ATI Practice Test - Learning System Fundamentals 2 A client’s provider has ordered that a sputum specimen be collected for culture and sensitivity. The nurse plans to collect his specimen A. after the client has taken an expectorant. D. in the morning, on arising. ATI Practice Test - Learning System Fundamentals 2 A nurse is informed during change-of-shift report that a client who is postoperative has not voided for 8 hr. The appropriate
initial nursing action is to A. assist the client to the bathroom. C. palpate and percuss the client’s bladder. Rationale: ATI Practice Test - Learning System Fundamentals 2 When assisting an older adult client with dysphagia at mealtime, the nurse should A. encourage the client to drink plenty of fluids. B. offer the client tart and sour foods. Rationale: ATI Practice Test - Learning System Fundamentals 2 A client admitted for evaluation and control of hypertension. Several hours after the client’s admission, the nurse discovers teh client supine on the floor, unresponsive to verbal or painful stimuli. The nurse’s first action at this time should be to A. establish an airway ATI Practice Test - Learning System Fundamentals 2 A client has just been transferred from the postanesthesia care unit following abdominal surgery. To prevent atelectasis, which measure does the nurse plan to include in the client’s care? A. Administer 40% oxygen via humidified face mask. B. Have the client use the incentive spirometer q1 to 2 hr while awake. ATI Practice Test - Learning System Fundamentals 2 A client is admitted to the hospital for evaluation of inadequate circulation to the lower extremities. The provider prescribes a tub bath at the client’s request. While assisting the client with the bath, the nurse would put the client at risk with which of the following actions? A. Filling the tub about one third full B. Asking if the water is the right temperature when the client steps into the tub ATI Practice Test - Learning System Fundamentals 2 A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as A. purulent. ATI Practice Test - Learning System Fundamentals 2 A client who reports shortness of breath requests the nurse’s help in changing position. In addition to repositioning the client, the nurse should give highest priority A. giving the client a back rub to
help her relax. D. observing the rate, depth, and character of the client’s respirations. ATI Practice Test - Learning System Fundamentals 2 A nurse is caring for a client who is 2 postoperative following had abdominal surgery. The nurse is concerned about which of the following findings? A. Shallow respirations 20/min D. A wound dressing with thick, light green drainage ATI Practice Test - Learning System Fundamentals 2 A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse A. refrigerates the collects specimen. A. refrigerates the collects specimen. ATI Practice Test - Learning System Fundamentals 2 A client is in the bathroom. The nurse hears a loud thud, and after opening the bathroom door, sees the client lying on the floor. The nurse’s first reaction should be to A. call for help. B. determine unresponsiveness. ATI Practice Test - Learning System Fundamentals 2 A client admitted to a long-term care facility requires total care. In providing mouth care for the client, the appropriate nursing action is to A. place the client on his back with a pillow under his head. D. turn the client on his side before starting mouth care. ATI Practice Test - Learning System Fundamentals 2 A provider prescribes a cleansing enema for a client having bowel surgery. Which of the following nursing interventions is appropriate during this procedure? A. Place the solution bag 3 feet above the client. D. Position the client on his left lateral side. ATI Practice Test - Learning System Fundamentals 2 A nurse caring for preoperative client administers atropine as prescribed to A. decrease oral and respiratory secretions. A. decrease oral and respiratory secretions. ATI Practice Test - Learning System Fundamentals 2 When obtaining a urine specimen and culture and sensitivity from an indwelling catheter, the nurse should: A. cleanse the entry port prior to withdrawing urine. A. cleanse the entry port prior to withdrawing urine. ATI Practice Test - Learning System Fundamentals 2 Following an accidental fall while playing volleyball, a client is sent home in a lower leg cast due to a hairline fracture of the tibia and must use crutches. When reinforcing teaching about the four-point gain, the nurse explains that the client should A. keep his elbows extended. B. be able to bear weight on both legs. ATI Practice Test - Learning System Fundamentals 2 A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by a secondary intention. When changing the client’s dressing, which observation should the nurse report to the charge nurse? A. A halo of erythema on the surrounding skin A. A halo of erythema on the surrounding skin Rationale: ATI Practice Test - Learning System Fundamentals 2 A client newly diagnosed with diabetes mellitus is admitted to the hospital. When obtaining a urine specimen from the client, the nurse should avoid A. putting the empty urine specimen cup in
