ATI Testing and Remediation Advanced
|A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder?||Unstable interpersonal relationships|
|A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.)||Blood stream, Urinary tract , Surgical wound, Respiratory tract|
|A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak?||Oliguria|
When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.
|A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning?||Advocate|
|A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider?||A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L|
|A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care?||Identify one’s own beliefs and values.|
To provide culturally competent care, it is essential to identify one’s own cultural background, values, and beliefs, especially those that are related to health and health care
|A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching?||Soybeans|
|A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider?||Slurred speech|
Slurred speech is an early clinical finding associated with lithium toxicity and can precipitate the onset of seizures or coma.
|A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider?||Tachycardia|
|A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril?||Aspirin (Bayer)|
|A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client’s total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations?||Shakiness and diaphoresis|
The nurse should observe the client for shakiness and diaphoresis. These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.
|A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching?||“I should eat low carbohydrate foods.”|
|A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.)||Drooling|
|A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney’s point. (Selectable areas, or “Hot Spots,” can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)||Lower right quadrant|
|A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse?||Place client in knee-chest position.|
Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take.
|A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching?||“This illness will not recur because my child has now had it.”|
|A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50 mg/kg IM. The infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?||The nurse should administer 0.8 mL ceftriaxone IM.|
|nurse in a pediatric provider’s office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. Listen to the audio clip and determine which of the following responses by the nurse is appropriate. (Click on the audio button to listen to the telephone conversation.)||“Do not attempt to remove it.”|
Yellow exudate covers the penis 24 hr after the circumcision and will persist for 2 to 3 days. This is an expected finding and should not be removed.
|A nurse is reviewing the electronic fetal heart rate tracing of a client who is in labor. Which of the following images exhibits variable decelerations?|
|A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client’s medical record, which of the following findings should be immediately reported to the provider? (Click on the “Exhibit” button below for additional client information. There are three tabs that contain separate categories of data.)||Temperature 37.6º C (99.8º F)|
Sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine.