ATI Assessment B - Internship PDF

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1. A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take? a) Choose the client’s dominant arm for IV access whenever possible. b) Select a site proximal to previous venipuncture sites. c) Initiate IV access on the palmar side of the client’s wrist d) Insert a larger gauge IV catheter to prevent phlebitis. 2. A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take? a) Use a 20-gauge IV catheter to transfuse the blood. b) Infuse the transfusion over 5 hours. c) Hang the transfusion with dextrose 5% in 0.9% sodium chloride. d) Monitor vital signs every hour throughout the transfusion. 3. A nurse is caring for a client who has deep-vein thrombosis and a new prescription for anti embolitic stockings. Which of the following actions should the nurse take? a) Measure the legs with a tape measure to determine stocking size. b) Fold the stockings at the top if they are too long. c) Remove the stockings every 24 hours. d) Massage the leg before applying the stockings. 4. A nurse is teaching about safe handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching? a) “I can dilute the ready-to-go formula with water when my baby wants more than 4 ounces at a feeding.” b) “I can keep a can of concentrated formula in the refrigerator for 3 days after I open it.” c) “I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula.” d) “I will be sure that all of my bottles contain BPA.” 5. A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler’s diet? a) Low sodium vegetable soup with barley b) Whole wheat pasta with shrimp c) A corn tortilla with black beans d) A bologna sandwich on rye bread 6. A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure? a) “I know the provider will replace the lens in my eyes during the procedure.” b) “I can expect my eyelids to be bruised after this procedure.” c) “I will see dark spots in my vision after this procedure.” d) “I will receive general anesthesia for this procedure.”

7. A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, “I’m afraid they will give me drugs that put me to sleep.” Which of the following statements should the nurse make? a) “You will need to rest so that you can recover from the episode that brought you here.” b) “I will make sure that we respect your right to refuse medications.” c) “Why do you think your provider will prescribe you medications that will make you sleep.” d) “It’s not your choice to be here, so you have to accept the treatment we plan for you.” 8. A nurse in an acute mental health facility is teaching a client about the potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might feel lightheaded, but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles? a) Fidelity b) Autonomy c) Veracity d) Beneficence 9. A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low back pain, and a feeling of “tightness” in his chest. The nurse should identify that the client has developed which of the following types of transfusion reactions? a) Allergic b) Febrile nonhemolytic c) Bacterial d) Acute hemolytic 10. A nurse at a health department is providing anticipatory guidance to the parent of a 1month old infant. The nurse should inform the patient that the infant should receive which of the following immunizations at the age of 2 months? a) Varicella b) Rotavirus c) Influenza d) Hepatitis A 11. A nurse is caring for a client who is 12-hour postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement? a) Place the client on an air mattress. b) Rewrap the bandage every 8 hours in a circular pattern. c) Instruct the client to use an overbed trapeze to move around in bed. d) Turn the client every 4 hours while in bed.

12. A nurse in an emergency department is administering naloxone to a client who had a heroin overdose. The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose? a) Bradycardia b) Polyuria c) Increased respiratory rate d) Decreased temperature 13. A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients? a) A client who had a right hemisphere stroke. b) A client who had blood drawn from the right antecubital area 1 hour ago. c) A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. d) A client who has a right peripherally inserted central catheter. 14. A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider? a) 4+ deep-tendon reflexes b) Bilateral ankle edema c) Urine output 2,500 mL/day d) Scant lochia rubra with a few small clots 15. A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take? a) Administer the mixture within 5 minutes of preparing it. b) Withdraw the NPH insulin before the regular insulin. c) Inject air into the regular insulin vial before injecting air into the NPH vial. d) Shake both insulin vials for 2 minutes before withdrawing the doses. 16. A nurse in an acute mental health facility is teaching a client about the potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might feel lightheaded, but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles? a) Beneficence b) Veracity c) Autonomy d) Fidelity

