ATI Exit Exam 2023 Flashcards

Questions and Answers

Which of the following statements by the client indicates an understanding of the information about advance directives?

I should discuss this document with my family after I sign it. (correct)

I have the right to make decisions about my healthcare. (correct)

I don't want any medical treatment.

Only my doctor can make decisions regarding my treatment.

Which of the following interventions should the nurse recommend for a client with Alzheimer's disease who has difficulty sleeping at night?

Limit evening activities.

Increase the client's caffeine intake.

Provide the client with stimulants.

Encourage the client to take frequent walks during the day. (correct)

Which of the following actions should the nurse take for a client who is 8 hours postpartum and has uterine atony with increased bleeding?

Encourage the client to rest.

Increase fluid intake.

Assist the client to empty her bladder. (correct)

Apply heat to the abdomen.

What should the nurse include in her instructions about effleurage during early stage labor?

Gently stroke her abdomen during contractions. Signup and view all the answers

Which of the following actions should the nurse take to prevent skin breakdown for an older adult client who is incontinent?

Use a moisture barrier on the client's skin. Signup and view all the answers

Which of the following instructions should the nurse take to promote the client's autonomy in terminal cancer care?

Allow the client to choose treatment times. Signup and view all the answers

Which of the following findings indicates an obstetric complication for a client at 40 weeks gestation experiencing a gush of vaginal fluids?

Fluid appears greenish-brown in color. Signup and view all the answers

What action should the nurse take immediately after a lumbar puncture for an adolescent client?

Inform the adolescent that he might experience a headache. Signup and view all the answers

Which of the following statements by the client indicates an understanding of teaching about advance directives with end-stage renal heart failure?

I should discuss this document with my family after I sign it. Signup and view all the answers

What action should the nurse take for a client with a continuous bladder irrigation who has clots and dark red blood?

Irrigate the bladder with 20-30 ml of 0.9% sodium chloride irrigation. Signup and view all the answers

What action should the nurse take while obtaining a 12-lead ECG for a client with a history of cardiac dysrhythmias?

Instruct the client to remain as still as possible during the recording. Signup and view all the answers

Which information should the nurse include when reinforcing teaching for a client who has genital herpes?

You should increase fluid intake to relieve dysuria. Signup and view all the answers

Which action should the nurse plan when preparing to empty a post-operative client's closed-wound drainage system?

Compress the container before replacing the drainage bag. Signup and view all the answers

Which instructions should the nurse include for the parents of a toddler who has a new diagnosis of asthma?

Administer the medication to the toddler each evening. Signup and view all the answers

Which responsibility should occur during the orientation phase of the nurse-client relationship in a mental health facility?

Defining responsibilities. Signup and view all the answers

Where should the fetal heart monitor be placed to auscultate the fetal heart rate for a client who reports having a decrease in fetal movement after an external cephalic version?

Lower left. Signup and view all the answers

What action should the charge nurse take when observing a newly licensed nurse perform suctioning for a client with a tracheostomy?

Intervene if the suctioning lasts for more than 30 seconds. Signup and view all the answers

Which interaction should the nurse monitor for a client taking atenolol and using a nitroglycerin transdermal patch?

Hypotension. Signup and view all the answers

Which action should the nurse take to verify a client's identity before administering medications?

Verify the client's identity using a photograph. Signup and view all the answers

Which statement made by the client with psoriasis should be reported to the provider?

I try not to look at the scales on my body. Signup and view all the answers

Which response in the medical record should the nurse use to determine potential causes of falls in a long-term care facility?

Medication record. Signup and view all the answers

Which task should the nurse assign to the AP following the death of a client?

Complete post-mortem care for a client who has died. Signup and view all the answers

For which manifestation should the nurse instruct the client taking allopurinol to monitor and report?

Skin rash with fever. Signup and view all the answers

Which statement made by a charge nurse about fall precautions indicates an understanding of the teaching?

I will instruct the client to sit when putting on a pair of pants. Signup and view all the answers

Which client should the nurse recommend for discharge after one episode of diarrhea?

A client who has a sodium level of 140 mEq/L. Signup and view all the answers

What intervention should be included in the plan of care for a newly admitted client with anorexia nervosa?

Administer liquid supplements. Signup and view all the answers

Which statement by a newly licensed nurse indicates an understanding of the teaching about floating to a different unit?

I will document in the medical record the support nurse who assists with planning care for my clients. Signup and view all the answers

Which finding should the nurse report to the provider for a client with dehydration due to diarrhea?

BUN 18 mg/dL. Signup and view all the answers

Which actions should the nurse take to evaluate the effectiveness of a performance improvement program?

Identify data collection methods. Signup and view all the answers

Which instruction should the nurse include when teaching staff about preparing for an external chemical disaster?

