A and B ATI 2022 .
A nurse is planning to improve selffeeding for a client who has vision loss.
Which of the following interventions should the nurse include in the plan of
care?
Use a clock pattern to describe food on the client's plate.
Describing the location of food using clock pattern allows client to have greater
independence during meals.
A nurse is planning an education session for an older adult client who has just
learned that she has type 2 diabetes mellitus. Which of the following
strategies should the nurse plan to use with this client?
Allow extra time for the client to respond to questions.
Older adults often process information at slower rate than younger clients allow
extra time to allow client to ask questions and absorb information
A nurse is caring for a client who has tuberculosis. Which of the following
actions should the nurse take? Select ALL that apply.
Place the client in a room with negativepressure airflow airborne precautions Wear
gloves when assisting the client with oral care standard precautions.
Use antimicrobial sanitizer for hand hygiene wash hands with soap & water when
visibly soiled.
A nurse is caring for a client who has a prescription for 5 units of regular insulin
and 10 units of NPH insulin to mix together and administer subcutaneously.
Determine the correct order of steps for this procedure.
Inject 10 units of air into the bottle of NPH insulin.
Inject 5 units of air into the bottle of regular insulin.
Withdraw the correct dose of regular insulin from the bottle.
Withdraw the correct dose of NPH insulin from the bottle.
A nurse is completing an admission assessment for a client who reports vomiting
and diarrhea for the past 3 days. Which of the following assessment findings
should the nurse expect?
Rapid heart rate
Tachycardia indicates fluidvolume deficit expected
Urine specific gravity would be > 1.030
Hypotension
A nurse is administering IV fluid to an older adult client. The nurse should
perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds.
ABCs monitor for fluidvolume excess
Moist crackles in lungs, dyspnea, SOB
,A and B ATI 2022 .
A nurse is assessing a client's readiness to learn about insulin 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." verbalizing best time for
him to learn.
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?
Contact precautions
Major wound infections require contact precautions admit client to private room.
Caregivers should wear gown & gloves during direct contact.
A nurse is reviewing practice guidelines with a group of newly licensed nurses.
Which of the following interventions should the nurse include that is within the
RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube.
Initiate feedings through nasoenteric, gastrostomy, and jejunostomy tubes.
A nurse is caring for a client who has a prescription for wound irrigation. Which
of the following actions should the nurse take?
Cleanse the wound from the center outward.
Prevent introduction of microorganisms from the outer skin surface.
A nurse is caring for a client who reports pain. When documenting the quality
of the client's pain on an initial pain assessment, the nurse should report which
of the following client statements?
"The pain is like a dull ache in my stomach."
Describing quality of pain
A nurse is caring for a client who is reporting difficulty falling asleep. Which of
the following measures should the nurse recommend?
Use progressive relaxation techniques at bedtime.
promotes sleep by decreasing stress & reducing muscle tension.
A nurse is caring for a client who is postoperative and refuses to use an incentive
spirometer following major abdominal surgery. Which of the following is the
nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
1st Assess
A nurse is preparing to administer multiple medications to a client who has an
enteral feeding tube. Which of the following actions should the nurse plan to
take?
, A and B ATI 2022 .
Flush the tube with 15 mL of sterile water.
Flush with 1530 mL of sterile water before administration and between each
medication. Flush feeding tube with 3060 mL of sterile water following
administration of last medication.
A nurse is caring for a client who has terminal liver cancer. Which of the
following statements should the nurse identify as an indication that the client is
experiencing spiritual distress?
"What could I have done to deserve this illness?"
Review life & question its meaning.
A nurse is administering an otic medication to an older adult client. Which of
the following actions should the nurse take to ensure that the medication reaches
the inner ear?
Press gently on the tragus of the client's ear.
A nurse is performing a Romberg's test during the physical assessment of a
client. Which of the following techniques should the nurse use?
Have the client stand with her arms at her side and her feet together.
Roberg's test helps identify alterations in balance. Observe for swaying & loss of
balance.
A nurse is teaching an older adult client who is at risk for osteoporosis about
beginning a program of regular physical activity. Which of the following types of
activity should the nurse recommend?
Walking briskly.
Weightbearing exercises are essential for maintaining bone mass. Walking engages
older adult clients in preventive & therapeutic strategy.
A charge nurse is discussing the responsibility of nurses caring for clients who
have a Clostridium difficile infection. Which of the following information should
the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
Nurses are responsible for ensuring family members wear gowns & gloves to prevent
transmission of C. diff spores.
A nurse is talking with a partner of an older adult male client who has dementia.
The client's partner expresses frustration about finding time to manage
household responsibilities while caring for his partner. The nurse should
identify that he is going through which of the following types of roleperformance
stress? Role overload.
Refers to having more responsibilities within a role than one person can perform.
A nurse is evaluating a client's use of a cane. Which of the following actions
should the nurse identify as an indication of correct use?
