ATI Fundamentals Quiz Bank1. A nurse is teaching a client who is postoperative about the importance of turning,coughing, and breathing deeply. Which statement is an indication that the patientunderstands: “If I do this often, I won’t get pneumonia.” (Turning, coughing, and deepbreathing prevent respiratory complications such as pneumonia by promoting lungexpansion and secretion removal)2. A nurse is teaching a middle ages client about health promotion and disease prevention.The nurse should inform the client that which of the following changes could occur:Decreased estrogen and testosterone production. (Tone of large intestines decreasesleading to risk for constipation, decrease in muscle mass, likelihood of chronic illnessincreases)3. A nurse if inserting an NG tube for bowel obstruction. Which action should she take first:Explain procedure (least invasive priority setting framework when caring for client,assign priority to nursing interventions least invasive. Informing client reduces fear andassists in gaining the client’s cooperation)4. A nurse is performing a physical examination for a client. To evaluate the client’s skinmoisture, the nurse should use which of the following techniques: Palpation5. A hospice nurse is reviewing religious practices of a group of clients with a newlylicensed nurse. Which of the following indicates an understanding of the teaching: Peoplewho practice Judaism stay with the body until burial (Islamic: body is washed andwrapped and buried as soon as possible; Hindu: may place body north following death,cremation; Buddhist: male family members prepare the body)6. A nurse is caring for an older client who becomes agitated when the nurse requests thatthe client’s dentures be removed prior to surgery. Which of the following responsesshould the nurse provide: “What worries you about being without your teeth?(therapeutic, validates the client’s feelings of agitation and seeks a reason)7. A nurse in urgent care is caring for a 15 year old with symptoms of STI. The client’sparents are unavailable but grandmother accompanied. Which action should nurse take:Ask adolescent to sign consent (unemancipated minors can legally give informed consentfor diagnostic procedures and treatment in some situations. These situations includetreatment of STI and substance abuse)8. A nurse is teaching to a group of unit nurses about wound healing by secondary intention.Which of the following should the nurse include in the teaching: Granulation tissue fillsthe wound (red tissue that fills during healing, it is left open to drain and heal bysecondary intention which occurs 5-21 days. Open wounds increase risk of infection.Primary intention involves closing the wound using sutures or staples at time the incisionis made, lines become well approximated. Tertiary intention includes using sutures toclose an open wound at a later date after the wound drains and it can include placinggrafted skin over the area. Grafting is required for full thickness burns/deeper wounds.)
- A nurse is changing dressing for a client recovering from appendectomy, wound isfeeling by secondary intention. Which observation should be reported: Halo of erythema(Can indicate underlying infection, this and any other manifestation of infection, purulentdrainage, swelling, warmth, odor, should be reported. Tenderness is expected, grainyappearance is granulation tissue and indicates proliferative stage of healing,serosanguineous drainage is made of RBCs and plasma and is expected in postoperativehealing)10. A nurse is caring in a LT facility. Which alerts the nurse for delirium: reduced level ofconsciousness (sudden memory impairment, illogical thinking, sleep disturbances.Gradual memory loss and difficulty with abstract thought is related to dementia.Verbalization of feelings of hopelessness is common in depression)11. A nurse is admitting a client who has a hearing aid. Which action should they take beforeinterviewing: Make sure the device is functioning12. A nurse is assessing a client who has fluid volume excess. Which findings should thenurse expect: Crackles in lung fields (manifestations include crackles, dependent edema,full neck veins when upright, elevated BP, and sudden weight gain)13. A nurse is caring for a client who has terminal pancreatic cancer. When the client states,It’s devastating that I will not be here to see my child graduate, the nurse should identifythat the patient is in: Depression14. A nurse is caring for a client who is scheduled to receive TENS for pain management.The client asks the nurse how a TENS unit helps to relieve pain. Which of the followingresponses should the nurse make: “It modulates the transmission of the pain impulse”(Applies a low voltage electrical stimulation directly over a location of pain at anacupressure point. It modulates the transmission of pain impulse and can cause a releaseof endorphins to assist with pain relief. Massage can be applied to facilitate relaxationwhich decreases muscle tension. It can also decrease pain intensity by increasingsuperficial circulation to an area of the body experiencing pain. Distraction can draw theclient’s attention away from the pain and help decrease perception of pain15. A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus andwill be caring for herself at home. The client expresses concerns about preparing anappropriate diet for her diabetes due to cultural preferences: The dietitian will help youchoose foods that you are used to that also meet your health needs16. A newly licensed nurse is preparing to administer medications. The nurse notes that theprovider has prescribed a medication that is unfamiliar to him. Which of the followingactions should the nurse take: Consult medication reference book (nurse must haveknowledge about medications to administer them safely. There is no reason to believethat the prescription is in error, therefore it is unnecessary for the nurse to confirm withthe provider)17. A nurse is caring for a client who has bilateral casts. Which of the following actionsshould the nurse take when assisting with feeding: Sit at the bedside
