ATI - Test 1 Practice Assessment Flashcards - NUR 101- Test 1

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ATI - Test 1 Practice Assessment Flashcards Preview NUR 101- Test 1 > ATI - Test 1 Practice Assessment > Flashcards Flashcards in ATI - Test 1 Practice Assessment Deck (36): 1

ATI - Test 1 Practice Assessment The nurse is caring for a client with a nosocomial infection. The nurse understands that a nosocomial infection is usually acquired A. in an industrial setting. B. during hosptialization. C. during a visit to the physician D. in a crowded environment. B. during hospitalization. Rationale: A nosocomial infection occurs following exposure of the client to a contaminated environment during hospitalization. 2

ATI - Test 1 Practice Assessment A nurse enters the hospital cafeteria for lunch and overhears two assistive personnel (AP) discussing a client who is currently hospitalized. Which of the following is an appropriate action for the nurse to take? A. Quietly tell the APs that this conversation is not appropriate. B. Report the incident to the provider. C. Complete an incident report. D. Document the occurrence in the client's medical record. A. Quietly tell the APs that this conversation is not appropriate. Rationale: The nurse has an obligation to protect the client's confidentiality and must terminate the discussion immediately. 3

ATI - Test 1 Practice Assessment A nurse works in a long-term facility which will be implementing a new protocol to meet the Joint Commission's (JCAHO) National Safety Goal of preventing health-care associated pressure ulcers. When educating assistive personnel about the new standard, the nurse emphasizes that it is most important to: A. Turn and position each resident q2h. B. Identify the residents at greatest risk for development of pressure ulcers. C. Use a barrier cream when delivering perineal care to residents. D. Supervise residents to ensure adequate nutritional intake B. Identify the residents at greatest risk for development of pressure ulcers. Rationale: 4

ATI - Test 1 Practice Assessment A nurse is providing instructions regarding heat therapy to a client who has cellulitis of the leg. Which of the following statements by the client indicates the understanding of therapy? A. "I'll place my leg under a heat lamp for 15 min q4h during the day." B. "I'll sleep with a dry heating pad on my right leg." C. "I'll apply warm, moist compresses to my leg twice a day." D. "I'll keep my leg at the level of my heart." C. "I'll apply warm, moist compresses to my leg twice a day." Rationale: Applying warm compresses twice daily can enhance comfort and indicates an understanding of therapy. 5

ATI - Test 1 Practice Assessment A nurse is caring for a client on a medical-surgical unit who is attempting to leave. Which of the following actions should the nurse take? A. Make sure the client understands that he is leaving against medical advice. B. Insist that the client exit the hospital via a wheelchair. C. Notify the facility's security department. D. Call the client's family. A. Make sure the client understands that he is leaving against medical advice. Rationale: The client should be informed that leaving the hospital is against medical advice (AMA), and this should be documented in the client's medical record. 6

ATI - Test 1 Practice Assessment A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take? A. Assure the client that this is a normal occurrence. B. Apply an abdominal binder to the wound area. C. Turn the client to her side. D. Cover the would with a moist sterile dressing. D. Cover the would with a moist sterile dressing. Rationale: A deep wound left open air could easily become contaminated, and exposed organ tissue could become dry and ischemic. Covering the wound with a most sterile dressing is the first actin the nurse should take to prevent further injury. 7

ATI - Test 1 Practice Assessment A nurse is caring for an alert and competent older adult who comes to the hospital accompanied by her son for elective cataract extraction. Who should the nurse have sign the consent form for the surgical procedure? A. The client B. The client and her son C. The client's health care proxy D. The client's son A. The client 8

ATI - Test 1 Practice Assessment A nurse observes an assistive personnel (AP) taking the call light away and reprimanding him for using it frequently. Which of the following actions should the nurse take first? A. Reassure the client. B. Inform the charge nurse. C. Speak with the AP. D. Document the incident A. Reassure the client. 9

ATI - Test 1 Practice Assessment A nurse is caring for a client who is hospitalized and asks to review his medical record. The appropriate response by the nurse is A. "I'm sorry, you do not have the right to read your chart." B. "You will need permission from the hospital administration to review your chart." C. "We'll give you a copy of your records when you are discharged." D. "We will need to review your chart together." D. "We will need to review your chart together." 10

