ATI-RN Assessment Level 1: Test A 2022
A nurse is assessing a preschooler who has a UTI. Which of the following should the nurse inspect?
A.
... [Show More] Diarrhea
B. Abdominal Pain
C. Increased Thirst
D. Skin Rash ans: B. Abdominal Pain
Other manifestations include constipation, dysuria, foul-smelling urine, fever
A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent GI cancers. Which of the following images indicated a food or beverage the nurse should encourage?
A. Wine
B. Fruit
C. Fried Chicken
D. Bread ans: B. Fruit
Consume at least 2.5 cups of fruit and vegetables per day to help reduce the risk of cancers of the GI system
A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should the nurse take?
A. Aim the extinguisher at the top of the flames
B. Pump the handles of the extinguisher up and down three times
C. Sweep the fire extinguisher in a circular motion until fire is extinguished
D. Slide the pin on the top of the fire extinguisher straight out ans: D. Slide the pin on the top of the fire extinguisher straight out
A nurse is caring for a child who has celiac disease. Which of the following items should be removed from the meal tray?
A. Corn-flake cereal
B. Orange juice
C. Scrambled eggs
D. Oatmeal with raisins ans: D. Oatmeal with raisins
Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats, and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue
A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into sleep promotion plan?
A. "If alcoholic beverages are desires, consume them in the early evening"
B. "Sleep in the location of your home where you feel you rest best."
C. "Turn on a favorite television show just before going to bed."
D. "Allow your sleep and wake times to vary depending on how you feel each day." ans: B. "Sleep in the location of your home where you feel you rest best."
Whether it be a bed, couch, or chair
A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks "why is it wrong to kick your baby sister?" Which of the following responses should the nurse expect?
A. "Its not wrong because she made me mad"
B. "Its wrong because my dad said I cant kick her"
C. "It wrong to kick her because the gods wont like it"
D. "Its wrong because she would get hurt and be sad" ans: B. "Its wrong because my dad said I cant kick her"
The nurse should expect the preschooler to be motivated to choose right from wrong because of rules taught to him by his parents. The nurse should understand that, even though the preschooler might know the rules, he is not yet able to understand the rationale for the rules
A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take?
A. Inform the client that he will not be receiving medications he took prior to his hospitalization
B. Compare a list of the clients current medications with the ones he will take in long-term care
C. Eliminate any OTC products from the clients current medication list
D. Omit the medication indications when listing the clients medication dose information ans: B. Compare a list of the clients current medications with the ones he will take in long-term care
The Joint Commission National Patient Safety Goals regarding medication reconciliation includes maintaining and communicating accurate client medication information. The nurse should complete a medication reconciliation to identify and resolve any discrepancies by comparing the client's list of current medications with the medications he will take in the long-term care facility and addressing any duplications, omissions, or interactions
A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experience in a dull, burning pain in the leg that was amputated. Which of the following should the nurse take to treat the client's neuropathic pain
A. Inform the client that phantom limb pain is not real
B. Administer a beta-blocking medication to the client
C. Place the client on a soft mattress
D. Loosen the bandage on the client's residual limb ans: B. 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
A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the rolling statements by the parent indicates an understanding of the teaching?
A. "I can offer her grapes as long as I peel them first?"
B. "I can give her watermelon pieces after I remove the seeds."
C. "I should give her popcorn that is air-popped and without salt or butter."
D. "I should cut hot dogs into thin, round slices before giving them to her." ans: B. "I can give her watermelon pieces after I remove the seeds."
The nurse should inform the parent that toddlers can easily choke on seeds from fruits, such as watermelon seeds or cherry pits, because of their round shape and size. Removing the seeds and cutting the watermelon into pieces provides the toddler with a nutritious snack that does not increase the toddler's risk of foreign body obstruction
A nurse is searching electronic databases for clinical research about behavior indications of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue
A. Cumulative Index to Nursing and Allied Health Literature (CINAHL)
B. The Nursing Minimum Data Set
C. The Omaha System
D. The Nursing Intervention Classification (NIC) ans: A. Cumulative Index to Nursing and Allied Health Literature (CINAHL)
A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration?