Move clients to a room above ground with a few windows. Signup and view all the answers

Which action should the nurse take for a client who has an AV shunt in his right arm?

Avoid range of motion in the right arm. Signup and view all the answers

What indicates hopelessness in a client with a terminal illness?

The client has a decreased level of energy. Signup and view all the answers

Which behaviors indicate that a preschooler is ready to cooperate? (Select all that apply)

Makes eye contact with the nurse Signup and view all the answers

Which client should the nurse see first?

A client who has schizophrenia and is having command hallucinations. Signup and view all the answers

What should the nurse say to a client struggling with newborn care?

"Let me show how to swaddle and cuddle him, then try." Signup and view all the answers

What action should the nurse take when using a glucometer?

Keep the finger in dependent position. Signup and view all the answers

Which OTC meds interact adversely with clopidogrel?

Naproxen. Signup and view all the answers

What should the nurse check for in a client with a long leg cast?

Check for pain with passive movement of the affected extremity. Signup and view all the answers

What adverse effect should the nurse include in teaching about cigarette smoking?

Somnolence. Signup and view all the answers

In which situation can a nurse medicate a client against his will?

A client who is attempting to hurt himself or others. Signup and view all the answers

What should the nurse monitor in a client taking digoxin?

"Monitor for muscle weakness while taking the medication." Signup and view all the answers

Who can a charge nurse share a client's medical info with?

A social worker who's assigned an involuntary committed school-age client. Signup and view all the answers

Which lab finding should a nurse report for a client at 34 weeks of gestation?

Urine protein plus. Signup and view all the answers

What finding requires immediate intervention for a client 4 hours post-op?

O2 sat 89%. Signup and view all the answers

What should the nurse report immediately in a client with a history of hypertension?

Blurred vision. Signup and view all the answers

What action should the nurse take for a client with sudden chest pain and dyspnea?

Elevate the client's HOB. Signup and view all the answers

Which lab test is most accurate for blood glucose effective management?

Glycosylated Hemoglobin. Signup and view all the answers

What action should the supervising nurse intervene for a newly licensed nurse?

Tells a client he will lose his phone privileges if he does not take his medication. Signup and view all the answers

What should the AP obtain for a client on seizure precautions?

Oral suction equipment. Signup and view all the answers

What action should the nurse take for a client with dependent personality disorder?

Encourage the client to be assertive. Signup and view all the answers

What instruction should a nurse give to a client post hip arthroplasty?

"You should avoid crossing your legs for 3 months." Signup and view all the answers

What dietary instruction should be included for a client with hyperemesis gravidarum?

Eat a small meal every 2-3 hours. Signup and view all the answers

What indicates understanding of ranitidine instructions?

"I should take this medication in the morning and at night." Signup and view all the answers

What type of isolation precautions should be implemented for a client with pulmonary TB?

Airborne. Signup and view all the answers

What instruction should the nurse give to a client with COPD?

"Perform pulmonary hygiene 1 hour before meals." Signup and view all the answers

What outcome should be expected from administering pancreatic enzymes for cystic fibrosis?

Reduced fat in stools. Signup and view all the answers

What should the nurse say to a client with paranoid schizophrenia?

The psychiatric staff, not the FBI, are here to help you. Signup and view all the answers

What should be ensured in Buck's traction?

Ensure the weights are hanging freely. Signup and view all the answers

What should be identified as a factor affecting oxygen saturation readings?

Peripheral Vascular Disease. Signup and view all the answers

What description indicates xanthelasma?

Lady with eyes closed with nodule on eyelid. Signup and view all the answers

What type of precautions are necessary for a client with VRE?

Contact precautions. Signup and view all the answers

What should the nurse do to simplify medical terminology during education?

Explain medical terminology using basic one-syllable words. Signup and view all the answers

What statement might indicate a priority concern for an adolescent?

I would rather be alone than with my fiance. Signup and view all the answers

What type of wound dressing should be used for a stage 1 pressure ulcer?

Transparent film. Signup and view all the answers

What action should be taken for a client with pain who has a prescription for ketorolac?

Administer the medication to the client. Signup and view all the answers

Which actions should a charge nurse take when developing a performance improvement plan for an AP? (Select all that apply)

Set a specific time frame for meeting performance goals Signup and view all the answers

What instruction should a nurse provide for a client undergoing radiation therapy to the neck?

Avoid exposing the neck to the cold. Signup and view all the answers

What fall precaution should the nurse implement for an older adult with impaired mobility?

Determine the client's ability to use the call light. Signup and view all the answers

What should the nurse include about intermittent catheterization?

"You will need to urinate before the procedure." Signup and view all the answers

What should the charge nurse do regarding a terminal cancer patient who has declined treatment?