ATI - Test 1 Practice Assessment A nurse is caring for a group of clients with the aid of an assistive personnel (AP). What determination must the nurse make before delegating a client care task to the AP? A. If the task is within the AP's scope of practice B. The AP's ability to prioritize. C. The AP's rapport with the client D. Whether the nurse can efficiently and effectively complete the task without assistance. A. If the task is within the AP's scope of practice Rationale: Delegation of client care tasks should be done in relation to the delegatee's scope of practice. This is one of the five rights of delegation and a critical determination the nurse must make prior to delegating tasks. 11

ATI - Test 1 Practice Assessment The nurse on an oncology unit is providing care for a client who is a hospital employee. Several nurses have called seeking information about the client. Which of the following actions should the nurse take in response to inquiries from the nurses? A. Refer questions to the nursing supervisor. B. Transfer calls directly to the client's room. C. Acknowledge that the person is a client on the unit, but give no specific details about the client's condition. D. Contact the client's provider. A. Refer questions to the nursing supervisor. Rationale: The nurse should give no information about the client and refer the calls to the nursing supervisor or follow established procedure in the institution. HIPAA regulations make it illegal for the nurse to share this information with anyone without the client's consent. 12

ATI - Test 1 Practice Assessment A nurse requests that an assistive personnel (AP) change all the linens and give bed baths to four different clients on the unit. The previous day, the AP was not able to complete these same tasks. Which of the following actions by the nurse is appropriate in addressing this situation? A. Set a time frame for the completion of the tasks assigned. B. Assign a more qualified individual to the tasks. C. Plan a more reasonable job assignment. D. Offer to help the AP complete the tasks as needed. A. Set a time frame for the completion of the tasks assigned. Rationale: When delegating work to others, the nurse should specify what is to be accomplished and the time frame. Setting time limits encourages others to decide how to achieve the goals. 13

ATI - Test 1 Practice Assessment A community health nurse is assisting with planning an immunization clinic for older adult clients. The nurse should advise the clients to receive an influenza vaccine A. only if they are in a high-risk group. B. q10 years C. annually. D. if the client has never had influenza. C. annually. Rationale: Influenza outbreaks occur annually, and the prevalent influenza viruses change yearly. Consequently, the previous year's influenza immunization will not protect a client exposed to the current year's influenza strains. 14

ATI - Test 1 Practice Assessment The nurse is caring for a hospitalized adolescent. The nurse understands that which major development task is important during adolescence? A. Building a sense of trust B. Learning to utilize creative energies C. Learning to defer gratification D. Defining a sense of self D. Defining a sense of self 15

ATI - Test 1 Practice Assessment The nurse is caring for a client who has a large wound which has a vacuum-assisted closure device placed over it. Which of the following finding should alert the nurse to a possible wound infection? A. Granulation tissue on the surface of the wound. B. Musty oder from the foam dressing upon removal. C. Serosanguineous drainage in the suction device. D. Peeling of the edges of the transparent dressing. B. Musty oder from the foam dressing upon removal. Rationale: A must odor is an unexpected finding and may indicate wound infection. 16

ATI - Test 1 Practice Assessment A nurse is caring for a client who has a fractured hip and is postoperative open reduction and internal fixation. The client has a closed-suction drain extending out of the wound. A. prevent fluid from accumulating in the wound. B. eliminate pain from the surgical site. C. prevent the development of a wound infection. D. eliminate the need for wound irrigations. A. prevent fluid from accumulating in the wound. Rationale: The purpose of this type of device is to promote healing by draining fluid out of the wound. 17

ATI - Test 1 Practice Assessment A nurse is planning care for a group of clients. In planning the assignment for an assistive personnel (AP), which of the following activities should the nurse consider to be unsafe for the AP to perform? A. Assisting an older adult client to take acetaminophen (Tylenol) crushed in applesauce. B. Administering a cleansing enema to a client who is preoperative. C. Obtaining a urine specimen for a urinalysis from a newly admitted client. D. Obtaining the vital signs of a client admitted with a history of angina. A. Assisting an older adult client to take acetaminophen (Tylenol) crushed in applesauce. Rationale: A licensed nurse must administer medications 18

ATI - Test 1 Practice Assessment A nurse is caring for a client who is postoperative following a mastectomy and returns to the surgical unit with a closed-wound drainage system in place. Which of the following actions by the nurse ensure proper operation of the device? A. Recollapse the reservoir immediately after emptying it. B. Empty the reservoir when it becomes full. C. Replace the drainage plug after releasing hand pressure on the device. D. Irrigate the tubing with sterile normal saline solution at least q8h. A. Recollapse the reservoir immediately after emptying it. Rationale: To re-establish the vacuum, the reservoir must be compressed fully after it is emptied. 19