A. Delay the clients meal-time if he is fatigued
B. Instruct the client to tilt his head to the side when swallowing
C. Assist the client with fluid intake by inserting it into the client's mouth with a syringe
D. Encourage the client to focus on a television program during mealtime ans: A. Delay the clients meal-time if he is fatigued
A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test?
A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test
B. Instruct the client to perform the TUG test without the use of the cane
C. Assist the client to stand up from the chair when starting the TUG test
D. Advise the client to use the arms of the chair to stand when starting the TUG test ans: A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test
The nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. The nurse should observe the client's ability to perform the test and use a stopwatch to time the client. The nurse should identify that the client is at increased risk of falls if it takes longer than 14 seconds to complete the test
A nurse in an emergency room is caring for an infant who required emergency surgery. The infant is accompanies by his 16 year old mother and his sternal grandfather. Which of the following should the nurse take when assisting with informed consent
A. Witness consent obtained from the infants mother
B. Inform the family that informed consent is not needed due to the emergency surgery
C. Notify the maternal grandfather that he is required to give informed consent
D. Request that a court-appointed representative provide consent ans: A. Witness consent obtained from the infants mother
The nurse should assist in obtaining informed consent from the infant's mother by witnessing her signature. Statutory guidelines indicate that a minor, even if unemancipated, can provide consent for her infant
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan
A. Change bags of IV solution every 72 hours
B. Perform hand hygiene before touching the IV tubing
C. Use hydrogen peroxide to cleanse the IV insertion site
D. Assess the IV insertion site every 12 hours for redness ans: B. Perform hand hygiene before touching the IV tubing
A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts 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?
A. Encourage the parent to speak with the family of the driver of the car.
B. Inform the parent that anger is a natural response when dealing with loss.
C. Ask the parent to leave and come back later after she has calmed down.
D. Contact a clergy member to come and speak with the parent. ans: B. Inform the parent that anger is a natural response when dealing with loss.
A nurse is teaching about advance directives with an older adult client who has a terminal illness. Which of the following statements should the nurse make?
A. "Having advance directives means that you don't want to receive CPR."
B. "Your next of kin can amend your advance directives for you if you are unconscious."
C. "Advance directives are verbal or written instructions."
D. "Your advance directives can designate a friend to make your health care decisions." ans: D. "Your advance directives can designate a friend to make your health care decisions."
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?
A. "I should stop participating in my bowling league."
B. "I should take a cool shower in the morning to relieve stiffness."
C. "I should decrease my intake of foods containing purine."
D. "I should use a warm paraffin dip for my hands and feet." ans: D. "I should use a warm paraffin dip for my hands and feet."
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
A nurse is caring for a child who has contact dermatitis due to poison ivy. The patient asks the nurse how to prevent further reactions. Which of the following responses should the nurse make?
A. "Rinse your child's skin with hot water within 30 min of contact with the poison ivy plant."
B. "Wash your child's exposed clothing with hot water and detergent."
C. "Scrub your child's exposed skin with warm water and antibacterial soap."
D. "Don't allow your child to have contact with other children who have poison ivy." ans: B. "Wash your child's exposed clothing with hot water and detergent."
This will remove the oil, urushiol, which causes the skin reaction
A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all steps)
- Flush the NG tube with 30 mL of water
- Aspirate 5 mL of gastric contents
- Assist the client to an upright position
- Measure the gastric residual volume
- Test the pH of gastric aspirate ans: 1. Assist the client to an upright position
2. Aspirate 5 mL of gastric contents
3. Test the pH of gastric aspirate
4. Measure the gastric residual volume
5. Flush the NG tube with 30 mL of water
A nurse is providing change of shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include?
