Exam 1 - ATI Quizzes

After assisting a newly admitted client with removing shoes and outerwear, nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take?

A. Clean their hands with an alcohol-based gel
B. Wash their hands with soap and water
C. Brush off the soil against a cloth surface
D. Use a wet paper towel to remove the soil

B

To decontaminate their hands with an alcohol-based gel, a nurse should rub hands together until all of gel has evaporated and hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?

A. drying provides full antiseptic effect
B. residual alcohol can easily stain clothing
C.excess gel could transfer to client
D. Slippery gel can make nurse drop supplies

A

After completing a procedure that required donning PPE, which of the following should the nurse remove first when removing PPE separately?

A. gloves
B. gown
C. face shield
D. N95 respirator

A (gloves, face/eye, gown, mask)

A nurse is about to irrigate a client's open wound. besides gloves, which of the following PPE should the nurse wear?

A. Sterile gown
B. goggles
C. face shield
D. n95 respirator

C

What should nurse do to maintain standard precautions?

A. rinse gloves that become visibly soiled during use
B. use an antimicrobial soap for routine handwashing
C. disinfect hands immediately after removing gloves
D. keep gloves on when touching environmental surfaces

C

A nurse is washing hands with soap and water prior to repositioning a client in bed. During handwashing, it is important to take which of the following actions?

A. make sure water is hot
B. wash for at least 20 secs
C. use liquid soap preparation
D. remove rings and watches first

B

Which of the following is an advantage of using alcohol-based gel?

A. takes less time to use than washing with soap and water
B. removes gross contamination better than soap and water does
C. protective nature reduces the need for frequent handwashing
D. provides adequate protection before surgical applications

A

A nurse is caring for a client with mycoplasma pneumoniae. client has been placed on droplet precautions. which of the following actions should the nurse take when caring for the client?

A. wear respirator
B. protect their eyes
C. Put on clean gloves
D. Wear shoe covers

B

A nurse is caring for a client who has HAI. which of the following describes an exogenous HAI?

A. salmonella infection that occurs after eating contaminated food from cafeteria
B. Infection that occurs during therapeutic procedure
C. yeast infection that occurs while receiving broad spectrum antibiotics
D. An UTI that occurs after sterile catheter insertion

A

Which of the following products can affect the permeability of latex gloves?

A. antimicrobial soap and water
B. alcohol-based antiseptic gel
C. petroleum-based hand lotion
D. water-based hand lotion

C

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?

A. hep B
B. measles
C. meningitis
D. infectious diarrhea

D

A nurse is providing teaching to an assistive personnel (AP) about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give?

A. "Ask another team member to assist with donning gloves"

B. "Choose a pair of gloves at least one size smaller than usual"

C. "Grasp only the underside of the cuff with your ungloved hand."

D. "Grasp only the inside of your glove with your ungloved hand"

d (inside of glove is considered nonsterile since it'll be placed against the skin of the hand)

Anurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field? (Select all that apply)

A. A cotton ball dampened with sterile normal saline placed on the field

B. A contaminated instrument touches outer edge of sterile field

C. A sterile instrument is dropped onto near side of sterile field

D. The nurse turns to address client's question concerning the procedure

E. The procedure is postponed for 30 min to accomodate the client

F. A liquid is poured into a sterile contained from distance of 25 cm (10 in)

a, d, e, f

Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items should a nurse don? (Select all that apply.)

A. Gown
B. Protective eyewear
C. Hair cover
D. Mask
E. Shoe covers

b, c, d, e (a gown used for a sterile procedure is considered sterile and is not donned until the surgical hand scrub has been completed and hands have been driec)

A nurse should identify that which of the following is the goal of surgical asepsis?

A. To create and maintain a micro-organism free environment

B. To kill all micro-organisms on all instruments involved in a procedure

C. To reduce the presence of pathogenic organisms in the environment

D. To minimize exposure to the client's blood during an invasive procedure

a (b = sterilization; c = medial asepsis; d = standard precautions)

A nurse should identify that which of the following areas of the hands requires special attention during the pre-scrub wash?

