ATI Final Exam ~ Review Questions
A charge nurse is leading a staff education session about caring for a client who has
hypocalcemia.
Which of the following statements by a staff nurse indicates the need for further
teaching?
1. "I should monitor for hand spasms during blood pressure cuff inflation."
2. "Clients who have a vitamin D deficiency are at risk for hypocalcemia."
3. "Clients who have hypocalcemia are at risk for pathologic fractures."
4. "I should implement seizure precautions for a client who has hypocalcemia." - ans3.
"Clients who have hypocalcemia are at risk for pathologic fractures."
A client demonstrates anger when the nurse does not respond within 5 min of ringing for
the nurse. Which of the following is an appropriate response by the nurse?
1. "I'm sorry, but another client needed my attention."
2. "I arrived as soon as I could. What can I do for you?"
3. "It must be frustrating. I have a few minutes now."
4. "We had an emergency on the unit, but now I'm here." - ans3. "It must be frustrating. I
have a few minutes now."
**therapeutic by acknowledging client's feelings**
A client has an admission blood glucose reading of 260 mg/dL and no documented
history of diabetes mellitus. While the nurse reviews the client's medication history,
which of the following types of medications should alert the nurse to the possibility that
the client has developed an adverse effect of pharmacologic therapy? (Select all that
apply.)
- Diuretics
- Corticosteroids
- Oral anticoagulants
- Opioid analgesics
- Antipsychotics - ans- Diuretics
- Corticosteroids
- Antipsychotics
A client is reporting pain at the insertion site of his IV catheter. The nurse observes a
red line extending outward from the insertion site. Which of the following actions should
the nurse take first?
1. Place a warm compress over the site
2. Restart the IV line at a different site.
3. Discontinue the infusion.
4. Document the findings. - ans3. Discontinue the infusion.
,**greatest risk = further injury to the vein; first action is to discontinue**
A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client
after anesthesia has been administered. Which of the following interventions should be
initiated?
1. Leave the necklace on the client.
2. Give the necklace to a family member.
3. Place the necklace in the client's chart.
4. Notify security for placement of the necklace. - ans4. Notify security for placement of
the necklace.
A client who has an indwelling catheter reports a need to urinate. Which of the following
interventions should the nurse perform?
1. Check to see whether the catheter is patent.
2. Reassure the client that it is not possible for her to urinate.
3. Recatheterize the bladder with a larger-gauge catheter.
4. Collect a urine specimen for analysis. - ans1. Check to see whether the catheter is
patent.
A client who has had a cerebrovascular accident has persistent problems with
dysphagia (difficulty
swallowing). The nurse caring for the client should initiate a referral with which of the
following members of the interprofessional care team?
1. Social worker
2. Certified nursing assistant
3. Occupational therapist
4. Speech-language pathologist - ans4. Speech-language pathologist
A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire.
After confirming the fire, which of the following actions should the nurse take next?
1. Call emergency fire code.
2. Extinguish the fire.
3. Confine the fire.
4. Evacuate the client. - ans4. Evacuate the client.
**rescue client first**
A client who is postoperative following knee arthroplasty is concerned about the
adverse effects of the medication he is receiving for pain management. Which of the
following members of the interprofessional care team may assist the client in
understanding the medication's effects? (Select all that apply.)
,- Provider
- Certified nursing assistant
- Pharmacist
- Registered nurse
- Respiratory therapist - ans- Provider
- Pharmacist
- Registered nurse
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The
nurse understands that the preoperative teaching regarding pain control has been
effective when the client states which of the following?
1. "I think I should take my pain medication more often, since it is not controlling my
pain."
2. "Breathing faster will help me keep my mind off of the pain."
3. "It may help me to listen to music while I'm lying in bed."
4. "I don't want to walk today, because I'm experiencing some pain." - ans3. "It may help
me to listen to music while I'm lying in bed."
**nonpharmacological intervention to pain**
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to
use adaptive devices. The nurse caring for the client should initiate a referral with which
of the following members of the interprofessional care team?
1. Social worker
2. Certified nursing assistant
3. Registered dietitian
4. Occupational therapist - ans4. Occupational therapist
A home health nurse is discussing the dangers of carbon monoxide poisoning with a
client. Which of the following information should the nurse include in her counseling?
1. Carbon monoxide has a distinct odor.
2. Water heaters should be inspected every 5 years.
3. The lungs are damaged from carbon monoxide inhalation.
4. Carbon monoxide binds with hemoglobin in the body. - ans4. Carbon monoxide binds
with hemoglobin in the body.
