ATI - Test 2 Practice Assessment Flashcards by Michelle Rainer

ATI - Test 2 Practice Assessment

A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear protective eye equipment? (Select all that apply)

A. Giving personal care to an infant who is HIV positive.
B. Bathing a newborn for the first time.
C. Drawing cord blood form a neonate.
D. Transporting a cerebral spinal fluid specimen to the laboratory.
E. Suctioning a child who has newly placed tracheostomy tube.

C. Drawing cord blood form a neonate.

E. Suctioning a child who has newly placed tracheostomy tube.

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ATI - Test 2 Practice Assessment

A nurse is caring for a toddler in contact isolation. Which of following is an appropriate toy to offer the toddler?

A. Plush stuffed animal
B. Chapter book
C. Plastic building blocks
D. Puzzle

C. Plastic building blocks

Rationale:
Plastic building blocks can be sterilized. Therefore, it is an appropriate toy to bring into contact isolation.

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ATI - Test 2 Practice Assessment

A nurse is reinforcing teaching to an assistive personnel to count respiration rate on a newborn. Which of the following statements indicate understanding of why the respiratory rate should be counted for a complete minute?

A. “Newborns are abdominal breathers.”
B. “Newborns do not expand their lungs fully with each respiration.”
C. “Activity will increase the respiration rate.”
D. “The rate and rhythm are irregular in newborns.”

D. “The rate and rhythm are irregular in newborns.”

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ATI - Test 2 Practice Assessment

A nurse is collecting data on a client’s circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

A. Brachial
B. Carotid
C. Femoral
D. Popliteal

B. Carotid

Rationale:
The nurse should avoid assessing the carotid pulse bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.

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ATI - Test 2 Practice Assessment

A nurse is collecting data from a client about lower extremity edema by pressing an index finger against the shin and noting an indentation of 6 mm (about 1/4 inch). The nurse should document the client’s degree of pitting edema as which of the following?

A. 4+
B. 3+
C. 2+
D. 1+

B. 3+

Rationale:

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ATI - Test 2 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 hospitalization.
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.

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ATI - Test 2 Practice Assessment

A nurse is reinforcing teaching with a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

A. “If you wear gloves, you do not have to wash your hands.”
B. “Hand hygiene is crucial in preventing the spread of germs.”
C. “Use an alcohol rub when your hands are visibly soiled.”
D. “If you don’t have an infection, your hands won’t infect others.”

B. “Hand hygiene is crucial in preventing the spread of germs.”

Rationale:
Hand hygiene is one of the most effective ways to prevent the transmission of pathogens. Either the nurse or the client may have microorganisms on or in their body that do not harm them but may harm others.

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ATI - Test 2 Practice Assessment

A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear gloves? (Select all that apply)

A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
D. Delivering a food tray to a client who has AIDS
E. Placing oral medication tablets into a client’s hand

A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch

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ATI - Test 2 Practice Assessment

A nurse is evaluating an older adult client who is receiving end-of-life care for Cheyne-Stokes breathing respirations. Which of the following observations confirms this respiratory pattern?

A. Breathing ranging from very deep to very shallow with periods of apnea.
B. Shallow breathing alternating with periods of apnea.
C. Rapid respirations that are usually deep and regular.
D. An inability to breathe without dyspnea unless sitting upright.

A. Breathing ranging from very deep to very shallow with periods of apnea.

Rationale:
This describes Cheyne-Stokes respirations, an indication that the client is approaching death.

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ATI - Test 2 Practice Assessment

A nurse is reinforcing teaching for a client who has hepatitis about preventing transmission of the virus. The nurse should emphasize which of the following strategies?

A. Not eating at fast food restaurants
B. Not eating raw foods
C. Practicing effective hand hygiene.
D. Wearing barrier protection during vaginal intercourse.

C. Practicing effective hand hygiene.

Rationale:
Hepatitis A is an enterovirus (enters the body through the GI tract).

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ATI - Test 2 Practice Assessment

A nurse is caring for a client with MRSA in an abdominal wound. The nurse enters the room to check the client’s pulse. Which of the following actions is appropriate?

A. Wear a gown.
B. Apply sterile gloves.
C. Apply clean gloves.
D. Don protective eyewear.

C. Apply clean gloves.

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ATI - Test 2 Practice Assessment

A nurse is caring for a client on droplet precautions. Which of the following equipment is required when setting up the client’s meal tray?

A. Gloves
B. Goggle
C. Gown
D. Mask

D. Mask

Rationale:
Droplets are transmitted in the air and can travel 3 to 6 feet; therefore, a mask is necessary equipment when setting up the client’s meal tray.