17. A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program? a) “If bitten by a tick, testing for Lyme disease should occur within 2 weeks.” b) “Remove embedded ticks by squeezing the body with tweezers.” c) “Use a product with DEET on your skin and clothes when you are walking in a wooded area.” d) “Symptoms of Lyme disease appear 2 days after being bitten by an infected tick.” 18. A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching? a) “I will wear a yellow wrist band so everyone knows I am at risk of falling.” b) “I should keep the overhead lights on at all times while I am here.” c) “I should store my personal items all together on the shelf in my bathroom.” d) “I will have to wear a restraint around my wrist when I am sitting up in a chair.” 19. A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take? a) Begin charting with an evaluation of the data. b) Chart a summary of the data at the change of the shift. c) Document the client’s vital signs obtains by an assistive personnel. d) Note whether the client has a living will. 20. A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect? a) Nervousness b) Warm skin c) Ketonuria d) Tachypnea 21. A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings? a) Weight gain b) Drowsiness c) Bradycardia d) Fever

22. A nurse is interpreting a cardiac rhythm strip from a client who has recurrent episodes of syncope. Which of the following images shows the client has atrial fibrillation?

23. A nurse in a provider’s office is talking with an older adult client who tells the nurse that he fears he is “aging badly” and feels “so useless.” Which of the following assessment questions is the nurse’s priority? a) “How long have you had these feelings of uselessness?” b) “Do you ever think about harming yourself?” c) “Would you tell me more about the changes you see in your body?” d) “Did anything in particular make you feel this way?” 24. A nurse is caring for a client who has Crohn’s disease. The nurse calculates that the client’s BMI is 17.2. The nurse should document the client’s weight status as being within which of the following categories? a) Healthy weight b) Overweight c) Obesity class 1 d) Underweight 25. A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN? a) Changing the inner cannula on a tracheostomy b) Inserting a tunneled central venous catheter c) Administering a platelet transfusion d) Irrigation of an external ear canal 26. A nurse is teaching a class of newly licensed nurses about infectious diseases that nurses are required to report to the health department. Which of the following diseases should the nurse include in the teaching? a) Methicillin-resistant Staphylococcus aureus b) Herpes simplex virus c) Pulmonary tuberculosis d) Fibromyalgia syndrome

27. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse include in the plan? a) Schedule the client for an MRI after the procedure. b) Encourage the client to take deep breaths during the procedure. c) Place the client leaning forward over the overbed table. d) Ensure the client has been NPO for 6 hours. 28. A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions? a) An infant who has respiratory syncytial virus b) An infant who has hypertrophic pyloric stenosis c) A child who has Kawasaki disease d) A child who has bacterial meningitis 29. A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referrals should the nurse anticipate for this client? a) Acupuncturist b) Chiropractor c) Occupational therapist d) Physical therapist 30. A nurse is teaching the guardian of a newborn about care seat safety. Which of the following statements by the guardian indicates an understanding of the teaching? a) “I will place the retainer clip on my baby’s upper abdomen.” b) “I will position my baby at a 45-degree angle in the car seat.” c) “I will position the shoulder harness straps 3 inches above my baby’s shoulders d) “I will turn the car seat forward facing when my baby is 1 year old.” 31. A nurse is caring for a client who has a new prescription for spironolactone and reports that he forgot to tell the provider that he takes over-the counter supplements. The nurse should instruct the client to avoid which of the following supplements? a) Potassium b) Iron c) Magnesium d) Calcium 32. A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take? a) Obtain the client’s vital signs every other day. b) Observe the client for 1 hour after meals. c) Allow the client to eat meals in his room. d) Weigh the client every 48 hours.

33. A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings to a contraindication for administration of this medication? a) Postterm pregnancy b) Intrauterine growth restriction c) Transverse fetal lie d) Preeclampsia 34. A nurse is evaluating the progress of a school-age child who takes methylphenidate. Which of the following findings indicates the effectiveness of the medication? a) Increased urine output b) Decreased abdominal pain c) Increased appetite d) Decreased impulsiveness 35. A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend? a) Scrambled eggs b) Crispy rice bar c) Peanut butter d) Soda crackers 36. A nurse is performing a physical assessment of a newborn whose mother used cocaine throughout the pregnancy. Which of the following findings should the nurse expect? a) Hypotonicity b) Increased head circumference c) Decreased auditory response d) Irritability 37. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first? a) Lubricate the catheter with water-soluble gel. b) Cleanse the client’s meatus with antiseptic solution. c) Position the sterile drape leaving the perineum exposed. d) Attach a prefilled syringe to the catheter inflation hub. 38. A nurse is teaching a client who has major depression disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client? a) “You’ll wake up about 30 minutes after the procedure.” b) “You can expect to feel some pulsations in your neck during the procedure.” c) “You might notice some changes in your voice after the procedure.” d) “You might feel a bit confused for a few hours after the procedure.”