A. The area between each finger

B. The area under each fingernail

C. The palm of each hand

D. The back of the hands

A

A nurse is preparing to wash hands prior to surgery. For which of the following reasons should nurse keep their hands above their elbows?

A. To prevent them from coming into contact with a contaminated object

B. To facilitate application of sufficient friction to hands

C. To provide good visualization of hands as they are scrubbed

D. To encourage water and soap to flow away from clean hands

d

A nurse is preparing to open a sterile package of instruments. In what order should these steps be performed?

A. Open side flaps

B. Open flap closest to body

C. Open flap furthest from body

D. Position try so that top flap is farthest away from body

d, c, a, b

When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand?

A. Splitting fingers beneath the cuff maintains the gloves' sterility

B. The inner edge of cuff will lie against skin and thus will not be sterile

C. Gloving dominant hand first allows for better control over process

D. The hand has been surgically scrubbed and is considered uncontaminated

b

A nurse is preparing to flush and change the dressing on a client's central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis?

A. To promote catheter's potency

B. To assess skin's integrity around catheter site

C. To provide clean, dry environment for catheter

D. To control introduction of microorganisms at catheter site

d

While waiting for sterile procedure to begin, how should nurse position hands and arms?

A. With hands clasped together in front of body above waist level

B. At sides of body with hands pointing downward

C. Folded across chest with hands on shoulders

D. With hands clasped together in the back of the body at waist level

a

When opening a sterile pack, what action by the nurse might compromise sterility of the instruments and supplies inside the pack?

A. Allowing movement of team members around field

B. Holding sterile pack below waist/table level

C. Keeping sterile items away from edge of table

D. Opening sterile pack just prior to procedure

b

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

A. Place stockings on client after client ambulates to restroom

B. Ensure client's toes are visible after placing stockings on client

C. After applying stockings, place two fingers between client's leg and stocking to check the fit

D. Measure the client's calf circumference and leg length from heel to knee

d

A nurse in emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. What instructions should the nurse include?

A. Lean on crutches to support your body weight when standing

B. Fully extend your arms when holding onto hand grips

C. Hold the crutches on your unaffected side when preparing to sit in a chair

D. Hold crutches 9 inches in front of and to the side of each foot

c

A nurse stands facing a client to demo active ROM exercises. Which of the following actions should the nurse take to demo hyperextension of the hip?

A. Move their leg behind body

B. Move their leg forward and up

C. Move their leg medially toward other leg

D. Turn their foot and leg away from other leg

a (b = flexion; c = adduction; d = external rotation)

A nurse is caring for a client who has been hospitalized and is performing active ROM exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

A. Adducting the arm so that it lies next to the client's side

B. Flexing the shoulder by raising the arm from a side position to a 180 deg angle

C. Abducting the arm to a 90 deg angle from the side of the body

D. Crcumducting the shoulder in a 180 deg half circle

b

A nurse is preparing to transfer client who has left-sided weakness from bed to chair. Which of the following actions by the nurse demonstrates correct transfer technique?

A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed

B. Placing client's left leg in front of right leg just prior to transfer

C. Aligning nurse's knees with the client's knees just before transfer

D. Grasping client under axillae to assist them to their feet

c

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. which of the following actions should the nurse take?

A. Wrap both arms around the client's arms and shoulders

B. Move both feet together when the client begins to fall

C. Protect the client's extremities while lowering them to the floor

D. Extend one leg and allow the client to slide down the leg to the floor

d

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

A. Place a removable cover over the sling

B. Leaves the bed in the lowest position throughout the procedure

C. Locks the hydraulic valve before attaching the sling to the lift

D. Raises the head of the bed to a sitting position just before transfer

b

A nurse is planning to administer a dose of morphine sulfate IV for a client who is postoperative. Which of the following pain management protocols should the nurse use when caring for this client?

