ATI PN EXIT EXAM FORM A PROCTORED1. A nurse in a long-term care facility is assisting with an in-
service for newly hired assistive personnel about legal ... [Show More] issues within the facility. Which ofIthe following should the nurse include as an example ofIassault?
ANS: Informing a client the nurse is going to administer an injection even thoug h the client refuses
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2. A nurse is collecting data from who is severe pain. Which ofIthe following questions s hould the nurse ask first?
ANS: "Where is your pain located?"
3. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. F or which of the following results should the nurse notify the provider?
ANS: Platelet count 95,000 mm3
4. A nurse is performing a dressing change for a client who had abdominal surgery 5 day s ago. The nurse notes organs protruding from the incision. Which ofIthe following act ions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked dressings.
5. A nurse is speaking with the adult daughter ofIa client who has Alzheimer's disease. T he daughter states, "I love my dad, but caring for him is wearing me out." Which ofIth e following response should the nurse make?
ANS: "Let's discuss how caring for your father is afollowingecting your health.
6. A nurse is contributing to the plan ofIcare for a care for a client who has chest tube co nnected to a closed drainage system. Which ofIthe following actions should the nurse i nclude in the plan of care?
ANS: Maintain the drainage system below the level ofIthe client's chest.
7. A nurse in an acute mental health facility is caring for a client who has borderline pers onality disorder and reports. "I am going to kill my girlfriend when I get out ofIhere." Which ofIthe following actions should the nurse take?
ANS: Notify the client's care team of the threats against the partner
8. A nurse is admitting a client who is at high risk for suicide. Which ofIthe following ac tions is the nurse's priority?
ANS: Search the client's personal belongings
9. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. W hich ofIthe following actions should the nurse take to promote the client's venous retur n?
ANS: Maintain the sequential compression device.
10. A nurse on an acute care unity is collecting data from a school-
age Child who has cystic fibrosis. Which ofIthe following findings is the priority for th e nurse?
ANS: Reports lack ofIappetite
11. a nurse working in a provider's ofollowingice receives a phone call from the parent ofI a school-
age child who has varicella. The parent asked the nurse when the child can return to sc hool. Which ofIthe following responses should the nurse make?
ANS: "When the lesions have scabbed over."
12. A nurse in a pediatric clinic is collecting the data from a school-
age child whose injuries are inconsistent with the parent's stated cause. Which ofIthe f ollowing actions should the nurse take?
ANS: Report the suspected abuse to a appropriate agency.
13. A nurse is collecting data from a middle adult female client who is taking melatonin. Which ofIthe following responses to the med should the nurse expect?
ANS: Improved sleep
14. A nurse on a pediatric unit is collecting data from four newly admitted clients. Which ofIthe following clients should the nurse identify as being at risk for urinary retention? ANS: A school-
age child who has allergic rhinitis and is taking diphenhydramine.
15. A nurse is preparing to administer purified protein derivative (PPD) to a client who ha s suspected TB. Which ofIthe following actions should the nurse plan to take?
ANS: Ensure the injection produces a wheal on the skin
16. A client who is diagnosed with Parkinson's disease verbalizes frustration due to increas e difollowingiculty with ambulation. Which ofIthe following responses should the nurs e take?
ANS: Perform active ROM with your arms and legs two times a day.
17. a Nurse is collecting data from a client who has multiple fractures following a motor- vehicle crash. For which of the following client statements
ANS: "I am so frustrated. I cannot even open my milk carton for breakfast."
18. A nurse is caring for a client who is 4 hr postoperative following a total thyroidectomy
. Which ofIthe following manifestations should the nurse report to the provider as indi cating possible hypocalcemia?
ANS: Tingling ofIfingers
19. A nurse is caring for a client who has a Penrose drain. To ensure proper placement an d functioning ofIthe drain, which ofIthe following should the nurse expect to observe? ANS: The safety pin is present at the distal end of the drain.
20. A community health nurse is helping to reinforce teaching about hepatitis A with a gro up ofIemployees at a childcare facility. Which ofIthe following characteristics should t he nurse identify as an external factor that can impede learning for the participants? ANS: Poor lighting in the learning setting
21. A nurse is observing newly licensed nurse who is providing tracheostomy care for a cli ent. The nurse identifies proper performance ofIthe procedure when the newly licensed nurse selects which ofIthe following solutions to clean the inner cannula?
ANS: Hydrogen peroxide
22. A nurse is caring for a client who has right sided heart failure. The client's partner exp resses concern the the client will die. Which of the following responses should the nur se make?
ANS: "It is difollowingicult to see someone so sick. What have you been told ab out your partner's prognosis?" [Show Less]
