NURSING 402 ATI Test B
1. A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include?
a. Flex the foot every hour when awake.
b. Place a pillow under the knee when lying in bed.
c. Lower the leg when sitting in a chair.
d. Ensure the leg is abducted when resting in bed.
The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
2. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage
system. Which of the following findings is an indication of lung re-expansion?
a. The chest tube is draining serosanguineous fluid at 65 mL/hr.
b. The client tolerates gentle milking of the
tubing. c. Bubbling in the water seal
chamber has ceased.
d. There is tidaling in the water seal chamber.
Bubbling in the water seal chamber ceases when the lung re-expands.
3. A nurse is reviewing the medical record of a client who is taking warfarin for chronic
atrial fibrillation. Which of the following values should the nurse identify as a desired
outcome for this therapy?
a. INR 1
b. INR
2.5
c. aPTT 45 seconds
d. aPTT 90 seconds
Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction
(MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant,
the medication must be monitored to ensure the anticoagulation is within the
therapeutic range and prevent hemorrhage (high levels of anticoagulation) or
stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted
therapeutic range of 2 to 3 for a client who has atrial fibrillation.
4. A home health nurse is providing teaching to a client who has a stage 1 pressure injury
on the greater trochanter of his left hip. Which of the following instructions should the
nurse include in the teaching?
a. Clean the wound daily with an antiseptic.
b. Use a donut-shaped pillow when sitting in a
chair. c. Change position every hour.
d. Massage the area two times daily.
Changing position every 1 to 2 hr decreases pressure on bony prominences. The
nurse should also instruct the client to limit the angle of the hips when in a lateral
position to no more than 30°. This positioning prevents direct pressure on the
trochanter.
5. A nurse is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse’s priority to report to the provider?
,a. Temperature 37.2° C (99° F)
b. Blood pressure 100/70 mm Hg
c. Weight loss
d.
Restlessness
Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding to report to the provider is restlessness, which can be an
indication the client is experiencing disequilibrium syndrome. Disequilibrium
syndrome is caused by the rapid removal of electrolytes from the client's blood and
can lead to dysrhythmias or seizures. Other manifestations include nausea,
vomiting, fatigue, and headache.
,6. A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following actions
should the nurse take first?
a. Document the client's intake and output.
b. Scan the bladder with a portable ultrasound.
c. Pour warm water over the client's perineum.
d. Perform a straight catheterization.
The first action the nurse should take using the nursing process is to assess the
client. Scanning the bladder with a portable ultrasound device will determine the
amount of urine in the bladder.
7. A nurse is planning a health promotional presentation for a group of African American
clients at a community center. Which of the following disorders presents the greatest
risk to this group of clients?
a. Multiple sclerosis
b. Skin cancer
c. Urolithiasis
d.
Hypertension
When using the safety/risk reduction approach to client care, the nurse should
determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
8. A nurse is caring for a client who has DKA. Which of the following findings should indicate
to the nurse that the client’s condition is improving?
a. Potassium 3.5 mEq/L
b. pH 7.28
c. Glucose 272 mg/dL
d. HCO3- 14 mEq/L
A glucose reading less than 300 mg/dL indicates improvement in the client's status.
9. A nurse is caring for a client following extubation of an endotracheal tube 10 minutes
ago. Which of the following findings should the nurse report to the provider immediately?
a. Stridor
b. Oral secretions
c. Hoarseness
d. Sore throat
Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is stridor. Stridor can indicate a narrowing airway or
possible obstruction caused by edema or laryngeal spasms. The nurse should
report the finding immediately and implement an intervention.
10.A nurse is caring for a client who had a nephrostomy tube inserted 12 hrs ago. Which of
the following findings should the nurse report to the provider?
a. The client's urinary output has
increased. b. The client reports back
pain.
c. The client's urine color is red tinged.
d. The client's BUN is 18 mg/dL.
The nurse should notify the provider if the client reports back pain, which can
indicate that the nephrostomy tube is dislodged or clogged.