ATI - Test 1 Practice Assessment A nurse observes another nurse performing a procedure in the incorrect sequence. The client is not harmed. Which of the following actions should the nurse take first? A. Speak with the other nurse privately. B. Submit an incident report. C. Correct the mistake independently. D. Volunteer to perform the procedure next time. A. Speak with the other nurse privately. Rationale: There may have been a reason for the way the other nurse performed the procedure, or she may simply need further information, which the nurse can provide. Using the data collection first priority-setting framework, the nurse will better know which course of action to take next to ensure continued client safety. 20

ATI - Test 1 Practice Assessment The nurse is changing the dressing on a client's wound. The nurse understands that which of the following symptoms indicate wound infection? A. Brownish, desquamating rash B. Edema and tenderness C. Petechiae and maculopapular rash D. Crusting over granulated tissue B. Edema and tenderness 21

ATI - Test 1 Practice Assessment A nurse is caring for a client who has a surgical wound healing by secondary intention. Which of the following observations regarding the client's wound should the nurse report to the charge nurse? A. Tenderness to touch B. Pink, shiny tissue with a granular appearance C. Serosanduineous drainage D. A halo of erythema on the surrounding skin D. A halo of erythema on the surrounding skin Rationale: A ring of redness on the surrounding skin may indicate underlying infection. This, and any other sign of infection such as purulent drainage, swelling, warmth, or strong odor, should be reported. 22

ATI - Test 1 Practice Assessment A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? A. Sanguineous B. Serous C. Serosanguineous D. Purulent D. Purulent Rationale: Purulent describes drainage that is thick yellow, green or brown in color. 23

ATI - Test 1 Practice Assessment A nurse is conducting a home health visit for an older client who lives with family members. The nurse notices that the client has several bruises in various stages of healing. The client explains that the bruises are a result of "clumsiness". However, based on the location and distribution of the bruises, the nurse suspects that the client may be abused. Which of the following actions should the nurse initially take? A. Follow the agency's guidelines for reporting suspected abuse. B. Discuss the client's bruises at the next team meeting. C. Institute more frequent visits to the client's home. D. Check the bruises at the next visit to the client's home. A. Follow the agency's guidelines for reporting suspected abuse. Rationale: To promote the client's safety, the nurse should report the suspected abuse according to the guidelines of the agency. 24

ATI - Test 1 Practice Assessment A nurse is caring for a client who has a wound. The nurse should recognize that which of the following findings is indicative of a wound infection? A. Copious serosanguineous drainage from the wound. B. Swelling and tenderness around the wound. C. Maculopapular rash and itching around the wound. D. Brownish-green crusting over the wound. B. Swelling and tenderness around the wound. 25

ATI - Test 1 Practice Assessment A nurse is contributing to the plan of car for a client who has a pressure ulcer on his heel. Which of the following should the nurse include in planning? A. Keep the ulcer dry. B. Clean the wound from the outer edge towards the center. C. Provide the client a diet high in vitamin C. D. Reposition the client at least q4h C. Provide the client a diet high in vitamin C. 26

ATI - Test 1 Practice Assessment An older adult client falls and fractures her hip while the nurse is assisting her to the bathroom. The client sues the nurse for negligence. In the legal proceedings, which of the following standards should be used to determine if the nurse is liable for the client's injury? A. Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances. B. An expert nurse describes how the same situation could have been handled differently. C. The plaintiff's attorney states that injury to the client could have been prevented. D. The client's provider testifies that the client's condition required her to have been moved differently A. Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances. 27

ATI - Test 1 Practice Assessment A nurse is caring for several clients at an urgent care center. For which of the following clients should the nurse suspect physcial abuse? A. A 6-year old with a sprial fracture of the tibia and fibula, which reportedly occurred while riding a bicycle. B. A 14-month old with many bruises over prominences, in various stages of healing. C. A 9-month old near drowning, who reportedly climbed into the tub and turned on the water D. A 3-year old with scalding burns over the face and chest reportedly sustained when a tablecloth was pulled, spilling a cup of tea. C. A 9-month old near drowning, who reportedly climbed into the tub and turned on the water 28