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ATI - Test 2 Practice Assessment

A nurse is collecting data on a client who has diabetes and is experiencing foot pain. Which of the following are signs and symptoms of an infection? (Select all that apply)

A. Bradycardia
B. Increased neutrophils
C. Increased RBC
D. Increased platelets
E. Localized edema

B. Increased neutrophils

E. Localized edema

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ATI - Test 2 Practice Assessment

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 and untie waist strings.
B. Untie front waist strings, remove gloves, and untie neck ties.
C. Remove gloves, wash hands, and until waist strings.
D. Remove gloves, untie neck strings, and untie waist strings.

B. Untie front waist strings, remove gloves, and untie neck ties.

Rationale:
When removing an isolation gown that has ties in the front, the nurse should untie the waist ties first while still wearing the gloves as the front ties are considered dirty.

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ATI - Test 2 Practice Assessment

A nurse is checking a client’s bowel sounds. The 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.

Rationale:
Auscultation should be performed prior to percussing the abdomen to prevent altering the bowel sounds.

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ATI - Test 2 Practice Assessment

A nurse is caring for a client one day post-operative from an appendectomy and is HIV positive. Which of the following actions requires the nurse to wear a gown as personal protective equipment.

A. Talking to the client at the bedside.
B. Administering an IV piggyback medication.
C. Completing a dressing change.
D. Administering an IM injection.

C. Completing a dressing change.

Rationale:
Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. While performing a dressing change on a client who is HIV positive, the nurse should wear appropriate personal protective equipment, which includes a gown.

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ATI - Test 2 Practice Assessment

A nurse in a community clinic is assessing a client who reports uncontrolled vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect. (Select all that apply.)

A. Poor skin turgor
B. Bradycardia
C. Hypotension
D. Pale yellow urine
E. Furrowed tongue

A. Poor skin turgor
C. Hypotension
E. Furrowed tongue

Rationale:
Furrowed tongue is correct. Uncontrolled vomiting and diarrhea cause dehydration, which manifests as longitudinal tongue furrows

ATI - Test 2 Practice Assessment

A nurse is auscultating the breath sounds of 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 continuous, high-pitched sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

ATI - Test 2 Practice Assessment

A nurse is assisting with the admission of a client who has tuberculosis and a productive cough. Besides standard precautions, which type of precautions should the nurse contribute to the client’s plan of care?

A. Contact
B. Droplet
C. Protective
D. Airborne

D. Airborne

Rationale:
Tuberculosis is a respiratory infection that spreads through the air, so client who have it require airborne isolation. The client needs a private room with negative airflow and at least six to 12 air exchanges/hr.

ATI - Test 2 Practice Assessment

A nurse is caring for a client who has an infection. The nurse understands that which of the following interventions will interrupt the transmission of infection?

A. Changing the linen for the client each day.
B. Encouraging a diet high in protein.
C. Following strict hand-washing protocols.
D. Placing the client in a room with positive pressure.

C. Following strict hand-washing protocols.

ATI - Test 2 Practice Assessment

A nurse is reinforcing teaching with a group of active personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

A. “As long as I am changing gloves between clients, it is not necessary to wash my hands.”
B. “I should wash my hands when my hands are visibly soiled.”
C. “I will not wear artificial nails when providing client care.”
D. “It is acceptable to use alcohol-based hand products after most client contact.”

A. “As long as I am changing gloves between clients, it is not necessary to wash my hands.”

ATI - Test 2 Practice Assessment

A nurse who is orienting a newly hired group of assistive personnel is briefing them about infection control measures on the unit. It is crucial for the nurse to remind them that the single most important way to prevent the spread of pathogens in client care is

A. properly disposing of contaminated equipment.
B. discarding used syringes in appropriate containers.
C. changing soiled linens daily for clients with draining wounds.
D. performing hand hygiene frequently and consistently.

D. performing hand hygiene frequently and consistently.

ATI - Test 2 Practice Assessment

A nurse is caring for a client with a respiratory infection. Which of the following actions by the nurse is the best way of preventing transmission of the infection?

A. Using nonsterile gloves when in contact with body fluid.
B. Washing hands before donning sterile gloves.
C. Wearing a gown to protect skin and clothing.
D. Washing hands after the removal of soiled gloves.

D. Washing hands after the removal of soiled gloves.

ATI - Test 2 Practice Assessment

An assistive personnel (AP) on the pediatric unit may be pregnant. The nurse is unsure of the AP’s immune status. Which of the following clients could the nurse safely assign to the AP?

A. A preschooler who has varicella
B. A toddler who has impetigo
C. A school-age child who has rubella
D. A school-age child who has fifth disease

B. A toddler who has impetigo

ATI - Test 2 Practice Assessment A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious disease? A. Pertussis B. Mycoplasmal pneumonia C. Tuberculosis D. Respiratory syncytial virus

C. Tuberculosis

ATI - Test 2 Practice Assessment A nurse is obtaining a client's vital signs. The nurse suspects that the client is developing shock based on which of the following values? A. BP 180/110 mm Hg, pulse 40/min B. BP 100/65 mm Hg, pulse 56/min C. BP 130/80 mm Hg, pulse 110/min D. BP 80/40 mm Hg, pulse 126/min

D. BP 80/40 mm Hg, pulse 126/min

ATI - Test 2 Practice Assessment A nurse is planning to collect data on a client's abdomen who reports "stomach pain". Which of the following actions should the nurse do first? A. Auscultate B. Percuss C. Inspect D. Palpate

C. Inspect

ATI - Test 2 Practice Assessment A nurse is preparing a sterile field. Which of the following actions should the nurse perform first? A. Grasp the outer edge of innermost flap and lay it on the table. B. Center the sterile pack on the work surface. C. Open outermost flap away from the body while arm is outstretched. D. Grasp side flap by outer edge and lay it on the table.