Talk with the nurse about the need to support the client's decision. Signup and view all the answers

What information should be provided to a postpartum client about breastfeeding?

Feed newborn 8-12 times/day every 24 hr. Signup and view all the answers

What action should be taken for a school-aged child upon admission?

Initiate contact precautions for the child. Signup and view all the answers

What intervention should be included in the plan for a client with ascites due to cirrhosis?

Measure the client's abdominal girth daily. Signup and view all the answers

What food should a nurse recommend to a client taking antibiotics to reduce diarrhea?

Yogurt. Signup and view all the answers

What action should be taken for a client with increased intracranial pressure?

Elevate HOB 30 degrees. Signup and view all the answers

What action should be included for a pregnant client in the third trimester with ankle edema?

Apply support stockings. Signup and view all the answers

What intervention should be recommended for a client experiencing delirium?

Remind the client of the day and time often. Signup and view all the answers

Which food should be included in pamphlets about choking hazards for toddlers?

Grapes. Signup and view all the answers

What should be instructed regarding sputum examination for a client with TB?

"You should have a sputum examination every 4 weeks." Signup and view all the answers

What action should be taken for a client at 37 weeks gestation undergoing a nonstress test?

Remind the client to press the button when she feels fetal movement. Signup and view all the answers

What intervention should be included for a client with dysphagia?

Tilt the client's head forward during meals. Signup and view all the answers

What finding should the nurse monitor and report in a client at 18 weeks gestation with mild hypertension?

Persistent headache. Signup and view all the answers

What statement should a nurse make to a client’s partner after a recent death?

"Tell me what I can do for you at this time." Signup and view all the answers

What response is appropriate to a client who felt neglected during their last hospitalization?

"That must have been a difficult experience for you." Signup and view all the answers

Which communicable disease should the nurse report to the state health department?

Neisseria gonorrhoeae. Signup and view all the answers

What finding should the nurse expect in a client suspected of bacterial meningitis?

Nuchal rigidity. Signup and view all the answers

What lab value is expected for a client with end-stage renal disease?

Creatinine 15 mg/dL. Signup and view all the answers

What instruction should the nurse follow for a client on warfarin with an INR of 5.5?

Obtain an aPTT level. Signup and view all the answers

What signs indicate fluid volume excess?

Distended neck veins. Signup and view all the answers

What should the nurse say regarding the benefits of a Pavlik harness?

"The harness can promote hip joint development." Signup and view all the answers

Where should the nurse document a medication administration error?

Incident report. Signup and view all the answers

How should the nurse prepare a sterile field for a dressing change?

Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field. Signup and view all the answers

What term describes the nurse's action of interrupting a bath to obtain food for a client?

Countertransference. Signup and view all the answers

What isolation precautions should be implemented for a client with herpes simplex?

Contact precautions. Signup and view all the answers

What should the nurse take if a space was left blank in documentation?

Draw a horizontal line through the space and sign at the end of the line. Signup and view all the answers

What disinfectant should be used after a blood spill for a client with AIDS?

Bleach. Signup and view all the answers

What safety risk is indicated by electrical wires running under the carpet?

The client's electrical wires are running under the carpet. Signup and view all the answers

What should be included in the informed consent teaching?

You can sign the informed consent form after the provider explains the pros and cons of the procedure. Signup and view all the answers

What should the nurse inform a client taking metronidazole?

You should expect your urine to turn brown. Signup and view all the answers

What should the nurse remind the client undergoing an invasive procedure?

Remind the client about the specifics of the procedure. Signup and view all the answers

Study Notes

Terminology and Nursing Concepts

"Decreased level of energy" may indicate hopelessness in clients with terminal illnesses.
Cooperative behaviors in preschoolers include allowing touch, answering questions, and making eye contact.

Mental Health and Safety

Clients experiencing command hallucinations (e.g., schizophrenia) should receive priority nursing care.
Involuntary medicating is permissible for clients attempting self-harm or harming others.

Client Education and Interaction

Providing guidance to new parents—like swaddling—can alleviate feelings of inadequacy.
Client education for medications includes interaction awareness, especially between clopidogrel and naproxen.

Patient Assessment and Interventions

For clients with leg casts, checking passive movement pain is crucial to assess complications.
Hypoxemia is indicated by an O2 saturation of 89%, requiring immediate intervention.

Sputum and Dietary Considerations

Clients with cystic fibrosis should be expected to show reduced fat in stools with pancreatic enzyme therapy.
For clients with hyperemesis gravidarum, eating small meals every 2-3 hours is advised.

Discharge Instructions and Health Teaching

Clients post-arthroplasty should be instructed to avoid crossing legs for 3 months.
Effective management of diabetes mellitus is indicated by glycosylated hemoglobin tests.