A home health nurse is discussing the dangers of food poisoning with a client. Which of
the following information should the nurse including in her counseling? (Select all that
apply.)
- Most food poisoning is caused by a virus.
- Immunocompromised individuals are at risk for complications from food poisoning
, - Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products.
- Healthy individuals usually recover from the illness in a few weeks.
- Handling raw and fresh food separately to avoid cross contamination may prevent food
poisoning. - ans- Immunocompromised individuals are at risk for complications from
food poisoning
- Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products.
- Handling raw and fresh food separately to avoid cross contamination may prevent food
poisoning.
A nurse attempts to collect a capillary blood specimen via finger stick to test the glucose
level of a client who has diabetes mellitus. The nurse is unable to obtain an adequate
drop of blood for the reagent strip. Which of the following actions should the nurse take?
1. Puncture another finger to obtain a capillary specimen.
2. Test the client's urine with a urine reagent strip.
3. Wrap the client's hand in a warm, moist cloth.
4. Perform a venipuncture to obtain a venous sample. - ans3. Wrap the client's hand in
a warm, moist cloth.
A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client
who does not speak English. Which of the following guidelines should the nurse follow
when working with the interpreter?
1. Speak slowly to allow the interpreter to interpret each word.
2. Explain the purpose of the communication to the interpreter.
3. Address the interpreter when explaining the procedure information.
4. Supplement words with gestures and nonverbal reinforcement. - ans2. Explain the
purpose of the communication to the interpreter.
A nurse educator is conducting a parenting class for new parents. Which of the
following statements made by a participant indicates a need for further clarification and
instruction?
1. "I will begin swimming lessons as soon as my baby can close her mouth under
water."
2. "Once my baby can sit up, he should be safe in the bathtub."
3. "I will test the temperature of the water before placing my baby in the bath."
4. "Once my infant starts to push up, I will remove the mobile from over the bed." - ans2.
"Once my baby can sit up, he should be safe in the bathtub."
A nurse educator is presenting a module on basic first aid for newly licensed home
health nurses. The nurse educator evaluates the teaching as effective when the newly
licensed nurse states the client who has heat stroke will have which of the following?
A charge nurse is leading a staff education session about caring for a client who has
hypocalcemia.
Which of the following statements by a staff nurse indicates the need for further
teaching?
1. "I should monitor for hand spasms during blood pressure cuff inflation."
2. "Clients who have a vitamin D deficiency are at risk for hypocalcemia."
3. "Clients who have hypocalcemia are at risk for pathologic fractures."
4. "I should implement seizure precautions for a client who has hypocalcemia." - ans3.
"Clients who have hypocalcemia are at risk for pathologic fractures."
A client demonstrates anger when the nurse does not respond within 5 min of ringing for
the nurse. Which of the following is an appropriate response by the nurse?
1. "I'm sorry, but another client needed my attention."
2. "I arrived as soon as I could. What can I do for you?"
3. "It must be frustrating. I have a few minutes now."
4. "We had an emergency on the unit, but now I'm here." - ans3. "It must be frustrating. I
have a few minutes now."
**therapeutic by acknowledging client's feelings**
A client has an admission blood glucose reading of 260 mg/dL and no documented
history of diabetes mellitus. While the nurse reviews the client's medication history,
which of the following types of medications should alert the nurse to the possibility that
the client has developed an adverse effect of pharmacologic therapy? (Select all that
apply.)
- Diuretics
- Corticosteroids
- Oral anticoagulants
- Opioid analgesics
- Antipsychotics - ans- Diuretics
- Corticosteroids
- Antipsychotics
A client is reporting pain at the insertion site of his IV catheter. The nurse observes a
red line extending outward from the insertion site. Which of the following actions should
the nurse take first?
1. Place a warm compress over the site
2. Restart the IV line at a different site.
3. Discontinue the infusion.
4. Document the findings. - ans3. Discontinue the infusion.
,**greatest risk = further injury to the vein; first action is to discontinue**
A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client
after anesthesia has been administered. Which of the following interventions should be
initiated?
1. Leave the necklace on the client.
2. Give the necklace to a family member.
3. Place the necklace in the client's chart.
4. Notify security for placement of the necklace. - ans4. Notify security for placement of
the necklace.
A client who has an indwelling catheter reports a need to urinate. Which of the following
interventions should the nurse perform?