39. A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station. Which of the following interventions should the nurse implement? a) Place the client in a warm bath. b) Request the provider prescribe a pudendal nerve block. c) Apply counterpressure during each contraction. d) Administer a dose of terbutaline to the client. 40. A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take? a) Turn on the faucets in the client’s sink. b) Pour cool water over the client’s perineum. c) Instruct the client to lean slightly backward. d) Tell the client to gently stroke her lower abdomen. 41. A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay? a) Falls when throwing a ball overhand. b) Runs with a wide stance. c) Refers to self by name. d) Goes up stairs with two feet on each step. 42. A nurse is caring for a client who is postpartum and expresses concern about how her preschoolage son will react to having a baby sister. Which of the following strategies should the nurse suggest? a) “Plan for your son to meet his sister for the first time at home.” b) “Give your son a little gift from his new sister.” c) “Hold your daughter when your son first meets her.” d) “Give your son plenty of “alone time” with his siter.” 43. A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take? a) Use medical terminology when discussing procedures with the child. b) Encourage the child to play with toys such as a pounding board. c) Perform the morning assessments when the parent is not in the room. d) Establish a new routine for the child to follow while in the facility. 44. A nurse is teaching a client how to care for his behind-the-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching? a) “I’ll replace the batteries every 2 weeks.” b) “I’ll use isopropyl alcohol to clean my hearing aids.” c) “I’ll disconnect the battery when I remove my hearing aids.” d) “I’ll clean my ear with cotton swabs before I insert my hearing aids.”

45. A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include? a) Avoid consuming foods containing chocolate. b) Increase dietary intake of citrus fruits. c) Take antacids that contain mint for heartburn. d) Lie down for 30 minutes after eating a meal. 46. A nurse is ordering breakfast meal tray for a client who has dysphagia and a prescription for a mechanically altered diet. Which of the following foods should the nurse select? a) Wheat toast with butter b) Yogurt and granola c) Banana and nut muffin d) Pancakes with syrup 47. A nurse is assessing a client for allergies. The client has a new prescription for total parenteral nutrition with fat emulsion. Which of the following findings should the nurse report to the provider? a) Peanut allergy b) Wheat allergy c) Shellfish allergy d) Egg allergy 48. A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment? a) The guardian wants to accompany the child from the ED to the radiology department. b) The guardian states the child fell off the swing in the backyard. c) The child cries loudly when their arm is moved or manipulated. d) The child was brought to the ED 2 days after the injury occurred. 49. A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority? a) Blood-tinged mucus b) Sore throat c) Dark brown emesis d) Frequent swallowing 50. A nurse is reviewing the medication administration record of a client who is to undergo excretory urography using contrast dye. The nurse should plan to withhold which of the following medications 24 to 48 hours before the procedure? a) Metformin b) Prednisone c) Acetaminophen d) Atenolol

51. A nurse in a pediatric clinic is assessing a toddler at a well-child checkup. After reviewing the child’s current medical record, which of the following interventions should the nurse expect the provider to prescribe? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data) a) Antibiotic therapy b) Iron supplementation c) Blood transfusion d) Protective environment 52. A nurse is planning care for a client who has a history of urinary tract infections (UTI) and requires placement of an indwelling catheter. Which of the following actions should the nurse take to help minimize the client’s risk for acquiring a UTI? a) Obtain urinary samples by disconnecting the tubing connections. b) Loop the tubing so that it is lower than the collection bag. c) Secure the catheter to the client’s thigh. d) Keep the urinary bag at bladder level when ambulating. 53. A nurse is preparing to administer timolol eye drops to a client who has glaucoma. In which order should the nurse perform the following steps?  Verify the clarity and color of the eye drops.  Tilt the client’s head backward toward the ceiling.  Pull the client’s lower lid down with the nondominant hand.  Administer the prescribed number of drops.  Apply gentle pressure to the client’s punctum. 54. A charge nurse observes smoke coming from a trash receptable in the unit’s waiting room. Which of the following actions should the nurse take first? a) Activate the fire alarm system. b) Obtain and use a fire extinguisher. c) Close the doors and windows on the unit. d) Evacuate clients from the area. 55. A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understating of the teaching? a) “The provider can go against the client’s wishes regarding advance directives.” b) “A health care surrogate must be a family member.” c) “The client can resume control of health care after a ...