ATI
Practice A
1) A nurse is caring for a patient who has a terminal illness and is approaching death. The patient is
short of breath and has noisy respirations from secretions in their airway. Which of the following
actions should the nurse take?
Turn the patient every 2 hr
i) The nurse should turn the pt at least once every 2 hr to break up the secretions in the pt’s
lungs and prevent noisy respirations
Administer an antiemetic every 6 hr
i) The nurse should admin antiemetics for pts experiencing nausea or vomiting. However, this is not the
correct action to take when assisting a pt who’s experiencing respiratory difficulty at the end of life
Hold oral care
i) The nurse should provide frequent oral care in order to keep the pt’s mouth moist and provide comfort
Increase the room’s temperature
i) Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening
windows is more comfortable for a pt who is dying and will decrease air hunger
2) A nurse is caring for a group of patients. Which of the following actions should the nurse take to prevent
the spread of infection?
Carry a patient’s soiled linens out of the room in a mesh linen bag
i) The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission
Place a patient who has tuberculosis in a room with negative pressure airflow
i) A pt who has tb req’s airborne precautions, which include placing the pt in a room that has
negative pressure airflow to reduce the risk of infection transmission
Provide disposable plates and utensils for a patient who is HIV positive
i) Ppl transmit HIV mainly by blood and sexual activity; therefore, a pt who is HIV+ does not req
disposable plates and utensils. Standard precautions are sufficient
Dispose of a patient’s blood saturated dressing in a trash bag inside a second trashbag
i) The nurse should dispose of items that have a large amount of blood in a biohazard bag that is
impervious to micro- organisms
3) 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?
Place the client in a side lying position
i) The nurse should place the client in a supine or dorsal recumbent position for maximal access to the
catheter
Instill 15 mL of irrigation fluid into the catheter with each flush
i) Open irrigation technique requires instilling 30-40 mL of
irrigation fluid c) Subtract the amount of irrigant used from the
client’s urine output
i) The nurse should calculate the fluid used for irrigation and subtract it from the clients total
urinary output
d) Perform the irrigation using a 20 mL syringe
i) The nurse should use a 30- 50 mL syringe to perform open irrigation
4) A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which
they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the
following findings should the nurse identify as a possible cause of the diarrhea?
The client is receiving formula at room temperature
i) Cold formula can cause gastric cramping; therefore, room temperature formula is appropriate and is
likely not because of the clients diarrhea
The feedings in fuse at a slow, continuous drip over 8 hr each night
i) Diarrhea is more likely to develop with rapid installation of enteral formula
The clients caregiver washes out the feeding bag with warm water once every 24 hr
i) Feeding bags should be washed out after each feeding and replaced with a new feeding back every
24 hr to prevent bacterial contamination. The nurse should reinforce this information with the
clients caregiver to avoid future contamination
The clients caregiver flushes the tubing with water before and after administering medications
i) It is correct to flush the tubing with water before and after administering medications to prevent clogging
of the tube
5) A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant.
Which of the following precautions should the nurse plan for this client?
, Make sure the client’s room has at least six air exchanges per hour
i) A protective environment requires at least 12 air exchanges per hour
Make sure the client wears a mask when outside her room if there is construction in the area
i) And allogeneic stem cell transplant compromises the client’s immune system, greatly
increasing the risk for infection. The client will need protection from breathing in any
pathogens in the environment.
Place the client in a private room with negative pressure airflow
i) The nurse should place the client in a private room that provides positive pressure airflow
Wear an N95 respirator when it giving the client direct care
i) The nurse should wear an N 95 respirator mask when caring for clients who require airborne
precautions, not a protective environment
, 6) A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of
the following types of transmission precautions should the nurse initiate?
Protective environment
i) Client to have a compromised immune system require a protective environment
Airborne precautions
i) Airborne precautions or a requirement for clients who have infections that spread via droplet nuclei
that are smaller than 5 microns in diameter, including tuberculosis and measles
Droplets precautions
i) Droplet precautions or a requirement for clients who have infections that spread via droplet nuclei that
are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and a
streptococcal pharyngitis
Contact precautions
i) Major wound infections required contact precautions, which means the nurse should admit the
client to a private room. All caregivers should wear a gown and gloves during direct contact with
this client
7) A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the
following instructions should the nurse include in the teaching?