the client’s bathroom. B. placing the full specimen cup in a clean plastic bag on arrival at the laboratory pickup area. ATI Practice Test - Learning System Fundamentals 2 A client who has pancreatic cancer will be using patient-controlled analgesia (PCA) with morphine sulfate (Roxanol) to manage chronic pain. Which of the following instructions should the nurse reinforce with the client and family? A. “Remember to press the button hen you begin to sense pain.” A. “Remember to press the button hen you begin to sense pain.” ATI Practice Test - Learning System Fundamentals 2 A client has just had an indwelling urinary catheter inserted. If the nurse took all of the following actions, he used improper technique when he A. inserted the catheter an additional 1 to 2 inches after observing urine in the drainage tubing. C. cleansed the client’s urinary meatus with soap and water prior to inserting the catheter. ATI Practice Test - Learning System Fundamentals 2 A nurse is caring for a client who is paralyzed on the right side following a cerebrovascular accident (CVA). When preparing to give a bed bath to the client, the nurse A. put the bed in low semi-Fowler’s position. C. raise the bed to the high horizontal position. ATI Practice Test - Learning System Fundamentals 2 A nurse is caring for a client who is 1-day postoperative following abdominal surgery. What is the first action the nurse should take after discovering that the client’s wound has eviscerated? A. Have the client lie on his back with his knees flexed. B. Cover the incision with a moist sterile dressing. ATI Practice Test - Learning System Fundamentals 2 A client receiving chemotherapy has developed stomatitis. An appropriate lunch selection for this client is A. cheese omelet, cherry gelatin, milkshake. A. cheese omelet, cherry gelatin, milkshake. Rationale: ATI Practice Test - Learning System Fundamentals 2 When reinforcing teaching about colostomy care, the nurse reminds the client to replace the bag. A. every other day. ATI Practice Test - Learning System Fundamentals 2 A client’s postoperative orders include administering a medication the nurse has never heard of. The drug reference available on the nursing unit does not list the medication. The nurse should A. call the charge nurse and ask her to question the order. C. call the facility’s pharmacy and ask for a package insert. ATI Practice Test - Learning System Fundamentals 2 In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will A. require skin grafting for the wound to heal. C. be at an increased susceptibility for infection. ATI Practice Test - Learning System Fundamentals 2 A client awake at 0100 says to the nurse, “The staff is making too much noise, and I haven’t had a decent night’s sleep since my wife died a year ago. Please get me a cup of hot tea to help me relax and quench my thirst.” Which of the following should the nurse do? A. Get the cup of hot tea the client requested. C. Offer to get a warm glass of milk for the client. ATI Practice Test - Learning System Fundamentals 2 A nurse overseeing an assistive personnel (AP) instructs the AP to include a draw sheet on the occupied bed she is making. THe nurse explains that the purpose of the draw sheet is to A. absorb urine, feces, and bodily secretions. D. aid in positioning the client. ATI Practice Test - Learning System Fundamentals 2 An nurse is performing an eye irrigation for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation? A. Cleansing the eyelids prior to the irrigation. C. Wearing gloves during the procedure. ATI Practice Test - Learning System Fundamentals 2 A nurse is observing a client who is postoperative following thoracic surgery. Which of the following manifestations should alert the nurse to the possibility of early hypovolemic shock? A. Bradycardia ATI Practice Test - Learning System Fundamentals 2 A nurse is caring for a client who has just had a mastectomy and has a closed wound-suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device? A. Emptying the device when it’s full B. Collapsing the device whenever it is 1/2 to 2/3 full of air ATI Practice Test - Learning System Fundamentals 2 An assistive personnel reports that a client’s intravenous (IV) infusion has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client’s infusion line and insertion site? A. The infusion slows or stops while the tubing is not kinked. B. The area around the injection site feels warm when touched. ATI Practice Test - Learning System Fundamentals 2 When reinforcing teaching for a client who has diabetes mellitus, the nurse should first A. advise the client that bathing regularly is very important. B. ask which hygienic measures the client is presently using. ATI Practice Test - Learning System Fundamentals 2 A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes,what should the nurse use to reduce skin irritation around the incision? A. Large absorbent pads ATI Practice Test - Learning System Fundamentals 2 A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour? A. Eight to 12 |
Which of the following actions should the nurse perform first after discovering that the clients wound has eviscerated?
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