A. "The client received a PRN dose of pain medication this morning."
B. "The client has been very tearful since finding out he has diabetes mellitus."
C. "The client's routine vital signs were obtained at 0700, 1100, and 1500."
D. "The client's husband visited during lunch as he has done each day." ans: B. "The client has been very tearful since finding out he has diabetes mellitus."
The nurse should include significant information such as a new diagnosis in the change-of-shift report. The nurse should also identify changes in the client's emotional status that might indicate a need for additional client support and teaching
A nurse is planning care for a newly admitted school age child who has rubeola. Which of the following isolation precautions should the nurse plan to initiate
A. Droplet
B. Airborne
C. Contact
D. Protective environment ans: B. Airborne
Airborne precautions include a private room with negative pressure airflow, with 6 to 12 air exchanges/hr via a high-efficiency particulate air (HEPA) filtration system
A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask?
A. Take the mask off immediately after leaving the client's room.
B. Perform hand hygiene prior to removing the mask.
C. Untie the top strings of the mask and then untie the lower strings.
D. Remove the mask by securely holding the ties and moving it away from the face ans: D. Remove the mask by securely holding the ties and moving it away from the face
A nurse is caring for a client who has cancer and is planning discharge to home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress?
A. "I am thankful for what I have, because things could be worse."
B. "I wish God had not allowed this cancer to invade my body."
C. "I will have to ask my son to read the Torah to me."
D. "I would like to speak to the rabbi at my synagogue." ans: B. "I wish God had not allowed this cancer to invade my body."
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)
A. "I should perform a BSE about 1 week before my period each month."
B. "I should use the fingers of my right hand to feel for lumps in my right breast."
C. "I should report a lump in my breast if it remains for two consecutive BSEs."
D. "I should expect to feel a firm ridge along the bottom curve of each breast." ans: D. "I should expect to feel a firm ridge along the bottom curve of each breast."
A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plant to take?
A. Assist the client to the toilet as soon as the urge to void is reported.
B. Apply an adult diaper to the client during nighttime hours.
C. Gradually lengthen the time between the client's scheduled voids.
D. Decrease the client's fluid intake beginning at 2000 ans: C. Gradually lengthen the time between the client's scheduled voids
A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. Which of the following actions should the nurse take
A. Have the client lie supine.
B. Tell the client to look down toward the floor.
C. Place a finger on the upper eyelid to pull it outward.
D. Instill the drops onto the client's cornea. ans: A. Have the client lie supine.
A nurse in a long term care facility discovers a small fire in a client's trash can. After moving the client to safety, which of the following actions should the ruse take next
A. Return to the room to extinguish the fire.
B. Close the doors and windows on the unit.
C. Pull the alarm to notify emergency services.
D. Turn off oxygen and electrical equipment. ans: C. Pull the alarm to notify emergency services.
A nurse on a pediatric unit is admitting an infant who has pertussis. Which of the follow isolation precautions should the nurse initiate?
A. Protective environment
B. Airborne
C. Droplet
D. Contact ans: C. Droplet
A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. Which of the following plans should the nurse recommend as part of tertiary prevention
A. Offer HIV testing.
B. Start a needle-exchange program.
C. Screen clients who are homeless for drug use.
D. Provide community education about needle sharing. ans: B. Start a needle-exchange program.
A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. Which of the following funding's should the nurse identify as a need for administration of a PRN pain medication?
A. Hypoactive reflexes
B. Increased sleep time
C. Pupils constricted bilaterally
D. Rapid breathing ans: D. Rapid breathing
This change in breathing is a sympathetic nervous system response to acute pain. The nurse should further assess the client's respiratory status and administer a PRN pain medication. Other nonverbal indicators of pain include muscle tension, restlessness, and moaning
A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals Regarding blood administration, which of the following actions should the nurse plan to take?
A. Review the client's medical record for previous transfusion information.
B. Administer premedication to the client as prescribed by the provider. [Show Less]