ATI
COMPREHENSIVE 2.0
1. Following abdominal surgery, a client's abdominal wound edges are
separating, and the wound is draining a large amount of serous drainage. Thenurse should place
the client:
Incorrect: This position is incorrect because it can increase tension on the suture line, and cause
further
wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it can
increase tension on thesuture line, and cause further wound separation and tearing
(dehiscence).Correct: The semi-Fowler's position
decreases tension on the wound, and it may prevent further separation and tearing of the
wound(dehiscence).Incorrect: This position is incorrect because it can increase tension on the
suture line, and cause further
wound separation and tearing (dehiscence).
flat on the back with legs straight.
in high-Fowler's position with legs straight.
in semi-Fowler's position with the knees slightly bent.
on the left side with knees bent .
2. The PN is preparing to administer an enteral feeding to a client. To prevent
gastric cramping and discomfort due to the feeding, the nurse should:
Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via
gastrostomy tube,
,the formula reaches the stomach quickly, with little or no opportunity to be warmed, as oral
feedings would as they
pass through the mouth and esophagus.Incorrect: Tube placement is confirmed prior to beginning
each feeding. This
action does not prevent gastric discomfort. However, checking tube placement does help prevent
the infusion of the
formula into the lungs.Incorrect: To prevent gastric discomfort, the concentration of the tube
feeding formula needs to
be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the
first few feedings areadministered.Incorrect: The head of the bed should be elevated at least 30°
during the feeding and for at least 30
minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent
cramping and discomfort.
allow time for the formula to reach room temperature prior to administration.
determine tube placement once every 24 hours.
prepare to administer full-strength rather than diluted formula.
elevate the head of the bed during and after feedings.
3. The nurse is caring for a child with cystic fibrosis (CF). Which intervention willhelp to
prevent respiratory complications?
Incorrect: Clients with CF should not receive cough suppressant syrups. These children need to
cough
frequently to clear lung secretions.Correct: Nebulization with mist or aerosol therapy followed
by chest physiotherapyhelps to keep secretions free-flowing. The pulmonary effects of CF are
progressive, and bronchial secretions must bekept moist.Incorrect: The child should change
positions frequently to promote drainage from the lungs, and promote
aeration of the lungs.Incorrect: Children with CF can safely receive the pertussis vaccine. These
children need
protection from pertussis because this infection causes severe respiratory complications.
Encourage the use of cough suppressant syrup.
,Give frequent nebulization treatments.
Limit changing the child's position to conserve the child's need for oxygen.
Withhold the vaccine for pertussis.
4. The nurse is caring for a client following insertion of a pacemaker. The client isplaced on
continuous ECG monitoring because it will:
Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time
of
insertion.Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker
insertion.Correct:
The heart rate may change following pacemaker insertion because the pacemaker fails to
maintain the pre-set heartrate. This problem can be detected immediately with continuous ECG
monitoring.Incorrect: Fluoroscopy is used to
determine dislodgement of pacer leads after a pacemaker insertion. Dislodgement can be
prevented with bedrest andminimal arm and shoulder activity.
allow the primary care provider to adjust voltage settings.
check placement of the pacer wires.
detect a dramatic change in heart rate.
, determine dislodgement of pacer leads.
5. The nurse is administering eye drops to a client. To prevent injury, the nurse
should:
Incorrect: The nurse should ask the client to "look up" before instilling the eye drops. This action
reduces
stimulation of the corneal reflex and injury to the eye, should the client jerk away.Incorrect: Eye
drops should never bedropped directly onto the cornea as this action may injure the cornea. The
nurse should deposit the medication onto
the lower conjunctiva.Correct: As a safety precaution, the nurse administering eye drops should
rest his hand on the
client's forehead. In case the client moves, the nurse's hand will move at the same time, lowering
the risk that thedropper will hit the client's eye.Incorrect: When administering eye drops, it is
essential to have an adequate amount oflight. However, the nurse should not shine a bright light
directly into the client's eye.
ask the client to "look down" before instilling the eye drops.
drop the eye drops directly onto the client's cornea.
rest his hand on the client's forehead.
shine a bright light into the client's eye.
6. Which statement is true regarding the behavior of clients who are in pain?
Incorrect: Many clients avoid conversation and social contacts when they are experiencing pain.