ATI - Test 1 Practice Assessment A nurse is working with two assistive personnel (AP). THe nurse notes that one of the APs has been taking long breaks and making personal phone calls. Which of the following comments is appropriate for the nurse to make when attempting to resolve this conflict? A. "Several staff members have commented that you don't do your fair share of the work." B. "I need to talk to you about unit expectations regarding timely completion of tasks." C. "If you don't do your share of the work, I will have to inform the nurse manager." D. "You have been very inconsiderate of others by not completing your share of the work." B. "I need to talk to you about unit expectations regarding timely completion of tasks." Rationale: This statement opens the conversations in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual. 29

ATI - Test 1 Practice Assessment A nurse is caring for an unidentified client who has been brought in unconscious to the trauma center. Upon the client's arrival, the surgeon determines that he requires immediate surgical intervention for acute intra-abdominal bleeding. The nurse should understanding that consent for the surgery A. can be implied, since the client is in critical condition B. must be obtained from fa relative of the client. C. should be obtained from an officer of the court. D. will be delayed until the client is identified. A. can be implied, since the client is in critical condition Rationale: In this situation, wince the surgeon has deemed the surgery necessary due to a life-threatening condition the consent can be assumed to be implied, and the surgery can proceed. 30

ATI - Test 1 Practice Assessment A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and A. vitamin C. B. folate. C. iron. D. potassium. A. vitamin C. Rationale: Diets high in protein and vitamin C are recommended because these nutrients are essential for promoting wound healing. 31

ATI - Test 1 Practice Assessment A nurse suspects that another nurse on the unit is removing a small amount of morphine sulfate from the syringe before administering the medication to the client. Which of the following actions by the nurse is appropriate? A. Inform the nurse manager about her suspicions. B. Approach the nurse involved to discuss her suspicions. C. Ask the assistive personnel (AP) to observe the other nurse's actions. D. Report the incident to the hospital's security department. A. Inform the nurse manager about her suspicions. Rationale: The nurse who is suspicious that another nurse may be mishandling narcotic medications has a legal and ethical responsibility to repot this to the nurse manager. 32

ATI - Test 1 Practice Assessment A nurse on a long term care unit is delegating tasks to an assistive personnel (AP). Which of the following should the nurse plan to include? A. Reinforcing teaching regarding bathing. B. Completing postmortem care. C. Initiating an enteral tube feeding. D. Performing a dressing change on a stage III pressure ulcer. B. Completing postmortem care. 33

ATI - Test 1 Practice Assessment A nurse is preparing to replace a client's abdominal dressing which is covering a large incision with a Penrose drain. Which of the following steps is appropriate for the nurse to take? A. Removing the entire dressing at once B. Loosening the dressing by pulling the tape away from the wound. C. Donning clean gloves to remove the dressing. D. Opening sterile supplies before removing the dressing. C. Donning clean gloves to remove the dressing. Rationale: Standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. Sterile gloves are not necessary until applying the new sterile dressing. 34

ATI - Test 1 Practice Assessment The nurse is caring for a group of clients. What nursing infection control intervention must be implemented? A. Needle precautions only B. Protective isolation techniques C. Standard precautions D. Contact precautions. C. Standard precautions Rationale: Standard precautions should be used when caring for all clients, including those with AIDS. 35

ATI - Test 1 Practice Assessment A nurse is collecting data from a client who was bitten by a tick. The nurse should check the client for the common early manifestations of Lyme disease, including flu-like manifestations, fever and A. an expanding circular rash. B. swollen, painful joints. C. sore throat. D. a diffuse maculopapular rash. A. an expanding circular rash. Rationale: Early Lyme disease is characterized by fever, flu-like manifestations and erythema migrans, and expanding circular (or "bulls-eye") rash that develops often at the bite site, the thighs, and the knees. 36

ATI - Test 1 Practice Assessment An assistive personnel (AP) appears to be chemically impaired. Which of the following action should the nurse take first? A. Ask the charge nurse to validate the observations. B. Arrange transportation home for the AP. C. Confront the AP regarding the behavior. D. Examine unit narcotic records. A. Ask the charge nurse to validate the observations. Decks in NUR 101- Test 1 Class (4): Unit I Introduction To Practical Nursing Unit Xvi Concepts Of Promoting Skin Integ Unit Ii Professional Accountability In Pr Ati Test 1 Practice Assessment Home Flashcards Teachers Companies About Contact Blog Pricing Gifts Terms Help Center Brainscape is a web and mobile study platform that helps you learn things faster. Our mission is to create a smarter world by simplifying and accelerating the learning process. © 2018 Bold Learning Solutions. Certified Flashcards All Flashcards: A B C D E F G H I

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ATI - Test 1 Practice Assessment Flashcards - NUR 101- Test 1

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