ATI NURS 1100 FINAL EXAM REVIEW
The school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following comments made by the client should the nurse be most concerned about?
A. My parents treat me like a baby sometimes
B. I haven’t gotten my period yet, and all my friends have theirs
C. None of the kids at this school like me, and I don’t like them either
D. There’s a big pimple on my face, and I worry that everyone will notice it
C. None of the kids at this school like me, and I don’t like them either
A nurse is assessing a client’s bowel sounds. The nurse understands that the bowel sounds should be auscultated…
A. After palpating the abdomen
B. Prior to percussing the abdomen
C. After checking for kidney tenderness
D. Prior to inspecting the abdomen
B. Prior to percussing the abdomen
A nurse is reinforcing home safety information to an older adult client. Which of the following statements indicate a need for further instruction?
A. I should have grab bars installed in my bathroom
B. I should leave a nightlight on when i retire for the night
C. I should use the handrail instead of my cane when going downstairs
D. I should have the batteries changed in my smoke detector twice a year
C. I should use the handrail instead of my cane when going downstairs
Rationale: The client should use both the handrail and the cane.
A nurse is removing an isolation gown after caring for a client who requires contact precautions. Which of the following steps should the nurse take to properly remove the isolation gown that has ties in the front?
A. Untie the neck strings, remove gloves & untie waist strings
B. Untie front waist strings, remove gloves, and untie neck ties
C. Remove gloves, wash hands, and untie waist strings
D. Remove gloves, untie neck strings, and untie waist strings
B. Untie front waist strings, remove gloves, and untie neck ties
A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse is aware that this sound represents which of the following?
A. Atrial gallop
B. Ventricular gallop
C. Closure of the aortic valve
D. Closure of the pulmonic valve
B. Ventricular gallop
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following?
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
D. Wheezes
Rationale: Wheezes are first evident on expiration, but possibly evident on inspiration as the airway obstruction worsens
A nurse is preparing an inservice for a group of newly licensed nurses about client confidentiality. The nurse should explain that they may share a client’s protected health information with which of the following groups?
A. The client’s immediate family members
B. Clergy affiliated with the facility
C. The facility’s administrators
D. Health care team members caring for the client
D. Health care team members caring for the client
A nurse is caring for a client who has a lacerated spleen and has been on strict bedrest for several days. The nurse notes decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely due to?
A. A cold because of decreased immune resistance
B. Pulomnary edema
C. Atelectasis
D. Respiratory depression from pain medications
C. Atelectasis
Rationale: Atelectasis is the collapse of part or all of the lung by blockage of the air passage or by very shallow breathing. Anesthesia, prolonged bedrest with few changes in position, and underlying lung disease are risk factors for the development of atelectasis
The nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which intervention behavior should the nurse use?
A. Call the client by his first name when providing an introduction
B. Verbalize understanding of how the client feels
C. Offer personal thoughts and beliefs to the client
D. Use attentive listening with the client
D. Use attentive listening with the client
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse incorporate?
A. Collect urine from the catheter port
B. Use a sterile specimen container
C. Ensure only sterile water is used to inflate the balloon
D. Instruct the client to clean from front to back with an antiseptic solution
B. Use a sterile specimen container
A client expresses interest in learning more about advance directives. Which of the following topics should the nurse anticipate discussing? SATA
A. Organ donation
B. Enteral feeding tubes
C. Cardiopulmonary resuscitation
D. Durable power of attorney for health care
E. Disclosure of personal health care information
B,C,D
A nurse is performing a physical examination of an older adult client who is postmenopausal and has a history of osteoporosis and a BMI of 23. Which of the following spinal deformities should the nurse expect to find?
A. Lordosis
B. Ankylosis
C. Kyphosis
D. Scoliosis
C but A???
A nurse is caring for a client who is discussing his PTSD and states: “everyone thinks you should be able to put it out of your mind. It happened so long ago, just get over it!” The nurse responds, “It must be very frustrating to encounter this kind of attitude.” The nurse is using which of the following therapeutic communication techniques?
A. Clarifying
B. Focusing
C. Paraphrasing
D. Reflection
D
A nurse is completing discharge teaching with a client. Which of the following is not a barrier to instruction?
Repetition of information
A nurse is preparing an inservice for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for implementing the use of restraints?
The nurse has already considered alternatives to restraint
A nurse applies wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following would be an appropriate action?
Document the client action that necessitated the restraints
A nurse is providing hygiene care for a client who is immobilized. Which of the following actions by the nurse is appropriate? SATA
A. Checking removed bed linens for personal items
B. Placing a clean gown on the strongest arm first
C. Maintaining the bath water temperature between 110-115
D. Shaving the client in the direction of the hair growth
E. Washing the client’s extremities from proximal to distal
A,C,D
A nurse is planning care for an older adult client who is at high risk for developing pressure ulcers. Which of the following is an appropriate measure for the nurse to include?
A. Use a draw sheet to move the client up in bed
A goal for a client who has difficulty with the physical aspects of feeding herself due to rheumatoid arthritis is to use adaptive devices to enhance her capabilities. The nurse caring for the client should initiate a referral with which of the following members of the collaborative health care team?
A. Occupational therapist
A nurse is providing care to a child who has an allergy to eggs. The nurse should question a prescription for which of the following immunizations?
A. Influenza
A client who has a femur fracture states, ” I can’t stay in this bed any longer. I need to get home so I can take care of my family.” The nurse responds by saying, “You have talked about your family. Can you tell me more about your specific concerns?” Which type of therapeutic communication response is the nurse using?
C. Focusing
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client’s pain?
B. Client’s Self-report of pain severity
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
D. Dysphagia
A nurse is discussing gender-related factors that affect communication. Which of the following is a characteristic of men when communicating with others?
A. They are more goal-oriented when discussing issues
A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
B. “Hand Hygiene is crucial in preventing the spread of germs.”
A nurse is caring for a client and is in the orientation phase of the nurse-client helping relationship. Which of the following communication techniques should the nurse use in this phase?
A. Elicit information from the client
A nurse is caring for an older adult client who is hospitalized. At bedtime, the client says, “I am afraid that I may fall while walking to the bathroom during the night. I tend to get a bit disoriented in new surroundings.” The nurse should…
C. Leave a night-light on in the client’s room
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings indicates a safety risk for the client?
D. Space heaters are present to ensure adequate heating
E. Throw rugs are used in the home
A nurse is assisting an older adult client to the bathroom when the client falls and breaks a hip. The client says he will sue the nurse for negligence because of the fall. The nurse should know that, in legal proceedings, the standard that will be used to determine if the nurse is liable for the client’s injury will be which?
B. Another staff nurse’s description of how a reasonably prudent nurse should have performed under the same circumstances
An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a DNR case. Which of the following nurse responses is appropriate?
D. Your provider needs to consult with you concerning your desires for DNR
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When assessing this client, the nurse should expect to find which of the following early indications of hypoxia?
D. Hypertension
A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as acceptable client identifiers? SATA
A. Client’s full name
C. Home telephone number
E. Hospital assigned ID number
A client who has emphysema and has difficulty with mobility is receiving home health care. He spends most of his day in a reclining chair. Which physiological response to prolonged immobility should the nurse inspect?
D. Increased calcium excretion
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