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A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain? ANSWER>>...

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2024 ATI RN CONCEPT BASED ASSESSMENT LEVEL 1
PROCTORED EXAM ACTUAL EXAM TEST BANK
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following
actions should the nurse take to treat the client's neuropathic pain? ANSWER>>>>Administer a
beta-blocking medication to the client.
(The nurse should administer a beta-blocking medication to the client. This classification of medication
has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain.)



A newly licensed nurse asks a charge nurse where to find information about scope of practice for
registered nurses. Which of the following responses should the charge nurse make? ANSWER>>>>"The
state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for nurses in that state. This
practice act is available on the board of nursing website for each state.)



A nurse is planning care to prevent a catheter-related bloodstream infection for a client who is receiving
IV fluid therapy. Which of the following interventions should the nurse include in the plan?
ANSWER>>>>Perform hand hygiene before touching the IV tubing.

(The nurse should perform thorough hand hygiene before touching any part of the infusion system or
the client to reduce the risk of catheter-related blood stream infections.)



A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel
incontinence. Which of the following interventions should the nurse include to prevent skin breakdown?
ANSWER>>>>Offer the client a glass of water every two hour when repositioning.

(The nurse should offer the client a glass of water every two hours on the clients repositioning schedule.
This helps prevent dehydration, which increases the risk of skin breakdown.)



A nurse is teaching a young adult female client about health screening for breast cancer. Which of the
following statements by the client indicates an understanding of breast self-examination (BSE)?
ANSWER>>>>"I should expect to feel a firm ridge along the bottom curve of each
breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom curve of each breast.
The client should be able to feel this area during the BSE. Performing a BSE promotes breast self

,awareness so that the client knows how her breast normally feel. The awareness increases the clients
ability to identify changes that require further evaluation.)



A nurse is caring for an adolescent who is in critical condition following a motor vehicle crash which he
was the passenger. The clients parent shout at the nurse, asking why her son is dying instead of the
driver. Which of the following actions should the nurse take to provide emotional support to the parent?
ANSWER>>>>Inform the parent that anger is a natural response when dealing with
loss.
(The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the
parent to understand that anger is a natural response to loss and encourage her to talk about her
feelings.)



A nurse is teaching an older adult client about accessing electronic resources for healthcare information
on the internet. Which of the following statements should the nurse include in the teaching?
ANSWER>>>>"Websites ending in '.gov' are reliable sites for obtaining health
information from government agencies."
(The nurse should teach the client how to select reliable internet websites when researching health care
information. The nurse should identify that websites ending in '.gov' and '.edu' are considered reliable
and credible sources for health information. Websites ending in '.com' should not be used for
researching credible healthcare information.)



A nurse enters a clients room and finds the client lying on the floor. The client states that on the way to
the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take
first? ANSWER>>>>Check the client for injuries.

(The first action the nurse should take when using the nursing process is to assess the client. The nurse
should first check the client for injuries and measure vital signs to help determine physiologic stability.
The nurse should also inform the provider of the clients fall and of the assessment findings.)



A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the
following statements by the client indicates an understanding of the teaching? ANSWER>>>>"I
should use a warm paraffin dip for my hands and feet."
(The nurse should instruct the client to dip her hands and feet in warm paraffin to alleviate pain and
stiffness. The client can more easily perform hand and finger exercises following the treatment.)

, A community health nurse is planning prevention strategies for hypertension among members of her
community. The nurse should identify that which of the following ethnic groups in the community is at
greatest risk of developing hypertension? ANSWER>>>>African American

(Evidence-based practice indicates that individuals of AA ethnicity have the highest prevalence of
hypertension. Therefore, the nurse should identify community members of this ethnicity are at greatest
risk of developing hypertension.)



A nurse is preparing to extinguish a small fire in a clients room. Which of the following actions should the
nurse take when using the fire extinguisher? ANSWER>>>>Slide the pin on top of the fire
extinguisher straight out.
(The nurse should pull the pin on top of the fire extinguisher to allow for use to extinguish the fire.)



A nurse is preparing to administer intermittent external nutrition via a clients NG tube. In which order
should the nurse take the following actions? ANSWER>>>>1. Assist the client to an upright
position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.
(First, the nurse should assist the client into high Fowler's position or raise the HOB at least 30 degrees to
help prevent aspiration. Then, the nurse should verify the tubes placement by aspirating 5 mL of gastric
contents and then testing the pH. Then, the nurse should check for gastric residual volume. Excessive
GRV is an indication of delayed gastric emptying, which places the client at risk of aspiration if additional
formula is given. Finally, the nurse should flush the tubing with 30 mL of water to ensure the tube is clear
and patent.)



A nurse is caring for a 47-year-old female client who had urinary incontinence. Which of the following
actions should the nurse take first? ANSWER>>>>Obtain a specimen from the client for
culture.
(The first action the nurse should take when using the nursing process is assessment. The nurse should
obtain a urine specimen from the client to rule out a UTI. If it is a determined the client has RBC's and
WBC's in the urine, the specimen will require a culture. If it is determined that the client has a UTI, this
will require treatment before any further assessment of incontinence would be indicated.)

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