Psychosocial Concepts for Nursing Practice1. A nurse is caring for adolescents in a school based clinic. Which statement should thenurse recognize as identity vs role confusion: “I think I might be gay”a. Identity vs Role confusion: Adolescence, forming an identity and answering thequestion of Who am I? Questions about sexuality, developing identity, and findingplace in societyb. Industry vs Inferiority: Childhood, clients who struggle with this stage candevelop a sense of incompetence; “I can’t seem to do anything right for myparents”c. Trust vs Mistrust: Infancy, clients who struggle with this stage experiencesuspicion, withdrawal, lack of confidence. “Why would someone want to helpme, what’s in it for them?d. Generativity vs stagnation: middle adulthood, associated with mentoring,coaching, and becoming involved in community and societal issues. “ I’mcoaching a little league team.”2. A nurse is planning an education session about human growth and develop. Universalprinciples:a. Cephalocaudal: head to toeb. Simple to complex: infants learn head control before crawlingc. Continuous: growth spurts and slow ratesd. Individualized rates: Varies from individual to individual, each with own timetable3. During a wellness visit for a 4 year old, a parent asks about screen time. Which shouldthe nurse respond with: 1 hour per day, screentime for preschoolers should be no morethan 1 hour of programming at home, school, or afterschool4. A nurse is caring for a 10 year old with diabetes, which describes their response related toindustry vs inferiority: Expresses confidence in ability to self administer insulina. Becomes frustrated when caregiver fills out child’s menu: Autonomy vs shameand doubtb. Apologizes to caregiver for wanting to manage insulin independently: Initiative vsguilt (conflict between continuing to become more independent and guilt at therealization that this may cause conflict with their caregiver’s desire to be involvedin carec. Identity vs role confusion: adolescents are concerned about how they appear toothers and seek to gain a sense of belonging5. Risks for suicide: expressing feelings of helplnessness/gloom, express loss of interest inactivities once considered important, making threats of self harm, having access toweapons6. A nurse is providing discharge teaching to parents of preschooler admitted due to asthma.Which actions should the nurse include: Instruct use of MDI, have family smoke outside,
make changes in home environment to reduce dust mites, share plan for managing attackwith child’s teacher7. A nurse is preparing an education session about school age children to caregivers, sheshould include: egocentrism decreases, begins to understand reversibility, understandsevents can be interpreted in different waysa. Animism: preschool, 2-6 years old, preoperationalb. Egocentrism: common in preschool, wanes during school age years due to morelife experience and exposure to other ways of thinkingc. Reversibility: some objects that have been changed can return to original, schoolaged. Conservation and spatiality, understands that events can be interpreted differently:school agee. Deductive reasoning: formal operational, 12+, ability to draw conclusions from aset of facts by organizing thoughts and problem solving.8. A nurse is planning a class on puberty, what should be included: Primary sex organsmature, begins with growth spurt in height and weight, secondary sex characteristicsemerge, onset is influenced by genetis, environment, and gender9. Discussion about climacteric changes: Both males and females, menopause in females,changes occur gradually over a number of years in males, manifest as heart palpitations,hot flashes, night sweats, and vaginal dryness in women10. A nurse is providing prenatal education in first trimester, which teratogens should beavoided: Hyperthermia, uncontrolled glucose, rubella, smokinga. Four types of teratogens: metabolic, drugs, infections, physical agents11. Which statements are consistent with Piaget’s theory: Individuals acquire knowledge overtime, intelligence is a natural ability, children construct knowledge that evolves overtime, knowledge is constructed in new ways at critical points during development12. Nurse teaching diabetes: weight management, glucose testing, daily exercise, foot carea. Elevated glucose can result in damage to blood vessels placing the client at riskfor delayed wound healing and damage to the neurologic system resulting inneuropathy and altered sensation to areas such as hands and feet13. A nurse asks a first grader about rules, they respond, “We need to wash our hands beforelunch, be respectful, and pay attention. If we don’t we get into trouble. Which ofKohlberg’s stages: Punishment and obediencea. Punishment and obedience: 4-10 years, preconventional, rules are viewed in termsof positive or negative consequences to actionb. Good boy nice girl: 10-13 through adulthood, conventional, actions are guided bydesire to please others, rules are maintained to gain acceptancec. Social contract: postconventional, concepts of right and wrong as well as sharedstandard values with the larger community, rules are challenged if they infringe onrights
d. Law and order: 10-13 through adulthood, conventional, actions are guided byexpectations and desire to please, rules are obeyed to maintain order14. Care for older adult, living alone, hypertension: Maintain functional capacity, encouragefree weights, participate in social functions, install grab bars