Exam (elaborations)
ATI Seminar Post-Test with complete solutions
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ATI Seminar Post-Test with complete solutions
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ATISeminar
Post-Test
A
nurse
is
collecting
data
from
a
client
who
is
having
repeated
episodes
of
emesis.
Which
of
the
following
findings
is
the
priority
for
the
nurse
to
report
to
the
provider?
Decreased
level
of
consciousness
A
client
who
has
repeated
episodes
of
emesis
is
at
risk
for
fluid
volume
deficit.
A
decreased
level
of
consciousness
indicates
extracellular
fluid
volume
deficit.
Based
on
the
stable
vs.
unstable
priority-setting
framework,
this
finding
is
the
priority
and
should
be
immediately
reported
to
the
provider.
A
nurse
is
reviewing
the
plan
of
care
for
several
clients
at
the
beginning
of
the
shift.
Which
of
the
following
tasks
should
the
nurse
plan
to
delegate
to
an
assistive
personnel
(AP)?
(Select
all
that
apply.)
Reviewing
pre-printed
instructions
with
a
client
regarding
diet
is
incorrect.
A
registered
nurse
should
develop
the
teaching
plan
for
a
client,
and
licensed
personnel
should
deliver
or
reinforce
client
teaching.
It
is
outside
the
AP's
scope
of
practice
to
reinforce
the
information
or
answer
client
questions.Feeding
a
client
who
had
a
stroke
2
years
ago
is
correct.
It
is
appropriate
for
the
nurse
to
delegate
feeding
a
client
to
an
AP
if
there
is
no
indication
of
acute
impairment
in
swallowing.Performing
a
bed
bath
for
a
client
who
is
paraplegic
is
correct.
It
is
appropriate
for
the
nurse
to
delegate
bathing
to
an
AP.
The
AP
should
seek
supportive
assistance
if
lifting
is
required
and
notify
the
nurse
if
IV
lines
need
to
be
manipulated.Comparing
a
client’s
peripheral
pulses
is
incorrect.
Comparing
a
client’s
pulses
requires
knowledge
of
physical
assessment
technique
and
pathophysiology.
The
nurse
should
not
delegate
this
task
to
an
AP.Determining
whether
a
client
has
rebound
tenderness
is
incorrect.
Determining
whether
a
client
has
rebound
tenderness
requires
knowledge
of
physical
assessment
technique
and
pathophysiology.
The
nurse
should
not
delegate
this
task
to
an
AP.
A
nurse
is
performing
blood
pressure
screenings.
For
one
client,
the
nurse
last
palpates
the
radial
pulse
at
120
mm
Hg.
How
many
mm
Hg
should
the
nurse inflate
the
cuff
in
order
to
auscultate
the
client's
blood
pressure?
(You
will
find
"Hot
Spots"
to
select
in
the
artwork
below.
Select
only
the
hotspot
that
corresponds
to
your
answer.)
150
mm
Hg.
Applying
the
use
what
you
know
default
strategy,
the
nurse
should
recall
that
that
a
client
can
have
an
auscultatory
gap,
or
break
in
the
systolic
blood
pressure,
of
about
40
mm
Hg.
To
avoid
a
false
low
systolic
blood
pressure
reading,
the
nurse
should
inflate
the
cuff
30
mm
Hg
higher
than
the
point
where
the
pulse
can
no
longer
be
palpated.
Systolic
blood
pressure
can
then
be
measured
allowing
the
sphygmomanometer
to
decrease
2
mm
Hg/sec,
and
noting
the
point
the
where
the
pulse
is
palpated
again
or
auscultated.
A
nurse
is
preparing
to
administer
medications
to
a
client
who
begins
having
a
seizure.
Which
of
the
following
actions
should
the
nurse
take
first?
Turn
the
client
on
her
side.
Using
the
ABC
priority-setting
framework,
maintaining
a
patent
airway
is
the
nurse's
priority
concern
for
a
client
who
is
having
a
seizure.
An
airway
obstruction
is
a
potential
complication
for
clients
during
a
seizure
secondary
to
production
of
secretions.
Placing
the
client
in
a
lateral
position
promotes
drainage
of
the
secretions.
Based
on
this
knowledge
and
using
the
ABC
priority-setting
framework,
the
nurse's
first
action
is
to
place
the
client
in
a
lateral
position
to
maintain
a
patent
airway.
note:
The
nurse
should
document
data
about
the
seizure
in
the
client's
medical
record
including
start
and
end
time,
seizure
manifestations,
nursing
interventions,
and
client
responses.
However,
this
is
not
the
action
the
nurse
should
perform
first.
A
nurse
is
caring
for
an
older
adult
client
who
is
agitated
and
attempting
to
pull
out
the
peripheral
IV
catheter.
Which
of
the
following
actions
should
the
nurse
take
first?
Place
a
stockinette
dressing
over
the
client's
IV
site.
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