Clients with
chronic pain may become withdrawn and isolated.Incorrect: Clients' reactions to pain are often
influenced by theircultural and ethnic background. The nurse needs to consider each client's
cultural background when assessing a
COMPREHENSIVE 2.0
1. Following abdominal surgery, a client's abdominal wound edges are
separating, and the wound is draining a large amount of serous drainage. Thenurse should place
the client:
Incorrect: This position is incorrect because it can increase tension on the suture line, and cause
further
wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it can
increase tension on thesuture line, and cause further wound separation and tearing
(dehiscence).Correct: The semi-Fowler's position
decreases tension on the wound, and it may prevent further separation and tearing of the
wound(dehiscence).Incorrect: This position is incorrect because it can increase tension on the
suture line, and cause further
wound separation and tearing (dehiscence).
flat on the back with legs straight.
in high-Fowler's position with legs straight.
in semi-Fowler's position with the knees slightly bent.
on the left side with knees bent .
2. The PN is preparing to administer an enteral feeding to a client. To prevent
gastric cramping and discomfort due to the feeding, the nurse should:
Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via
gastrostomy tube,
,the formula reaches the stomach quickly, with little or no opportunity to be warmed, as oral
feedings would as they
pass through the mouth and esophagus.Incorrect: Tube placement is confirmed prior to beginning
each feeding. This
action does not prevent gastric discomfort. However, checking tube placement does help prevent
the infusion of the
formula into the lungs.Incorrect: To prevent gastric discomfort, the concentration of the tube
feeding formula needs to
be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the
first few feedings areadministered.Incorrect: The head of the bed should be elevated at least 30°
during the feeding and for at least 30
minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent
cramping and discomfort.
allow time for the formula to reach room temperature prior to administration.
determine tube placement once every 24 hours.
prepare to administer full-strength rather than diluted formula.
elevate the head of the bed during and after feedings.
3. The nurse is caring for a child with cystic fibrosis (CF). Which intervention willhelp to
prevent respiratory complications?
Incorrect: Clients with CF should not receive cough suppressant syrups. These children need to
cough
frequently to clear lung secretions.Correct: Nebulization with mist or aerosol therapy followed
by chest physiotherapyhelps to keep secretions free-flowing. The pulmonary effects of CF are
progressive, and bronchial secretions must bekept moist.Incorrect: The child should change
positions frequently to promote drainage from the lungs, and promote
aeration of the lungs.Incorrect: Children with CF can safely receive the pertussis vaccine. These
children need
protection from pertussis because this infection causes severe respiratory complications.
Encourage the use of cough suppressant syrup.
,Give frequent nebulization treatments.
Limit changing the child's position to conserve the child's need for oxygen.
Withhold the vaccine for pertussis.
4. The nurse is caring for a client following insertion of a pacemaker. The client isplaced on
continuous ECG monitoring because it will:
Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time
of
insertion.Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker
insertion.Correct:
The heart rate may change following pacemaker insertion because the pacemaker fails to
maintain the pre-set heartrate. This problem can be detected immediately with continuous ECG
monitoring.Incorrect: Fluoroscopy is used to
determine dislodgement of pacer leads after a pacemaker insertion. Dislodgement can be
prevented with bedrest andminimal arm and shoulder activity.
allow the primary care provider to adjust voltage settings.
check placement of the pacer wires.
detect a dramatic change in heart rate.
, determine dislodgement of pacer leads.
5. The nurse is administering eye drops to a client. To prevent injury, the nurse
should:
Incorrect: The nurse should ask the client to "look up" before instilling the eye drops. This action
reduces
stimulation of the corneal reflex and injury to the eye, should the client jerk away.Incorrect: Eye
drops should never bedropped directly onto the cornea as this action may injure the cornea. The
nurse should deposit the medication onto
the lower conjunctiva.Correct: As a safety precaution, the nurse administering eye drops should
rest his hand on the
client's forehead. In case the client moves, the nurse's hand will move at the same time, lowering
the risk that thedropper will hit the client's eye.Incorrect: When administering eye drops, it is
essential to have an adequate amount oflight. However, the nurse should not shine a bright light
directly into the client's eye.
ask the client to "look down" before instilling the eye drops.
drop the eye drops directly onto the client's cornea.
rest his hand on the client's forehead.
shine a bright light into the client's eye.
6. Which statement is true regarding the behavior of clients who are in pain?
Incorrect: Many clients avoid conversation and social contacts when they are experiencing pain.
Clients with
chronic pain may become withdrawn and isolated.Incorrect: Clients' reactions to pain are often
influenced by theircultural and ethnic background. The nurse needs to consider each client's
cultural background when assessing a