A. Withhold the medication for a respiratory rate of 14/min

B. Perform the IV injection over 1 min

C. Avoid administering opioid agonists on a fixed schedule

D. Have an opioid antagonist available during the administration

d

A nurse is speaking with a client who reports experiencing frequent, severe migraines and asks, "can you tell me about biofeedback?" Which of the following responses should the nurse make?

A. Biofeedback measures skin tension and uses learned techniques to relieve pain

B. Biofeedback provides soothing visual images identified by the client to promote relaxation

C. Biofeedback includes listening to an increasing volume of music until the pain subsides

D. Biofeedback stimulates the skin with a mild electric current when pain occurs

a (biofeedback uses devices with electrode sensors that monitor a client's physiological response to pain, which gradually helps the client determine techniques that can control migraines and other types of pain.)

A nurse is preparing to assess the pain level of a 4-year old child. Which of the following pain assessment tools should the nurse use?

A. CRIES instrument

B. COMFORT Behavior scale

C. FACES

D. PAINAD scale

c (cries = 0 to 6 months; COMFORT = clients who are unable to use traditional numeric rating scales or FACES; PAINAD = clients with dementia)

During a pain assessment, a nurse asks questions about the quality of an adult client's pain. Which of the following statements by the client refers to pain quality?

A. The pain in my abdomen began last night and has gotten worse

B. My pain is at a 9 on a scale of 0-10

C. My pain feels like I'm being stabbed by a knife

D. The pain is worse when i bend over at my waist

c

A nurse caring for a client who was admitting to ED for severe pain following fall from ladder. The client reports taking opioid prescription for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question?

A. Morphine sulfate

B. Naloxone

C. Fentanyl

D. Hydromorphone

b (naloxone is an opioid antagonist and not an analgesic)

A nurse is caring for a client prescribed IV morphine via patient controlled analgesia (PCA) with demand of 1 mg every 15 min and a 4 mg/hr lockout. The client reports unbearable pain after attempting 6 demand doses within the last hour. After assessing client's pain, which action should the nurse take?

A. Check IV site and PCA pump for proper functioning

B. Teach client proper use of PCA system

C. Ask the provider to increase morphine dose and shorten interval between doses

D. Encourage fam members to administer dose of morphine via pca when client is in too much pain to do it themselves

a

A nurse is caring for two clients who are 2 hr post-operative following same procedure. Which of the following factors should the nurse expect to be similar for both clients?

A. Perception of intensity of post-operative pain

B. Prescriptions containing guidelines for pain medication administration

C. Goal of pain management for each client

D. Level of pain indicated by each client on a numeric pain scale

b

A nurse is caring for a patient who is on long term bed rest and requires frequent linen changes due to excessive diaphoresis. Which of the following is the priority rationale for frequent linen changes?

A. Moisture from excessive diaphoresis (sweating) can cause skin breakdown

B. Moisture on the sheets can cause discomfort to the client

C. It provides an opportunity to frequently evaluate the skin on the client's back side

D. It provides an opportunity to turn the client from side to side to facilitate clearing potential fluid from the lungs

a

A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take?

A. Raise the room temperature

B. Completely remove the linens

C. Add soap to the water in the basin before beginning the bath

D. Bathe one side of the body at a time

a (helps keep the patient warm while body parts are exposed and washed)

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient

A. "ill swab patient's mouth with lemon-glycerin swabs"

B. I'll swab the client's mouth with mouthwash

C. I'll swab the client's mouth with chlorhexidine

D. I'll swab the client's lips with a very small amount of mineral oil

c (Chlorhexidine prevents microbial build-up.)

A nurse is preparing to provide oral care for client who is NPO (nothing by mouth). The client tells nurse, "I don't need oral care because I haven't eaten anything". Which of the following responses should the nurse make?

A. Since you are not eating, we can wait and do it before bedtime

B. Oral care is still important even though you are not eating

C. I'll give you a sip of water to swish around in your mouth, and then you can spit it out

D. We will wait until your fam gets here to help

b

A nurse is observing an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure?