11.A nurse is admitting a client who has active tuberculosis. Which of the following types of
, transmission precautions should the nurse initiate?
a. Airborne
b. Droplet
1. A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include?
a. Flex the foot every hour when awake.
b. Place a pillow under the knee when lying in bed.
c. Lower the leg when sitting in a chair.
d. Ensure the leg is abducted when resting in bed.
The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
2. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage
system. Which of the following findings is an indication of lung re-expansion?
a. The chest tube is draining serosanguineous fluid at 65 mL/hr.
b. The client tolerates gentle milking of the
tubing. c. Bubbling in the water seal
chamber has ceased.
d. There is tidaling in the water seal chamber.
Bubbling in the water seal chamber ceases when the lung re-expands.
3. A nurse is reviewing the medical record of a client who is taking warfarin for chronic
atrial fibrillation. Which of the following values should the nurse identify as a desired
outcome for this therapy?
a. INR 1
b. INR
2.5
c. aPTT 45 seconds
d. aPTT 90 seconds
Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction
(MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant,
the medication must be monitored to ensure the anticoagulation is within the
therapeutic range and prevent hemorrhage (high levels of anticoagulation) or
stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted
therapeutic range of 2 to 3 for a client who has atrial fibrillation.
4. A home health nurse is providing teaching to a client who has a stage 1 pressure injury
on the greater trochanter of his left hip. Which of the following instructions should the
nurse include in the teaching?
a. Clean the wound daily with an antiseptic.
b. Use a donut-shaped pillow when sitting in a
chair. c. Change position every hour.
d. Massage the area two times daily.
Changing position every 1 to 2 hr decreases pressure on bony prominences. The
nurse should also instruct the client to limit the angle of the hips when in a lateral
position to no more than 30°. This positioning prevents direct pressure on the
trochanter.
5. A nurse is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse’s priority to report to the provider?
,a. Temperature 37.2° C (99° F)
b. Blood pressure 100/70 mm Hg
c. Weight loss
d.
Restlessness
Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding to report to the provider is restlessness, which can be an
indication the client is experiencing disequilibrium syndrome. Disequilibrium
syndrome is caused by the rapid removal of electrolytes from the client's blood and
can lead to dysrhythmias or seizures. Other manifestations include nausea,
vomiting, fatigue, and headache.
,6. A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following actions
should the nurse take first?
a. Document the client's intake and output.
b. Scan the bladder with a portable ultrasound.
c. Pour warm water over the client's perineum.
d. Perform a straight catheterization.
The first action the nurse should take using the nursing process is to assess the
client. Scanning the bladder with a portable ultrasound device will determine the
amount of urine in the bladder.
7. A nurse is planning a health promotional presentation for a group of African American
clients at a community center. Which of the following disorders presents the greatest
risk to this group of clients?
a. Multiple sclerosis
b. Skin cancer
c. Urolithiasis
d.
Hypertension
When using the safety/risk reduction approach to client care, the nurse should
determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
8. A nurse is caring for a client who has DKA. Which of the following findings should indicate
to the nurse that the client’s condition is improving?
a. Potassium 3.5 mEq/L
b. pH 7.28
c. Glucose 272 mg/dL
d. HCO3- 14 mEq/L
A glucose reading less than 300 mg/dL indicates improvement in the client's status.
9. A nurse is caring for a client following extubation of an endotracheal tube 10 minutes
ago. Which of the following findings should the nurse report to the provider immediately?
a. Stridor
b. Oral secretions
c. Hoarseness
d. Sore throat
Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is stridor. Stridor can indicate a narrowing airway or
possible obstruction caused by edema or laryngeal spasms. The nurse should
report the finding immediately and implement an intervention.
10.A nurse is caring for a client who had a nephrostomy tube inserted 12 hrs ago. Which of
the following findings should the nurse report to the provider?
a. The client's urinary output has
increased. b. The client reports back
pain.
c. The client's urine color is red tinged.
d. The client's BUN is 18 mg/dL.
The nurse should notify the provider if the client reports back pain, which can
indicate that the nephrostomy tube is dislodged or clogged.
11.A nurse is admitting a client who has active tuberculosis. Which of the following types of
, transmission precautions should the nurse initiate?
a. Airborne
b. Droplet