A nurse is planning to improve selffeeding for a client who has vision loss.
Which of the following interventions should the nurse include in the plan of
care?
Use a clock pattern to describe food on the client's plate.
Describing the location of food using clock pattern allows client to have greater
independence during meals.
A nurse is planning an education session for an older adult client who has just
learned that she has type 2 diabetes mellitus. Which of the following
strategies should the nurse plan to use with this client?
Allow extra time for the client to respond to questions.
Older adults often process information at slower rate than younger clients allow
extra time to allow client to ask questions and absorb information
A nurse is caring for a client who has tuberculosis. Which of the following
actions should the nurse take? Select ALL that apply.
Place the client in a room with negativepressure airflow airborne precautions Wear
gloves when assisting the client with oral care standard precautions.
Use antimicrobial sanitizer for hand hygiene wash hands with soap & water when
visibly soiled.
A nurse is caring for a client who has a prescription for 5 units of regular insulin
and 10 units of NPH insulin to mix together and administer subcutaneously.
Determine the correct order of steps for this procedure.
Inject 10 units of air into the bottle of NPH insulin.
Inject 5 units of air into the bottle of regular insulin.
Withdraw the correct dose of regular insulin from the bottle.
Withdraw the correct dose of NPH insulin from the bottle.
A nurse is completing an admission assessment for a client who reports vomiting
and diarrhea for the past 3 days. Which of the following assessment findings
should the nurse expect?
Rapid heart rate
Tachycardia indicates fluidvolume deficit expected
Urine specific gravity would be > 1.030
Hypotension
A nurse is administering IV fluid to an older adult client. The nurse should
perform which priority assessment to monitor for adverse effects?
Auscultate lung sounds.
ABCs monitor for fluidvolume excess
Moist crackles in lungs, dyspnea, SOB
,A and B ATI 2022 .
A nurse is assessing a client's readiness to learn about insulin 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." verbalizing best time for
him to learn.
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?
Contact precautions
Major wound infections require contact precautions admit client to private room.
Caregivers should wear gown & gloves during direct contact.
A nurse is reviewing practice guidelines with a group of newly licensed nurses.
Which of the following interventions should the nurse include that is within the
RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube.
Initiate feedings through nasoenteric, gastrostomy, and jejunostomy tubes.
A nurse is caring for a client who has a prescription for wound irrigation. Which
of the following actions should the nurse take?
Cleanse the wound from the center outward.
Prevent introduction of microorganisms from the outer skin surface.
A nurse is caring for a client who reports pain. When documenting the quality
of the client's pain on an initial pain assessment, the nurse should report which
of the following client statements?
"The pain is like a dull ache in my stomach."
Describing quality of pain
A nurse is caring for a client who is reporting difficulty falling asleep. Which of
the following measures should the nurse recommend?
Use progressive relaxation techniques at bedtime.
promotes sleep by decreasing stress & reducing muscle tension.
A nurse is caring for a client who is postoperative and refuses to use an incentive
spirometer following major abdominal surgery. Which of the following is the
nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
1st Assess
A nurse is preparing to administer multiple medications to a client who has an
enteral feeding tube. Which of the following actions should the nurse plan to
take?
, A and B ATI 2022 .
Flush the tube with 15 mL of sterile water.
Flush with 1530 mL of sterile water before administration and between each
medication. Flush feeding tube with 3060 mL of sterile water following
administration of last medication.
A nurse is caring for a client who has terminal liver cancer. Which of the
following statements should the nurse identify as an indication that the client is
experiencing spiritual distress?
"What could I have done to deserve this illness?"
Review life & question its meaning.
A nurse is administering an otic medication to an older adult client. Which of
the following actions should the nurse take to ensure that the medication reaches
the inner ear?
Press gently on the tragus of the client's ear.
A nurse is performing a Romberg's test during the physical assessment of a
client. Which of the following techniques should the nurse use?
Have the client stand with her arms at her side and her feet together.
Roberg's test helps identify alterations in balance. Observe for swaying & loss of
balance.
A nurse is teaching an older adult client who is at risk for osteoporosis about
beginning a program of regular physical activity. Which of the following types of
activity should the nurse recommend?
Walking briskly.
Weightbearing exercises are essential for maintaining bone mass. Walking engages
older adult clients in preventive & therapeutic strategy.
A charge nurse is discussing the responsibility of nurses caring for clients who
have a Clostridium difficile infection. Which of the following information should
the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
Nurses are responsible for ensuring family members wear gowns & gloves to prevent
transmission of C. diff spores.
A nurse is talking with a partner of an older adult male client who has dementia.
The client's partner expresses frustration about finding time to manage
household responsibilities while caring for his partner. The nurse should
identify that he is going through which of the following types of roleperformance
stress? Role overload.
Refers to having more responsibilities within a role than one person can perform.
A nurse is evaluating a client's use of a cane. Which of the following actions
should the nurse identify as an indication of correct use?