1. Check to see whether the catheter is patent.
2. Reassure the client that it is not possible for her to urinate.
3. Recatheterize the bladder with a larger-gauge catheter.
4. Collect a urine specimen for analysis. - ans1. Check to see whether the catheter is
patent.
A client who has had a cerebrovascular accident has persistent problems with
dysphagia (difficulty
swallowing). The nurse caring for the client should initiate a referral with which of the
following members of the interprofessional care team?
1. Social worker
2. Certified nursing assistant
3. Occupational therapist
4. Speech-language pathologist - ans4. Speech-language pathologist
A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire.
After confirming the fire, which of the following actions should the nurse take next?
1. Call emergency fire code.
2. Extinguish the fire.
3. Confine the fire.
4. Evacuate the client. - ans4. Evacuate the client.
**rescue client first**
A client who is postoperative following knee arthroplasty is concerned about the
adverse effects of the medication he is receiving for pain management. Which of the
following members of the interprofessional care team may assist the client in
understanding the medication's effects? (Select all that apply.)
,- Provider
- Certified nursing assistant
- Pharmacist
- Registered nurse
- Respiratory therapist - ans- Provider
- Pharmacist
- Registered nurse
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The
nurse understands that the preoperative teaching regarding pain control has been
effective when the client states which of the following?
1. "I think I should take my pain medication more often, since it is not controlling my
pain."
2. "Breathing faster will help me keep my mind off of the pain."
3. "It may help me to listen to music while I'm lying in bed."
4. "I don't want to walk today, because I'm experiencing some pain." - ans3. "It may help
me to listen to music while I'm lying in bed."
**nonpharmacological intervention to pain**
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to
use adaptive devices. The nurse caring for the client should initiate a referral with which
of the following members of the interprofessional care team?
1. Social worker
2. Certified nursing assistant
3. Registered dietitian
4. Occupational therapist - ans4. Occupational therapist
A home health nurse is discussing the dangers of carbon monoxide poisoning with a
client. Which of the following information should the nurse include in her counseling?
1. Carbon monoxide has a distinct odor.
2. Water heaters should be inspected every 5 years.
3. The lungs are damaged from carbon monoxide inhalation.
4. Carbon monoxide binds with hemoglobin in the body. - ans4. Carbon monoxide binds
with hemoglobin in the body.
A home health nurse is discussing the dangers of food poisoning with a client. Which of
the following information should the nurse including in her counseling? (Select all that
apply.)
- Most food poisoning is caused by a virus.
- Immunocompromised individuals are at risk for complications from food poisoning
, - Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products.
- Healthy individuals usually recover from the illness in a few weeks.
- Handling raw and fresh food separately to avoid cross contamination may prevent food
poisoning. - ans- Immunocompromised individuals are at risk for complications from
food poisoning
- Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products.
- Handling raw and fresh food separately to avoid cross contamination may prevent food
poisoning.
A nurse attempts to collect a capillary blood specimen via finger stick to test the glucose
level of a client who has diabetes mellitus. The nurse is unable to obtain an adequate
drop of blood for the reagent strip. Which of the following actions should the nurse take?
1. Puncture another finger to obtain a capillary specimen.
2. Test the client's urine with a urine reagent strip.
3. Wrap the client's hand in a warm, moist cloth.
4. Perform a venipuncture to obtain a venous sample. - ans3. Wrap the client's hand in
a warm, moist cloth.
A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client
who does not speak English. Which of the following guidelines should the nurse follow
when working with the interpreter?
1. Speak slowly to allow the interpreter to interpret each word.
2. Explain the purpose of the communication to the interpreter.
3. Address the interpreter when explaining the procedure information.
4. Supplement words with gestures and nonverbal reinforcement. - ans2. Explain the
purpose of the communication to the interpreter.
A nurse educator is conducting a parenting class for new parents. Which of the
following statements made by a participant indicates a need for further clarification and
instruction?
1. "I will begin swimming lessons as soon as my baby can close her mouth under
water."
2. "Once my baby can sit up, he should be safe in the bathtub."
3. "I will test the temperature of the water before placing my baby in the bath."
4. "Once my infant starts to push up, I will remove the mobile from over the bed." - ans2.
"Once my baby can sit up, he should be safe in the bathtub."
A nurse educator is presenting a module on basic first aid for newly licensed home
health nurses. The nurse educator evaluates the teaching as effective when the newly
licensed nurse states the client who has heat stroke will have which of the following?
