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ATI PN Comprehensive Practice B with guiding test questions correctly answered
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ATI PN Comprehensive Practice B withguiding test questions correctly answered
A nurse is collecting data from a client who is in severe pain. Which of the following questions
should the nurse ask first?
A. How have you managed pain in the past?
B. Does anything make your pain worse?
C. Where is your pain located
D. Is the pain preventing you from performing any activities? - ANS Where is your pain
located?
When using the urgent vs. Non-urgent approach to collect data from a client who is having
acute and severe pain, the nurse should first ask the client about location, severity, and quality
to identify appropriate nursing interventions for pain relief. The nurse should collect more
detailed data about the client's pain experiences after administering pain med, when the clients
pain level is tolerable.
A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn.
Which of the following statements indicates an understanding of the teaching?
A. I will secure the care seat in the car by using the seatbelt.
B. While traveling, I should use a blanket underneath my baby for padding.
C. When my baby is able to hold their head upright, I can turn the seat forward-facing.
D. I can place the car seat in the front passenger seat as long as there is a working airbag. -
ANS I will secure the car seat by using the seatbelt.
The nurse should instruct the guardian to secure the car seat by using the seatbelt.
A nurse is reinforcing teaching with a client who is bottle feeding their full-term newborn with
formula. Which of the following instructions should the nurse include in the teaching?
A. Feeding the newborn at least every 3 to 4 hours.
B. Refrigerate formula that remains in the bottle.
C. Wake the newborn if she falls asleep during a feeding.
D. Prop the bottle with a folded towel for middle of the night feedings. - ANS Feed the
newborn at least every 3 to 4 hours.
Although it is unnecessary to be rigid about feeding times. 6 to 8 feedings every 24 hours
should support a full-term newborn's needs adequately. Fewer feedings in the initial weeks
could delay the establishment of an adequate weight gain pattern.
,A nurse is collecting data from a male who is scheduled for a left inguinal herniorrhaphy. Which
of the following findings is the priority for the nurse to report to the provider?
A. An inguinal bulge when coughing.
B. Decreased bowel sounds
C. Swelling of the left groin area
D. Tenderness in the scrotum - ANS Decreased bowel sounds.
The greatest risk to this bowel necrosis or perforation due to bowel obstruction or strangulation.
This is a surgical emergency. Therefore decreased bowel sounds are the priority finding to
report to the provider.
A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which
of the following statements by the client indicates an understanding of the teaching?
A. If I need to floss my teeth, I can use wax-coated floss twice a day.
B. I'll take ibuprofen if I get a headache.
C. I'll use a safety razor to shave each day.
D. If I forget to take a dose, I can take it later on the same day. - ANS If I forget to take a
dose, I can take it later on the same day.
A nurse in a long-term care facility is reviewing information about health care associated
infections with a newly licensed nurse. Which of the following information should the nurse
include?
A. Older adults are resistant to pathogens that cause infection.
B. Use alcohol-based antiseptic hand cleansers after caring for a client with Clostridium difficile.
C. Prolonged use of corticosteroid is a risk factor for infection.
D. Blood pressure cuffs can be a source of endogenous infections. - ANS Prolonged use of
corticosteroids is a risk factor for infection.
Prolonged use of corticosteroids places the client at risk for a health care associated infection.
A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about
weight gain during pregnancy. Which of the following responses should the nurse make?
A. Your weight gain should be the same as for someone without diabetes.
B. Weight gain should be 2 pounds during the first trimester and 2 pounds per week thereafter.
C. Weight reduction during pregnancy is often necessary for clients who have diabetes.
D. Your weight gain should average between 10 and 15 pounds. - ANS Your weight gain
should be the same as for someone without diabetes.
,A client who is pregnant and has diabetes mellitus should gain the same amount of weight as a
client without diabetes mellitus.
Whether a cleint has dm or not, a pregnant client should gain 2.2-4.4 lbs the first trimester.
Then, 1 lb per week during the duration of pregnancy.
A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the
following actions should the nurse take to promote the client's venous return?
A. Encourage the client to cough and deep breath
B. Maintain a sequential compression device.
C. Elevate the head of the bed.
D. Massage the client's legs. - ANS Maintain a sequential compression device.
Sequential compression devices promote venous return by providing intermittent periods of
compression of the leg.
Massaging the clients legs is contraindicated due to risk of dislodging a thrombus.
A nurse is caring for a female client who has an indwelling urinary catheter. Which of the
following actions should the nurse take?
A. Cleanse the catheter at the insertion site with an alcohol wipe daily.
B. Gently irrigate the catheter and bladder once per shift.
C. Wipe the drainage port with an antiseptic after emptying urine from the bag.
D. Ensure the urinary catheter bag is maintained at the level of insertion. - ANS Wipe the
drainage port with an antiseptic after emptying urine from the bag.
To prevent the spread of infection when emptying the drainage bag, the nurse should cleanse
the clients drainage port with an antiseptic wipe to remove any residual urine prior to securing
the spout back in place.
A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of
the following supplies should the nurse plan to use for the task?
A. Water-soluble lubricant
B. Yankauer catheter
C. Chlorhexidine gluconate
D. Artificial oral airway - ANS Yankauer catheter.
A yankauer catheter is a clean suction catheter used when performing oral and oropharyngeal
suctioning to remove secretions from the clients mouth to facilitate breathing or obtain a sample
of diagnostic evaluation.
, A nurse is collecting data from a client who has iron deficiency anemia. Which of the following
findings should the nurse expect?
A. Bradycardia
B. Decreased respiratory rate
C. Pink mucous membranes
D. Difficulty concentrating - ANS Difficulty concentrating.
In clients who have iron deficiency anemia, body cells do not receive the required oxygen
because there's less hemoglobin for binding. The nurse should recognize that impaired
oxygenation of brain tissue can lead to dizziness and difficulty concentrating.
A nurse manager is preparing to complete a performance analysis for a group of assistive
personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of
the following actions should the staff nurse take?
A. Limit comments to information about each AP's performance in the last month.
B. Focus the feedback on the strengths of each AP.
C. Compare the AP to each other when describing their behaviors.
D. Discuss how each AP's actions measure against the job description. - ANS Discuss how
each AP's actions measure against the job description.
To provide objective information, the staff nurse should compare the behavior of each AP to the
facility job description. The nurse can provide specific information about how each AP either
meets the standard or demonstrated a need for improvement.
A nurse is reviewing a client's electronic medical record and finds that an assistive personnel
(AP) recorded the client's temperature as 35.3 C (95.5 F) 2 hours earlier. which of the following
actions should the nurse take first?
A. Check the client's temperature.
B. Notify the client's provider.
C. Instruct the AP to cover the client with a blanket.
D. Review the procedure with the AP. - ANS Check the client's temperature.
A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis
(CF). Which of the following findings is the priority for the nurse to report to the provider?
A. Reports lack of appetite.
B. Frothy stools with a foul odor.
C. Height at the 55th percentile for age and gender.
D. Report of gastroesophageal reflux. - ANS Reports lack of appetite.
The nurse should identify that the greatest risk to a child who has a decreased appetite is
pulmonary infection. Anorexia, along w/ other manifestations, such as weight loss and lethargy,
are commonly seen in children who have CF with an infection exacerbation. Typical
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