastroenteritis and is beginning oral intake.
Which of the following foods should the nurse recommend?

-vanilla pudding
-cream of broccoli soup
-Lime ice popsicle
-Orange juice
69. A nurse is caring for a client who received a tuberculosis skin test 73 hours ago. When collecting data from the
test site. Which of the following findings indicated a need for further testing?

-Area of ecchymosis, greater than 12 mm in diameter

-Absence of skin response form the test site
-Nonpalpable are of redness less than 5 mm in diameter
-Palpable area of induration, greater than 10 mm in diameter