ATI FINAL

1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The

nurse understands that the most important aspect of hand hygiene is the amount of

Friction

2. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client

about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the

client may be unprepared to learn if the client

reports severe pain.

3. A client comes to the emergency department reporting that he has had diarrhea for 4 days

and is urinating less than usual. When assessing the client’s skin turgor, the nurse should

grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back.

4. A nurse is planning interventions for a group of clients who are obese. What can the

nurse do to improve their commitment to a long term goal of weight loss?

Attempt to develop the clients’ self-motivation.

5. When admitting a client, the nurse records which information in the client’s record first?

Assessment of the client

6. A nurse tells a client that the provider has prescribed IV fluids. The client appears to be

upset about the IV catheter insertion, but says nothing to the nurse. Which of the

following of the following is an appropriate nursing response?

"Is there something about this procedure that concerns you?"

7. A client who is unstable and requires frequent vital signs has an electronic blood pressure

machine automatically measuring his blood pressure every 15 min. However, the

machine is reading the client’s blood pressure at more frequent intervals, and the readings

are not similar. The nurse checks the machine settings and observes the additional

readings, but the problem continues. Which of the following is the appropriate nursing

action?

Disconnect the machine, and measure the blood pressure manually every 15 min.

8. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is

resistant to learning self injection of insulin and asks the nurse to administer all the

injections. The nurse explains the importance of learning self care and appropriately adds

which of the following statements?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

9. An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or

four times a day. I get angry, and I think that the client is doing it just to get attention. I

think we should put adult diapers on her." Which is the appropriate nursing response?

"It is very upsetting to see an adult client regress."

10. A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated

that a moderate amount of blood loss is expected during the surgery, and the neighbor is

anxious about acquiring an infection from a blood transfusion. Which of the following is

appropriate for the nurse to suggest?

Donating autologous blood before the surgery

11. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart

murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the

stethoscope at which location?

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Second intercostal space to the right of the sternum.

12. A client is admitted to the hospital with decreased circulation in the left leg. During the

admission assessment, which is the most important nursing action initially?

Evaluate the pedal pulses.

13. A nurse is caring for a client who requires rectal temperature monitoring. Available at the

client's bedside is a thermometer is with a long, slender tip. Which of the following is the

appropriate action for the nurse to take?

Obtain a thermometer with a short, blunt insertion end.

14. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of

sodium and cholesterol. The nurse understands that the most significant factor in

planning dietary changes for this client is the

involvement of the client in planning the change.

15. A nurse is caring for an older adult client who is confused and continually grabs at the

nurses. Which of the following is an nursing action?

Firmly tell him to not grab

16. An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure

cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?"

The nurse replies that taking the blood pressure of a morbidly obese client with a regular

blood pressure cuff will result in a reading that is

high

17. Which of the following should the nurse do first when preparing to provide tracheostomy

care?

Perform hand hygiene.

18. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The

client returns from the post anesthesia care crying, but awake, from the recovery room.

Which approach is likely to be successful?

Examine the mouth last.

19. A nurse admits a client to a same-day surgery center for an exploratory laparotomy

procedure this morning. The client’s surgeon asks the nurse to witness the signing of the

preoperative consent form. In signing the form as a witness, the nurse affirms that

the signature on the preoperative consent form is the client's.

20. To use proper body mechanics while making an occupied bed for a client on bed rest, the

nurse should

place the bed in a high horizontal position.

21. Which of the following should a group of community health nurses plan as part of a

primary prevention program for occupational pulmonary diseases?

Elimination of the exposure

22. When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of

the following assessment findings prior to beginning chest compressions?

Absence of pulse

23. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a

back injury, which of the following techniques should the nurse use?

Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on

the nurse’s shoulders, and the nurse’s hands under the client’s axillae.

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