NUR 101- ATI Practice Assessment 1 Questions And Answers 2022-2023

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NUR 101- ATI Practice Assessment 1 Questions And Answers 2022-2023 A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ens... ure that the medication reaches the inner ear? - Answer- Press gently on the tragus of the client's ear A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? - Answer- A client who has an IV infusion pump receives an additional 250 mL of IV fluid. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? - Answer- Reassure the client that this is an expected response to grief. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? - AnswerFlush the tube with 15 mL of sterile water -Each medication should be dissolved in at least 30 mL of warm, sterile water -medications should be drawn up separately - if the nurse encounters resistance when adm. meds, he should stop and contact the provider A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? - Answer- Stand close to the cabinet when lifting it. DO NOT bend at the waist, keep his feet close together, or use his back muscles for lifting Good Ergonomics p 1043-1044 (Taylor) A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? *** a. "I'm having mild pain" b. "The pain is like a dull ache in my stomach" c. "I notice the pain gets worse after I eat" d. "The pain makes me feel nauseous" - Answer- "The pain is like a dull ache in my stomach" -"I'm having mild pain" (describes the sevarity of the pain. The nurse should use a pain scale to make this more accurate) -"I notice the pain gets worse after I eat" (this is a factor that aggravates the pain) -"The pain makes me feel nauseous" (manifestation of the pain) A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? - Answer- Potassium 5.4mEq/L A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? - Answer- The client holds the cane on the stronger side of the body Proceeding with Ambulation: 1. the patient stands with weight evenly distributed between the feet and the cane 2. The cane is held on the patients stronger side and is advanced 4-12in (10-30cm) 3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane 4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane 5. The weaker leg is moved forward until even with the stronger leg along with advancement of the cane pg 1078 (Taylor) A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? - Answer- Semi-fowler's A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? - Answer- Have family members wear a gown and gloves when visiting. See page 546 (Taylor) A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? - Answer- Ask another nurse to observe the medication wastage. (locking the remaining controlled substance in the cabinet would be a violation of the Controlled Substances Act, page 760-Taylor) A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? - Answer- Narrowed arterial lumen (hearing bruits on the audiotape indicates that blood flowing through the occluded or narrowed arteries Heart Sounds https://www.youtube.com/watch?v=6YY3OOPmUDA A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? - Answer- Subtract the amount of irrigant used from the client's urine output. A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? - AnswerPupil clarity Visual fields Visual acuity Risk for Falls p692 (Taylor) **A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? - Answer- Skin Blanching along with edema and coolness at the IV site A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? - Answer- Gently shake the container of medication prior to administration. DO: Place P in high-fowlers position prior to med admin. DO NOT" a. transfer pre-packaged liquid med into a cup due to risk of altered dosing A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds b. Measure urine output c. Monitor BP readings d. Monitor serum electrolyte levels - Answer- Auscultate lung sounds Why? This assessment is priority when using airway, breathing, and circulation (ABC) approach to monitor fluid-volume excess, which can be a complication of IV therapy. Moist crackles, dyspnea (difficult/labored breathing), and shortness of breath can be adverse effects. A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? - Answer- Use a clock pattern to describe food on the client's plate. (allows for greater independence during meals) A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? a. Erythema on pressure points b. Lower-extremity pulse strength of 2+ c. Fluid intake of 3,000 mL per day d. A bowel movement every other day - Answer- Erythema on pressure points -2+ is an expected finding -Clients should drink between 2,000-3,000mL of fluids a day -bowel movements less frequent than 3/wk indicate constipation and should be further evaluated **A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. Use a restriction bag w/ 80% O2 prior to the procedure b. Select a suction catheter that is half the size of the lumen. c. PLace the end of the suction catheter in a water-soluble lubricant d. Adjust the wall suction apparatus to a pressure of 170 mm Hg - Answer- Select a suction catheter that is half the size of the lumen. (selecting a suction catheter 1/2 size prevents hypoxemia and trauma to the mucosa) Why? -100% O2 should be used - the nurse should lubricate with sterile water or 0.9% sodium irrigation to decrease trauma to the mucosa - 120 mm Hg, no higher than 150 mm hg should be used to prevent hypoxemia and trauma to the mucosa nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? Airborne - Answer- airborne precautions are used for Pts whom have infections that spread via droplet nuclei, that are smaller than 5 microns (includes varicella, TB, and measles) >Droplet nuclei larger than 5 microns require DROPLET precautions (include rubella, meningococcal pneuomia, and streptococcal pharyngitis) >Contact precautions are used for infections spread via direct contact or contact with the environment (incl. vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies) > Protective Equiptment: Clients with a compromised immune system A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend? - Answer- Use progressive relaxation techniques at bedtime. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take FIRST? - Answer- Check the client for injuries A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? a. Smoothie b. Banannas c. Pancakes d. Fried Egg - Answer- fried egg eggs that are poached or scrambled are an acceptable replacement for this item A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? - Answer- "Are you able to help with your hygiene care?" A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? - Answer- "I'll check the wires and cables on my TV to make sure they are in good working order." Additinal Safety Info: >visitors must smoke outside the house >use cotton materials, not woolen or synthetic materials (they can create sparks) >ensure any electrical equipment in the room is functioning properly to avoid electrical sparks >keep the tank upright and secure in its holder at all times A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take FIRST? a. Rinse the feeding bag with water between findings b. Tell the client to keep the head of the bed elevated at least 30 degrees. c. Make sure the enteral formula is at room temperature d. Wipe the top of the formula with alcohol - Answer- Tell the client to keep the head of the bed elevated at least 30 degrees. *all other steps should be followed but the height of the bed is most important Administration Skill is onp1247 (Taylor) A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? - Answer- Have the client stand with her arms at her side and her feet together. (Assesses balance) Romberg Test Skill p680 (Taylor) **A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? - Answer- "You should have a fecal occult blood test every year." -avg risk starts at age 50 Additional Tips: >blood-contrast barium enema every 5yrs >Colorectal cancer screenings begin at age 50. One option is colonoscopy Q10yrs > flexible sigmoidoscopy Q5yrs (Starting on p419-Taylor. See Table 19-1 on p424) A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention b. Decreased blood pressure c. Calf swelling d. Deminished bowel sounds - Answer- Calf swelling Calf swelling includes swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility -bladder distention can cause urinary retention, bladder distention, can be a complication of bed rest due to a loss of muscle tone in bladder and detrusor muscles -A pt on bed rest can develop postural hypotension manifested by a drop in BP when the client moves from lying to sitting. The nurse should also assess for a increase in pulse rate and dizziness -diminished bowel sounds reflect slowed peristalsis and constipation A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? - Answer- Rapid heart rate A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? - Answer- Allow extra time for the client to respond to questions... [Show More]

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