ATI RN Concept Based Assessment Level 1, Exam Questions & Answers-A nurse is caring for a client who is 2 days postoperative following an above-the-knee
... [Show More] amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain?
- Administer a beta-blocking medication to the client.
(The nurse should 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 newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. Which of the following responses should the charge nurse make?
- "The state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for nurses in that state. This practice act is available on the board of nursing website for each state.)
A nurse is planning care to prevent a catheter-related bloodstream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan?
- Perform hand hygiene before touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part of the infusion system or the client to reduce the risk of catheter-related blood stream infections.)
A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown?
- Offer the client a glass of water every two hour when repositioning.
(The nurse should offer the client a glass of water every two hours on the clients repositioning schedule. This helps prevent dehydration, which increases the risk of skin breakdown.)
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)?
- "I should expect to feel a firm ridge along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom curve of each breast. The client should be able to feel this area during the BSE. Performing a BSE promotes breast self awareness so that the client knows how her breast normally feel. The awareness increases the clients ability to identify changes that require further evaluation.)
A nurse is caring for an adolescent who is in critical condition following a motor vehicle crash which he was the passenger. The clients parent shout 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?
- Inform the parent that anger is a natural response when dealing with loss.
(The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings.)
A nurse is teaching an older adult client about accessing electronic resources for healthcare information on the internet. Which of the following statements should the nurse include in the teaching?
- "Websites ending in '.gov' are reliable sites for obtaining health information from government agencies."
(The nurse should teach the client how to select reliable internet websites when researching health care information. The nurse should identify that websites ending in '.gov' and '.edu' are considered reliable and credible sources for health information. Websites ending in '.com' should not be used for researching credible healthcare information.)
A nurse enters a clients room and finds the client lying on the floor. The client states that on the way to the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take first?
- Check the client for injuries.
(The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the client for injuries and measure vital signs to help determine physiologic stability. The nurse should also inform the provider of the clients fall and of the assessment findings.)
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?
- "I should use a warm paraffin dip for my hands and feet."
(The nurse should instruct the client to 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 community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk of developing hypertension?
- African American
(Evidence-based practice indicates that individuals of AA ethnicity have the highest prevalence of hypertension. Therefore, the nurse should identify community members of this ethnicity are at greatest risk of developing hypertension.)
A nurse is preparing to extinguish a small fire in a clients room. Which of the following actions should the nurse take when using the fire extinguisher?
- Slide the pin on top of the fire extinguisher straight out.
(The nurse should pull the pin on top of the fire extinguisher to allow for use to extinguish the fire.)
A nurse is preparing to administer intermittent external nutrition via a clients NG tube. In which order should the nurse take the following actions?
- 1. Assist the client to an upright position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.
(First, the nurse should assist the client into high Fowler's position or raise the HOB at least 30 degrees to help prevent aspiration. Then, the nurse should verify the tubes placement by aspirating 5 mL of gastric contents and then testing the pH. Then, the nurse should check for gastric residual volume. Excessive GRV is an indication of delayed gastric emptying, which places the client at risk of aspiration if additional formula is given. Finally, the nurse should flush the tubing with 30 mL of water to ensure the tube is clear and patent.)
A nurse is caring for a 47-year-old female client who had urinary incontinence. Which of the following actions should the nurse take first?
- Obtain a specimen from the client for culture.
(The first action the nurse should take when using the nursing process is assessment. The nurse should obtain a urine specimen from the client to rule out a UTI. If it is a determined the client has RBC's and WBC's in the urine, the specimen will require a culture. If it is determined that the client has a UTI, this will require treatment before any further assessment of incontinence would be indicated.)
A nurse is talking with a client who has a major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse make?
- "It sounds as though you're feeling hopeless."
(This statement by the nurse is an example of restraining, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding.)
A charge nurse is teaching a group of newly licensed nurses how to prevent errors during administration of blood transfusions. Which of the following actions should the nurse include?
- Use a new blood administration tubing set for each blood bag infused.
(The nurse should use a new blood infusion tubing set for each component of blood. A blood infusion set should not be reused, even for the same client.)
A nurse is caring for a client who has C. diff infection and is incontinent of stool following a long-term antibiotic therapy. Which of the following actions should the nurse take?
- Wear a gown when providing care for the client.
(The nurse should wear a gown when providing care for a client who has C. diff infection and is incontinent of stool. Applying a clean, water-resistant gown prior to entering the clients room prevents the nurses clothing from becoming contaminated while caring for the client. The nurse should remove the gown prior to exiting the clients room.)
A nurse is providing discharge teaching about nutrition management to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- Have a high-calorie protein drink between meals.
(The nurse should encourage a client who has COPD to drink a high-calorie protein drink between meals. Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain.)
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?
- Delay the clients meal-time if he is fatigued.
(To facilitate safe swallowing and decrease the risk of aspiration, the nurse should encourage the client to test prior to meal-time. If the client is fatigued, the nurse should delay the meal-time and give the client time to rest.)
120 mg x 0.8 mL/80 mg= - 1.2 mL
A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching?
- "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.) [Show Less]