Remove the outer cannula cautiously for routine cleaning
i) The outer cannula stabilizes the airway; therefore, the client should never remove it
for cleaning b) Use a tracheostomy covers when outdoors
i) Tracheostomy covers protect the client’s airway from cold air, dust and other airborne particles
c) Use sterile technique when performing tracheostomy care at home
i) In the home environment, medical a sepsis with clean technique is appropriate
d) Cleaned irritated skin with full strength hydrogen peroxide
i) Hydrogen peroxide can irritated skin; therefore, the nurse should instruct the client and family to
use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation
8) A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse
notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to
report back in 1 hr. Which of the following actions should the nurse take next?
Document the provider’s statement in the medical record
i) The nurse should document the provider’s directions in the medical record for later reference;
however, another action is the nurse’s priority
Complete an incident report
i) The nurse should prepare an incident report detailing the delay in treatment for later review and action
for prevention of future occurrences; however, another action is the nurse’s priority
Consult the facility’s risk manager
i) The nurse should discuss the situation with the facility’s risk management dept to help
determine the need for preventative actions; however, another actions is the nurse’s priority
Notify the nursing manager
i) The greatest risk to the client is not receiving timely intervention for a deterioration in
physiological status; therefore, the next action the nurse should take is to activate the chain of
command to ensure that the client receives the necessary care
9) A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following
statements should the nurse identify as an indication that the client understands the preoperative teaching she
received about pain management?
“I think I should take my pain medication more often, since it is not controlling my pain”
i) As a 2 on a scale of 0 to 10, this client’s pain is mild. Additional analgesic medication is unnecessary at
this time
“Breathing faster will help me keep my mind off the pain.”
i) Rapid breathing can lead to hyperventilation, while slow, focused, breathing helps induce
relaxation, which can help with managing pain
“It might help me to listen to music while I’m lying in bed.”
i) Listening to music is an effective nonpharmacological intervention for the management of mild
pain
“I don’t want to walk today because I have some pain.”
i) Postoperative clients need to ambulate even if they are having mild pain
10) A nurse is assessing a client’s readiness to learn about insulin self administration. Which of the following
statements should the nurse identify as an indication that the client is ready to learn?
“I can concentrate best in the morning.”
Practice A
1) A nurse is caring for a patient who has a terminal illness and is approaching death. The patient is
short of breath and has noisy respirations from secretions in their airway. Which of the following
actions should the nurse take?
Turn the patient every 2 hr
i) The nurse should turn the pt at least once every 2 hr to break up the secretions in the pt’s
lungs and prevent noisy respirations
Administer an antiemetic every 6 hr
i) The nurse should admin antiemetics for pts experiencing nausea or vomiting. However, this is not the
correct action to take when assisting a pt who’s experiencing respiratory difficulty at the end of life
Hold oral care
i) The nurse should provide frequent oral care in order to keep the pt’s mouth moist and provide comfort
Increase the room’s temperature
i) Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening
windows is more comfortable for a pt who is dying and will decrease air hunger
2) A nurse is caring for a group of patients. Which of the following actions should the nurse take to prevent
the spread of infection?
Carry a patient’s soiled linens out of the room in a mesh linen bag
i) The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission
Place a patient who has tuberculosis in a room with negative pressure airflow
i) A pt who has tb req’s airborne precautions, which include placing the pt in a room that has
negative pressure airflow to reduce the risk of infection transmission
Provide disposable plates and utensils for a patient who is HIV positive
i) Ppl transmit HIV mainly by blood and sexual activity; therefore, a pt who is HIV+ does not req
disposable plates and utensils. Standard precautions are sufficient
Dispose of a patient’s blood saturated dressing in a trash bag inside a second trashbag
i) The nurse should dispose of items that have a large amount of blood in a biohazard bag that is
impervious to micro- organisms
3) 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?
Place the client in a side lying position
i) The nurse should place the client in a supine or dorsal recumbent position for maximal access to the
catheter
Instill 15 mL of irrigation fluid into the catheter with each flush
i) Open irrigation technique requires instilling 30-40 mL of
irrigation fluid c) Subtract the amount of irrigant used from the
client’s urine output
i) The nurse should calculate the fluid used for irrigation and subtract it from the clients total
urinary output
d) Perform the irrigation using a 20 mL syringe
i) The nurse should use a 30- 50 mL syringe to perform open irrigation
4) A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which
they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the
following findings should the nurse identify as a possible cause of the diarrhea?
