ATI CBC 3 - Exam A With Complete
Solutions!!
A nurse is providing family education for a client who wishes to conceive...the nurse should identify
that ovulation is expected to occur on which of the following calendar dates?
D-the 19th.
- The nurse should teach the client that ovulation is expected to occur 13-15 days after day one of her
menses.
A nurse in an acute care mental health facility is planning care for a client who has bipolar disorder
and who is experiencing acute mania. What action should the nurse take?
- encourage client to take part in daily group meetings (no, they should have one-to-one activities)
-allow client to pick from a variety of activities on the unit (no nurse should provide scheduled meals
& rest periods)
- assign the client to a semiprivate room (no, reduce stimuli and assign to a PRIVATE room w reduced
noise/lighting)
- provide client w finger foods
(YES, pts experiencing mania are often unable to sit and eat, finger foods allow them to get up and
move around
Provide the client with finger foods to eat.
(pts experiencing mania are often unable to sit and eat * can become dehydrated & lose weight,
finger foods (sandwiches) allow pt to eat while standing/walking & obtain nutrition even though she
cannot sit down for a meal)
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the infant exhibits a
sudden onset of cyanosis and is hyperpneic. What action should the nurse take?
Place the infant in a knee-chest position.
This maximizes the oxygenation status of the infant during hypercyanotic episodes
(Remember this was a test question you got wrong bc hyde said to calm infant then do knee chest
position)
R/t last question... what would you do If an infant is experiencing hypercyanotic episodes?
-admin 100% O2 via facemask
-give morphine subQ or thru existing IV line
-initiate or increase rate of IVF
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of
obesity. What is a client statement that indicates understanding of the teaching?
- i will apply lotion b/w skin folds (no, you want to keep skin dry to prevent breakdown)
- i will remain in a reclining position for 30 min after i eat (YES bc clients are at risk for dumping
syndrome)
,- i will return to my normal diet in 3 weeks (no, diet should be pureed/liquid for at least 6 weeks)
- i will need to take digestive enzymes weekly (no, pt will need monthly injections of B12 and iron)
"I will remain in a reclining position for 30 minutes after I eat"
Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining in a reclining
position slows gastric emptying and minimizes the risk of dumping syndrome.
A nurse is teaching a client who has genital herpes simplex virus. What statement should the nurse
include in the teaching about this STI?
- 14-day course of acyclovir will iradicate infection (no, there is no cure and this antiviral medications
will only reduce symptoms)
- the law requires you to contact all sexual partners so they can be treated (no, the client should
contact partners as a courtesy but it is not required by law)
- avoid taking OTC meds that contain aspirin while you have lesions (no, pt should take OTC meds like
acetaminophen/ibuprofen/aspirin to control pain associated w infection)
- you should cleanse the lesions w a saline solution twice each day (YES, to prevent secondary
infections)
"You should cleanse the lesions with a saline solution twice each day."
This helps to prevent secondary bacterial infections.
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the
following actions should the nurse take?
- position client in supine position (no, HOB should be elevated to ease breathing, if pt has
congestion/nausea place them on their side)
- encourage client to stay awake during daylight hours (no, a dying pt has a decreased metabolism
which results in increased sleeping. nurse should allow rest and not force the pt to stay awake)
- keep the clients curtains open to provide light in the room (no, dying pt's are usually restless due to
slowed circulation to the brain. RN should keep room dimly lit, reduce # of people, & keep noise to a
minimum)
- apply a thin coat of lip balm to the client's lips (YES, pt can experience dehydration, causing lips to be
dry/chapped)
Apply a thin coating of lip balm to the client's lips.
A client who is dying can experience dehydration. Applying lip balm to the client's lips promotes
comfort.
A nurse in an emergency department is assessing a client who was in a motor-vehicle crash. The client
has a BAC of 0.18% and states, "I would never drink and drive." This is demonstrating use of which
defense mechanism?
- intellectualization (when a pt uses reasoning/logic to prevent thinking about emotional aspects of
situation)
- denial (pt refuses to acknowledge the reality of the situation)
, - rationalization (pt tries to use logical argument to excuse unacceptable behavior)
- projection (pt attributes his feelings as the feelings of another person)
Denial
Client refuses to acknowledge the reality of a situation.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is experiencing
moderate placental abruption. What should the nurse do?
-strainer device on pts bedside toilet (no, pt should have a indwelling urinary catheter)
- assess fetal condition once hourly (no, it should be continuous monitoring)
- insert large-bore IV ( YES 16-18 gauge in brachial artery to replace fluid being lost)
- vaginal exam to determine presence of bleeding (no pt should be placed on pelvic rest)
Insert a large-bore IV catheter.
A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid volume and
blood replacement might be necessary to correct defects in coagulation.
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of the following
interventions should the nurse plan to include?
-remind client of non-weight-bearing status (no, this is required in pts who have bonegrafting for
primary/cancerous tumors)
-palpate for changes in muscle of affected extremity (YES, palpate to monitor for changes that might
indicate enlargement of the tumor)
- prepare for needle biopsy (no, this is not needed for benign tumors)
-teach about pain management w. raiation therapy (no, pain management is required for pts who
have a malignant tumor. BENIGN tumors are managed w analgesics & heat/cold therapy)
Palpate for changes in the muscle of the affected extremity.
The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or swelling. These
manifestations indicate enlargement of the tumor.
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum hemorrhage.
What actions should the nurse take immediately?
-massage the clients fundus (to expel clots & promote contractions)
- insert indwelling urinary catheter (catheter should be place but this is not the priority action)
-elevate clients right hip on a pillow (should do this but its not priority action)
- admin o2 via nonrebreather facemask @ 10L/min (should do this but not priority action)
Massage the client's fundus
The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots and promotes
contractions.