A. The AP records the task when it's completed

B. The AP wears sterile gloves while making the bed

C. The AP changes the client's pillowcase

D. The AP reuses the client's clean blanket and spread

d (linens can be reused if they are not wet or soiled)

A nurse is preparing to assist a client with a tub bath. What is the proper sequence of steps the nurse should take?

A. Instruct client to remain in tub for no longer than 20 min

B. Assist client into bathroom

C. Place rubber mat on tub floor

D. Instruct client on using safety bars when getting in and out of tub

E. Gather all necessary supplies

e, c, b, d, a

A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection?

A. Massage reddened areas of the client's skin

B. Wash eyes from outer canthus to inner canthus

C. Wash the client from the shoulder down to the fingertips with smooth and short strokes

D. Clean the least-soiled areas prior to cleaning the most-soiled areas

d (wash from inner to outer to prevent secretions from entering nasolacrimal duct)

A nurse is planning hygiene care for a post-operative. Which of the following actions should the nurse take?

A. Inform the client when morning hygiene care is provided at the hospital

B. Schedule the client's morning hygiene care at the same time as their roommate

C. Ask the client in what order they typically perform their morning routine

D. Plan to provide care before the next schedule dose of pain medication

c

A nurse in a pediatrician's office is speaking on the telephone with a guardian of a school-age child who will become a new client at the office. The nurse should instruct the guardian to call the child's previous provider's office to request which of the following?

A. The guardian be allowed to take the child's medical records and make photocopies for the new pediatrician's office.

B. The child's original medical records be given to the new pediatrician's office.

C. A form authorizing release of copies of the child's medical records to be signed by the guardian.

D. A form authorizing release of the child's medical records to be signed by the new pediatrician and sent back to the previous provider.

c

Which of the following methods of information exchange can occur without client authorization?

A. Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room.

B. Recording shift report on a device for all oncoming staff to access information about all clients on the unit.

C. Talking about a client's information during a staff in-service with all levels of unit staff present.

D. Providing an employer with confirmation that their employee is currently being treated in the facility.

a (acceptable if the 2 nurses are both assigned to this client and no one else is in the room)

A nurse in the emergency department is caring for a client following a motor vehicle crash. The client is unresponsive and the client's spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client's surgery?

A. Ask the facility's privacy officer to witness the informed consent to document
B. Inform the client's friends that are present about the surgery and obtain group consent
C. Ask the nursing supervisor to provide implied emergency consent
D. Inform the provider of the spouse's contact information so consent can be obtained over the phone.

d

A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurse take to ensure the study complies with the HIPAA privacy rule?

A. Contact the medical record department to obtain permission to access clients' charts

B. Submit their proposal to the institutional review board for review and describe how they will de-identify client information

C. Notify the clients who will be included in the study to submit a written request if they choose not to participate

D. Obtain permission form from the risk management department to gain access to incident reports that were filed due to clients' falls

B

Which of the following actions should the nurse take after witnessing a breach of a client's confidentiality in a provider's office?

A. Complete a health information privacy complaint form

B. Anonymously notify the proper governmental agency

C. Notify the client and ask them to complete a health information privacy complaint form

D. Inform the provider that a formal complaint will be submitted if another breach is committed.

A

A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instruct the client to file the complaint?

A. Occupational Safety and Health Administration (OSHA)

B. The Joint Commission

C. Office for Civil Rights (OCR)

D. Privacy and Civil Liberties Office

c

A nurse is teaching a newly licensed nurse about using a computer to document in a client's health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "I should share my computer password with the nurse orienting care."

B. "I should remain aware of my surroundings when documenting in the computer."

C. "I can step away from the computer for a short time if I am logged on and no one is around."

D. "I can review the health records of other clients on the unit not assigned to me.

b

A newly hired nurse is reviewing information about the HIPAA privacy rule during facility orientation. Which of the following statements by the nurse indicates an understanding of the privacy rule?

A. "Clients do not have the right to read their charts."

B. "I can read the charts of other clients on my floor."

C. "I will expect a list of clients and their admitting diagnoses to be posted on my unit."

D. "I can give information about a client over the phone if the client gives permission."

d