B. Center the sterile pack on the work surface.

ATI - Test 2 Practice Assessment A nurse is responsible to check that an assistive personnel (AP) uses appropriate protection equipment while caring for clients. Which of the following states made by the AP indicates an appropriate understanding of standard precautions techniques? A. "I will wear gloves at all times when in contact with any clients, regardless of the diagnosis." B. "I will wear gloves and gown when bathing a client who has open skin lesions." C. "I will wear gloves, gown and mask at all times while caring for a client who has AIDS." D. "I will wear gloves when taking a client's BP."

B. "I will wear gloves and gown when bathing a client who has open skin lesions."

ATI - Test 2 Practice Assessment The nurse is working with a client after surgery. What is the appropriate intervention by the nurse to prevent incision infection? A. Protective isolation B. Allowing the wound to air periodically C. Cleaning the incision with soap and water during bath. D. Proper handwashing prior to dressing changes.

D. Proper handwashing prior to dressing changes.

ATI - Test 2 Practice Assessment A nurse is preparing to measure a client's level of oxygen saturation and notes edema on both of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin fold

B. Earlobe

ATI - Test 2 Practice Assessment A nurse is planning care for a client who is placed in transmission-based respiratory precautions (airborne precaution). Which of the following is an appropriate nurse precaution? A. Provide a positive air pressure room. B. Apply an N95 respirator mask. C. Allow the client to ambulate in the hall. D. Stand 6 feet away from the client.

B. Apply an N95 respirator mask.

ATI - Test 2 Practice Assessment A nurse is collecting data on a client's cardiac functioning and auscultates an S2 sound. The nurse is aware that his 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

ATI - Test 2 Practice Assessment A nurse is checking a client's radial pulse and determines the pulse is regular. Which of the following actions by the nurse is appropriate? A. Checking the apical pulse for a full minute. B. Checking the apical pulse with a doppler. C. Checking the pedal pulses for a full minute. D. Checking the pedal pulses with a doppler.

A. Checking the apical pulse for a full minute.

ATI - Test 2 Practice Assessment An assistive personnel (AP) asks a nurse what type of precautions are necessary when obtaining vital signs for a client who has pneumonia. Which of the following is an appropriate response by the nurse? A. "Gloves are not necessary if you wash your hands well." B. "Admit the clint to a room by the nurse's station." C. "Wear a mask when entering the client's room." D. "Wear gloves when you are changing the linens."

C. "Wear a mask when entering the client's room."

ATI - Test 2 Practice Assessment On auscultation of a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following is the appropriate nursing intervention? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day C. Prepare to administer antibiotics D. Place the client on bedrest in semi-Fowler's position.

A. Repeat auscultation after asking the client to breathe deeply and cough.

ATI - Test 2 Practice Assessment Following several episodes of vomiting with an increasing temperature in a 2-year-old child, the nurse plans to monitor the client for dehydration. Which of the following findings indicates the child is dehydrated? A. Specific gravity of 1.034 B. Irritable behavior C. Blood pressure of 90/58 D. Depressed fontanel

A. Specific gravity of 1.034

ATI - Test 2 Practice Assessment A sterile is preparing a sterile field. Which of the following actions by the nurse contaminates the field? A. Placing a sterile dressing 2 inches from the boarder of the sterile field. B. Holding a sterile item just about waist level. C. Opening a sterile package over the middle of the sterile field. D. Pouring sterile normal saline into container with the bottle label facing upward.

C. Opening a sterile package over the middle of the sterile field.

ATI - Test 2 Practice Assessment A nurse is preparing for the hospital admission of client who is suspected to have active tuberculosis (TB). Which of the following precautions should the nurse plan to implement to safely care for this client? A. Staff and visitors are to wear gowns, masks, and gloves while in the room. B. The client should be placed in a private room with a special ventilation system. C. The client may be placed in a room with other clients who require droplet isolation precautions. D. The protocol for donning and removing personal protective equipment before entering or leaving the room of a client with TB is different than for clients who are in other types of isolation.

B. The client should be placed in a private room with a special ventilation system.

ATI - Test 2 Practice Assessment While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A cardiac murmur B. A third heart sound (S3) C. An expected heart sound D. A fourth heart sound (S4)

A. A cardiac murmur