Safety Protocols

Ensure sterile practices during dressing changes by keeping objects at least 1 inch away from the sterile field.
Use of appropriate isolation precautions for clients with VRE includes contact precautions.

Assessment and Observation Techniques

Distended neck veins indicate potential fluid volume excess in clients on continuous IV.
Urine that is brown after metronidazole is expected for clients with trichomoniasis.

Emotional Support and Communication

When supporting clients with terminal illnesses, affirming their decisions is essential.
Engaging in open-ended conversations with grieving families helps validate their experiences.

Health Indicators and Risks

Persistent headaches in pregnant clients should be monitored as they can signal complications.
Xanthelasma appears as yellowish nodules on eyelids and is associated with lipid imbalance.

Autonomy and Patient Engagement

Empower clients with terminal illnesses by allowing them to choose treatment schedules and times.
Encourage assertiveness in clients with dependent personality disorders during discharge teaching.

Clinical Knowledge and Skills

Utilize transparent films as dressings for stage 1 pressure ulcers.
Recognize that countertransference may occur when personal feelings influence care decisions.

Documentation and Reporting Protocols

Document medication errors (e.g., overshooting dosage) in incident reports for transparency.
Report communicable diseases like Neisseria gonorrhoeae to health authorities as required.

Nursing Interventions for Specific Conditions

Clients with early labor should be taught effleurage techniques to manage discomfort.
Regularly remind clients with delirium of day and time orientation to reduce confusion.

Additional Practical Guidelines

Practice safe handling by ensuring that electrical wires are not a tripping hazard for older patients.
Advise dietary adjustments for clients on antibiotics to mitigate diarrhea, such as incorporating yogurt.

Critical Assessments in Labor

Assessing and noting any complications in vaginal fluid discharge at 40 weeks is vital for maternal and fetal health.### Lumbar Puncture Care
Inform the adolescent that headaches may occur post-procedure.

Advance Directives

Discussing advance directives with family is essential after signing; shows client understanding of the process.

Bladder Irrigation Post-TURP

Administer 20-30 ml of 0.9% sodium chloride for bladder irrigation if clots and dark blood are observed.

ECG Procedure

Instruct the client to stay as still as possible during a 12-lead ECG to ensure accurate results.

Genital Herpes Management

Increase fluid intake to alleviate dysuria in clients with genital herpes.

Postoperative Drainage Care

Compress the container prior to replacing the drainage bag to maintain suction.

Asthma Management for Toddlers

Administer Montelukast daily each evening to children diagnosed with asthma.

Nurse-Client Relationship

Defining responsibilities occurs during the orientation phase in a mental health facility.

Fetal Heart Rate Monitoring

Place the fetal heart monitor on the lower left side to assess fetal heart rate in right occiput anterior position.

Tracheostomy Suctioning

Limit suction duration to 30 seconds to prevent hypoxia; monitor newly licensed nurses for adherence.

Monitoring Medication Interactions

Observe for hypotension in clients taking atenolol and nitroglycerin together.

Client Identity Verification

Verify the client’s identity using a photograph before medication administration to ensure safety.

Psoriasis and Body Image

Report statements indicating poor body image, such as avoiding scales, to the provider.

Fall Risk Assessment

Review medication records for clients in long-term care facilities to identify potential fall causes.

Post Mortem Care Assignment

Assign the task of completing post mortem care to an unlicensed assistive personnel (AP).

Allopurinol and Stevens-Johnsons Syndrome

Monitor and instruct clients on the signs of skin rash accompanied by fever, indicating a severe reaction.

Fall Precautions in Long-Term Care

Encourage sitting while dressing as a fall prevention strategy.

Client Discharge Recommendations

Recommend discharge for stable clients, such as those with a sodium level of 140 mEq/L post-diarrhea.

Nutritional Support for Anorexia

Include the administration of liquid supplements in the care plan for clients with anorexia nervosa.

Floating and Documentation

Document the support received from a nurse when floating to different units to ensure accountability.

Reportable Findings for Dehydration

Report a BUN level of 18 mg/dL in dehydration cases, as it signals potential complications.

Performance Improvement Evaluation

Identify and implement data collection methods to assess program effectiveness in nursing care.

Chemical Disaster Preparedness

Move clients to above-ground rooms with windows during external chemical disasters for safety.

AV Shunt Care

Avoid performing range of motion exercises on the right arm in clients with an AV shunt to prevent complications.

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Prepare for the ATI Exit Exam 2023 with these helpful flashcards. Each flashcard covers essential nursing concepts and patient indicators that you might encounter in clinical practice. Test your understanding and improve your knowledge in patient care and assessment.