Solutions!!
A nurse is providing family education for a client who wishes to conceive...the nurse should identify
that ovulation is expected to occur on which of the following calendar dates?
D-the 19th.
- The nurse should teach the client that ovulation is expected to occur 13-15 days after day one of her
menses.
A nurse in an acute care mental health facility is planning care for a client who has bipolar disorder
and who is experiencing acute mania. What action should the nurse take?
- encourage client to take part in daily group meetings (no, they should have one-to-one activities)
-allow client to pick from a variety of activities on the unit (no nurse should provide scheduled meals
& rest periods)
- assign the client to a semiprivate room (no, reduce stimuli and assign to a PRIVATE room w reduced
noise/lighting)
- provide client w finger foods
(YES, pts experiencing mania are often unable to sit and eat, finger foods allow them to get up and
move around
Provide the client with finger foods to eat.
(pts experiencing mania are often unable to sit and eat * can become dehydrated & lose weight,
finger foods (sandwiches) allow pt to eat while standing/walking & obtain nutrition even though she
cannot sit down for a meal)
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the infant exhibits a
sudden onset of cyanosis and is hyperpneic. What action should the nurse take?
Place the infant in a knee-chest position.
This maximizes the oxygenation status of the infant during hypercyanotic episodes
(Remember this was a test question you got wrong bc hyde said to calm infant then do knee chest
position)
R/t last question... what would you do If an infant is experiencing hypercyanotic episodes?
-admin 100% O2 via facemask
-give morphine subQ or thru existing IV line
-initiate or increase rate of IVF
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of
obesity. What is a client statement that indicates understanding of the teaching?
- i will apply lotion b/w skin folds (no, you want to keep skin dry to prevent breakdown)
- i will remain in a reclining position for 30 min after i eat (YES bc clients are at risk for dumping
syndrome)
,- i will return to my normal diet in 3 weeks (no, diet should be pureed/liquid for at least 6 weeks)
- i will need to take digestive enzymes weekly (no, pt will need monthly injections of B12 and iron)
"I will remain in a reclining position for 30 minutes after I eat"
Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining in a reclining
position slows gastric emptying and minimizes the risk of dumping syndrome.
A nurse is teaching a client who has genital herpes simplex virus. What statement should the nurse
include in the teaching about this STI?
- 14-day course of acyclovir will iradicate infection (no, there is no cure and this antiviral medications
will only reduce symptoms)
- the law requires you to contact all sexual partners so they can be treated (no, the client should
contact partners as a courtesy but it is not required by law)
- avoid taking OTC meds that contain aspirin while you have lesions (no, pt should take OTC meds like
acetaminophen/ibuprofen/aspirin to control pain associated w infection)
- you should cleanse the lesions w a saline solution twice each day (YES, to prevent secondary
infections)
"You should cleanse the lesions with a saline solution twice each day."
This helps to prevent secondary bacterial infections.
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the
following actions should the nurse take?
- position client in supine position (no, HOB should be elevated to ease breathing, if pt has
congestion/nausea place them on their side)
- encourage client to stay awake during daylight hours (no, a dying pt has a decreased metabolism
which results in increased sleeping. nurse should allow rest and not force the pt to stay awake)
- keep the clients curtains open to provide light in the room (no, dying pt's are usually restless due to
slowed circulation to the brain. RN should keep room dimly lit, reduce # of people, & keep noise to a
minimum)
- apply a thin coat of lip balm to the client's lips (YES, pt can experience dehydration, causing lips to be
dry/chapped)
Apply a thin coating of lip balm to the client's lips.
A client who is dying can experience dehydration. Applying lip balm to the client's lips promotes
comfort.
A nurse in an emergency department is assessing a client who was in a motor-vehicle crash. The client
has a BAC of 0.18% and states, "I would never drink and drive." This is demonstrating use of which
defense mechanism?
- intellectualization (when a pt uses reasoning/logic to prevent thinking about emotional aspects of
situation)
- denial (pt refuses to acknowledge the reality of the situation)
, - rationalization (pt tries to use logical argument to excuse unacceptable behavior)
- projection (pt attributes his feelings as the feelings of another person)
Denial
Client refuses to acknowledge the reality of a situation.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is experiencing
moderate placental abruption. What should the nurse do?
-strainer device on pts bedside toilet (no, pt should have a indwelling urinary catheter)
- assess fetal condition once hourly (no, it should be continuous monitoring)
- insert large-bore IV ( YES 16-18 gauge in brachial artery to replace fluid being lost)
- vaginal exam to determine presence of bleeding (no pt should be placed on pelvic rest)
Insert a large-bore IV catheter.
A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid volume and
blood replacement might be necessary to correct defects in coagulation.
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of the following
interventions should the nurse plan to include?
-remind client of non-weight-bearing status (no, this is required in pts who have bonegrafting for
primary/cancerous tumors)
-palpate for changes in muscle of affected extremity (YES, palpate to monitor for changes that might
indicate enlargement of the tumor)
- prepare for needle biopsy (no, this is not needed for benign tumors)
-teach about pain management w. raiation therapy (no, pain management is required for pts who
have a malignant tumor. BENIGN tumors are managed w analgesics & heat/cold therapy)
Palpate for changes in the muscle of the affected extremity.
The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or swelling. These
manifestations indicate enlargement of the tumor.
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum hemorrhage.
What actions should the nurse take immediately?
-massage the clients fundus (to expel clots & promote contractions)
- insert indwelling urinary catheter (catheter should be place but this is not the priority action)
-elevate clients right hip on a pillow (should do this but its not priority action)
- admin o2 via nonrebreather facemask @ 10L/min (should do this but not priority action)
Massage the client's fundus
The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots and promotes
contractions.
