ATI Comprehensive Practice Test Lead Me Lord

1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing. a. Erythema on the skin surrounding ...

1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing. a. Erythema on the skin surrounding a client's wound b. Deep red color on the center of the clients wound c. Inflammation noted on the tissue edges of a client's wound d. Increase in serosanguineous exudate from the clients wound (damaged capillaries) Rationale: Leadership 7.0 pg 329: - Stages of Wound Healing - Inflammatory stage - beginning stage, also usually suggests infection - Begins with the injury and lasts 3 to 6 days - Effects to the wound: controlling bleeding with vasoconstriction and retraction of blood vessels, and with clot formation. Delivering oxygen, WBCs, nutrients to the area via blood supply. Hemostasis occurs along with fibrin formation. Macrophages engulf microorganisms and cellular debris (phagocytosis). - Proliferative stage - Lasts the next 3 to 24 days - Effects to the wound: replacing lost tissue with connective or granulated tissue or collagen. Contracting the wound’s edges. Resurfacing of new epithelial cells. Healthy granulation tissue does not bleed easily. Dark granulation tissue can be a sign of infection, ischemia, or poor perfusion. In the final phase of the proliferative stage of wound healing, epithelial cells resurface the injury. - Maturation or remodeling stage - Occurs after day 21 and involves that strengthening of the collagen scar and restoration of a more normal appearance. It can take more than 1 year to complete, depending on the extent of the original wound. When scar tissues are forming. - Appearance: - Note the color of open wounds. - Red: healthy regeneration of tissue. - Yellow: presence of purulent drainage and slough - Black: presence of eschar that hinders healing and requires removal. 2. A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform first? a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart. - (fast-acting insulin...usually takes effect after 15 minutes) b. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400. c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours 3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse? a. A client who has multiple sclerosis and ataxia - (normal finding for someone that has multiple sclerosis = most stable - showed up on online practice tests) b. A client who has brain tumor and is admitted for chemotherapy ← dead c. A client who has guillain-barre syndrome and a tracheostomy -unstable d. A client who sustained a concussion and is being monitored for complication -unstable 4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? a. “Once I sign my living will, a family member must co-sign it” b. “I will wait until I have a serious health problems to sign my advance directives” c. “My doctor will need to provide approval for the decisions outlines in my living will d. “My durable power of attorney for health care is part of my advance directives”-durable power of will and living will are components of advance directives. Rationale: Leadership 7.0 page 38 5. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? a. Identify the industry standards for infant safety b. Evaluate the selected infant safety system c. Choose an infant safety system d. Establish measurement criteria for infant safety systems 6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the following providers? a. Physical therapist b. Respiratory therapist c. Speech therapist d. Occupational therapist 7. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (select all that apply) - A wheeled office chair at the client's computer desk - A raised vinyl seat on the toilet in the bathroom - A throw rug covering some cracked vinyl flooring in the kitchen - A folding chair without arm rests. - A two wheeled walker used to assist the client with ambulation 8. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the following clients should the nurse assign to a LPN a. An older adult who has lung cancer and has periodic episodes of severe dyspnea b. A middle adult client who has a below the knee amputation and requires a dressing change - stable; only needs dressing change c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus d. An adolescent who is new diagnosed with DM and requires teaching regarding insulin administration 9. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority for the nurse to take? a. Remind nurses to obtain this information during the admission processb. Reinforce the potential consequences of not having his information on record to the nursing staff c. Meet with nursing staff to review the policy regarding advance directive d. Ask nurse who are caring for client without his information in the medical record to obtain it 10. A nurse is caring for a group of clients. Which of the following should the nurse see first? a. A client who is postoperative and his a fever. b. A client whose pressure ulcer has serosanguineous drainage on the dressing-normal c. A client who has diabetes mellitus and is diaphoretic- hypoglycemia d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0 to 10.-no Rationale:Hypoglycemia may lead to SZ, coma or death if it’s not treated right away. Other S/S: Tachycardia, cold sweats, irritability, confusion, and diaphoretic aka sweating. 11. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first? a. A client who is 4 hr post-operative following a hernia repair and has pitting edema of the right leg b. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea c. A client who has pneumonia and requires a tracheostomy dressing change d. A client who has a new colostomy and requires discharge teaching 12. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working on the night shift. Which of the following actions should the nurse manager take first? a. Acknowledge the conflict and encourage the nurses to focus on working as a team. b. Gather information regarding the situation c. Encourage the nurses to resolve the conflict autonomously d. Meet with a committee from each shift to discuss issues related to the conflict 13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. Don personal protective equipment - protect yourself first b. Irrigate the exposed area with water c. Remove the client’s clothing d. Report the incident to OSHA 14. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? a. Complete an incident report b. Measure the client’s vital signs c. Inform the nurse manager d. Call the provider 15. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? a. Decreased level of consciousness - getting sleepier..neurological damage? Maybe? I liike disss, baka INC ICP b. Generalized rash over trunk c. Increased temperature d. Report of photophobia Rationale:Seek immediate medical care if you or someone in your family has meningitis symptoms, such as: ● Fever. ● Severe, unrelenting headache. ● Confusion. ● Vomiting. ● Stiff neck. 16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? a. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.???? b. A blood culture was obtained after antibiotic therapy had been initiated c. An allergy to penicillin required an alternative antibiotic to be prescribed HMM d. The route of antibiotic therapy on the care pathway was changed from IV to PO A variance report should be initiated whenever an error is made involving a client, even if no injury occurred. 17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit? a. A client who is postterm and is receiving oxytocin for labor induction b. A client who gave birth to her first child and requires instruction on breastfeeding techniques c. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating. - most stable d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion 18. A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following members of the interprofessional team should the nurse consult? a. Risk management coordinator b. Clinical pharmacist c. Nursing supervisor d. Infection control nurse 19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? a. Discuss with the client her concerns regarding the procedure b. Provide the client with information on treatment options and outcomes c. Inform the client of the consequences of uterine prolapse and the need for intervention d. Initiate a mental health consult to determine the client’s reasons for refusing surgery 20. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery c. Ask the anesthesiologist to sign the consent d. Transport the client to the operating room without verifying informed consent 21. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Performing postmortem care prior to transferring the client to the morgue b. Advising a client on self-administration of acetaminophen c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Informing a family of a client’s progress in physical therapy 22. A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? a. Notify staff of the increased fall rate b. Review current literature regarding client falls c. Implement a fall prevention plan d. Identify clients who are at risk for falls 23. A nurse is completing a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse? a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile . b. The AP closes the door of a client who is on airborne precautions c. The AP removes cut flowers from the room of a client who is in a protective environment. d. The AP wears a mask when caring for a client who has varicella Rationale: Alcohol-based hand sanitizers are highly effective against non–spore-forming organisms, but they do not kill C. difficile spores or remove C. difficile from the hands 24. A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse? a. Asses the staff nurses’ knowledge deficit - assess first b. Pair an inexperienced nurse with an experienced nurse c. Demonstrate use of the pump during medication administration d. Plan an in-service education program on the unit 25. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP? a. Administer the initial bolus feeding to a client who has an NG tube → admin of med b. Check a client’s pain level 30 min after receiving acetaminophen → assessment of pain c. Collect a urine specimen from a newly admitted client d. Instruct a client to splint an abdominal incision → considered teaching/assessment 26. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? a. Treat the client’s injuries within 30 min b. Provide treatment for life-threatening injuries c. Provide treatment for minor injuries d. Allow the client to die without further intervention BLACK