The client is receiving formula at room temperature
i) Cold formula can cause gastric cramping; therefore, room temperature formula is appropriate and is
likely not because of the clients diarrhea
The feedings in fuse at a slow, continuous drip over 8 hr each night
i) Diarrhea is more likely to develop with rapid installation of enteral formula
The clients caregiver washes out the feeding bag with warm water once every 24 hr
i) Feeding bags should be washed out after each feeding and replaced with a new feeding back every
24 hr to prevent bacterial contamination. The nurse should reinforce this information with the
clients caregiver to avoid future contamination
The clients caregiver flushes the tubing with water before and after administering medications
i) It is correct to flush the tubing with water before and after administering medications to prevent clogging
of the tube
5) A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant.
Which of the following precautions should the nurse plan for this client?
, Make sure the client’s room has at least six air exchanges per hour
i) A protective environment requires at least 12 air exchanges per hour
Make sure the client wears a mask when outside her room if there is construction in the area
i) And allogeneic stem cell transplant compromises the client’s immune system, greatly
increasing the risk for infection. The client will need protection from breathing in any
pathogens in the environment.
Place the client in a private room with negative pressure airflow
i) The nurse should place the client in a private room that provides positive pressure airflow
Wear an N95 respirator when it giving the client direct care
i) The nurse should wear an N 95 respirator mask when caring for clients who require airborne
precautions, not a protective environment
, 6) A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of
the following types of transmission precautions should the nurse initiate?
Protective environment
i) Client to have a compromised immune system require a protective environment
Airborne precautions
i) Airborne precautions or a requirement for clients who have infections that spread via droplet nuclei
that are smaller than 5 microns in diameter, including tuberculosis and measles
Droplets precautions
i) Droplet precautions or a requirement for clients who have infections that spread via droplet nuclei that
are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and a
streptococcal pharyngitis
Contact precautions
i) Major wound infections required contact precautions, which means the nurse should admit the
client to a private room. All caregivers should wear a gown and gloves during direct contact with
this client
7) A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the
following instructions should the nurse include in the teaching?
Remove the outer cannula cautiously for routine cleaning
i) The outer cannula stabilizes the airway; therefore, the client should never remove it
for cleaning b) Use a tracheostomy covers when outdoors
i) Tracheostomy covers protect the client’s airway from cold air, dust and other airborne particles
c) Use sterile technique when performing tracheostomy care at home
i) In the home environment, medical a sepsis with clean technique is appropriate
d) Cleaned irritated skin with full strength hydrogen peroxide
i) Hydrogen peroxide can irritated skin; therefore, the nurse should instruct the client and family to
use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation
8) A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse
notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to
report back in 1 hr. Which of the following actions should the nurse take next?
Document the provider’s statement in the medical record
i) The nurse should document the provider’s directions in the medical record for later reference;
however, another action is the nurse’s priority
Complete an incident report
i) The nurse should prepare an incident report detailing the delay in treatment for later review and action
for prevention of future occurrences; however, another action is the nurse’s priority
Consult the facility’s risk manager
i) The nurse should discuss the situation with the facility’s risk management dept to help
determine the need for preventative actions; however, another actions is the nurse’s priority
Notify the nursing manager
i) The greatest risk to the client is not receiving timely intervention for a deterioration in
physiological status; therefore, the next action the nurse should take is to activate the chain of
command to ensure that the client receives the necessary care
9) A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following
statements should the nurse identify as an indication that the client understands the preoperative teaching she
received about pain management?
“I think I should take my pain medication more often, since it is not controlling my pain”
i) As a 2 on a scale of 0 to 10, this client’s pain is mild. Additional analgesic medication is unnecessary at
this time
“Breathing faster will help me keep my mind off the pain.”
i) Rapid breathing can lead to hyperventilation, while slow, focused, breathing helps induce
relaxation, which can help with managing pain
“It might help me to listen to music while I’m lying in bed.”
i) Listening to music is an effective nonpharmacological intervention for the management of mild
pain
“I don’t want to walk today because I have some pain.”
i) Postoperative clients need to ambulate even if they are having mild pain
10) A nurse is assessing a client’s readiness to learn about insulin self administration. Which of the following
statements should the nurse identify as an indication that the client is ready to learn?
“I can concentrate best in the morning.”
