Download Adult Health ATI questions with Solution and more Exams Nursing in PDF only on Docsity!
Adult Health ATI questions with Solution
1. A nurse is caring for a client who is post procedure following lumbar punc- ture and reports a throbbing
headache when sitting upright. Which of the following actions should the nurse take? (select all that apply)
a. use the Glasgow coma scale when assessing the client
b. assist the client to a supine position
c. administer an opioid medication
d. encourage the client to increase fluid intake
e. instruct the client to perform deep breathing and coughing exercises: b. assist the client to a supine position
c. administer an opioid medication
d. encourage the client to increase fluid intake
2. A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?
a. headache
b. infection
c. aphasia
d. hypertension: b. infection
3. A nurse is assessing a client for changes in the level of consciousness using the Glasgow coma scale. The client
opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of
the following GCS scores should the nurse document?
a. E2 + V3 + M5 = 10
b. E3 + V4 + M4 = 11
c. E4 + V5 + M6 = 15
d. E2 + V2 + M4 = 8: b. E3 + V4 + M4 = 11
4. A nurse is developing a plan of care for a client who scheduled for cerebral angiography with contrast dye.
Which of the following statements by the client should the nurse report to the provider? (select all that apply)
a. "I think I might be pregnant"
b. "I take warfarin"
c. "I take antihypertensive medication"
d. "I am allergic to shrimp"
e. "I ate a light breakfast this morning": a. "I think I might be pregnant"
b. "I take warfarin" d. "I am allergic to shrimp" e. "I ate a light breakfast this morning"
5. A nurse is providing education to a client who is to undergo an electroen- cephalogram (EEG) the next day.
Which of the following information should the nurse include in the teaching?
a. "Do not wash your hair the morning of the procedure."
b. "Try to stay awake most of the night prior to the procedure."
c. "The procedure will take approximately 15 minutes."
d. provide client hygiene: a. keep the client in a side-lying position
8. A nurse is providing discharge instructions to a female client who has
a prescription for phenytoin. Which of the following information should the nurse include?
a. consider taking oral contraceptives when on this medication
b. watch for receding gums when taking the medication
c. take the medication at the same time every day
d. provide a urine sample to determine therapeutic levels of the medication: c. take the medication at the same time
every day
9. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of
generalized seizures. Which of the following information should the nurse include in the review? (select all that apply)
a. avoid overwhelming fatigue
b. remove caffeinated products from the diet
c. limit looking at flashing lights
d. perform aerobic exercise
e. limit episodes of hypoventilation
f. use of aerosol hairspray is recommended: a. avoid overwhelming fatigue
b. remove caffeinated products from the diet c. limit looking at flashing lights
10. A nurse is completing discharge teaching to a client who has seizures and receiving a vagal nerve stimulator
to decrease seizure activity. Which of the following statements should the nurse include in the teaching?
a. "It is safe to use microwaves that are 1,200 watts or less."
b. "You should avoid the use of CT scans with contrast."
c. "You should place a magnet over the implantable device when you feel an aura occurring."
d. "It is recommended that you use ultrasound diathermy for pain manage- ment.": c. "You should place a
magnet over the implantable device when you feel an aura occurring."
11. A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the
nurse expect?
a. fluctuations in blood pressure
b. loss of cognitive function
c. ineffective cough
d. drooping eye lids: b. loss of cognitive function
12. A nurse is beginning a physical assessment of a client who has anew diagnosis of multiple sclerosis.
Which of the following findings should the nurse expect? (select all that apply)
a. areas of paresthesia
b. involuntary eye movements
c. alopecia
d. increased salivation
e. ataxia: a. areas of paresthesia
b. involuntary eye movements
d. "this medication will lower my sensitivity to food triggers": c. "I should except facial flushing when I take this
medication"
16. A nurse in a provider's office is obtaining a health history form a client who has cluster headaches. Which of
the following are expected findings? (select all that apply)
a. pain is bilateral across the posterior occipital area
b. client experiences altered sleep-wake cycle
c. headache occurs at approximately at the same time of the day
d. client describes headache pain as dull and throbbing
e. nasal congestion and drainage occur: b. client experiences altered sleep-wake cycle
c. headache occurs at approximately at the same time of the day
e. nasal congestion and drainage occur
17. A nurse is providing discharge instruction to a client who has a new diagnosis of migraine headaches. Which
of the following instructions should the nurse include?
a. use music therapy for relaxation with the onset of the headache
b. increase physical activity when a headache is present
c. drink beverages that contain artificial sweeteners to prevent headaches
d. apply a cool cloth to the face during a headache: d. apply a cool cloth to the face during a headache
18. A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent
headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches?
a. "do the headaches occur at the same time each day?"
b. "is your headache accompanied by profuse facial sweating?"
c. "does your headache occur on one of your head?"
d. "is there a pattern of headaches among family members?": d. "is there a pattern of headaches among family
members?"
19. A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of
peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases?
a. cataracts
b. open-angle glaucoma
c. macular degeneration
d. angle-closure glaucoma: b. open-angle glaucoma
20. A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following
statements should the nurse include in the teaching?
a. "you can resume playing golf in 2 days"
b. "you need to tilt you head back when washing your hair"
c. "you can get water in your eyes in 1 day"
d. "you need to limit your housekeeping activities": d. "you need to limit your housekeeping activities"
23. A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of
the following instructions should the nurse include in the teaching?
a. increase intake of deep yellow and orange vegetables
b. administer eye drops twice daily
c. avoid bending at the waist
d. wear an eye patch at night: a. increase intake of deep yellow and orange vegetables
24. A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected
finding?
a. pearly, gray tympanic membrane
b. malleus visible behind the TM
c. presence of soft cerumen in the external canal
d. fluid bubble seen behind the TM: d. fluid bubble seen behind the TM
25. A nurse is reviewing the health recorder of a client who has severe otitis media. Which of the following are
expected findings? (select all that apply)
a. enlarged adenoids
b. report of recent colds
c. client prescription for daily furosemide
d. ligt reflex visible on otoscopic exam in the affected ear
e. ear pain relieved by meclizine: a. enlarged adenoids
b. report of recent colds
e. ear pain relieved by meclizine
26. A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo die to benign
paroxysmal vertigo for several weeks. Which of the following action should the nurse recommend to help control the vertigo? (select all that apply)
a. reduce exposure to bright lighting
b. move head slowly when changing positions
c. do not eat fruit high in potassium
d. plan evenly spaced daily fluid intake
e. avoid fluids containing caffeine: a. reduce exposure to bright lighting
b. move head slowly when changing positions
d. plan evenly spaced daily fluid intake
e. avoid fluids containing caffeine
27. A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected
finding?
a. presence of a purulent lesion in the external ear canal
b. feeling of pressure in the ear
c. bulging, red bilateral tympanic membranes
d. unilateral hearing loss: d. unilateral hearing loss
28. A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following
b. dry, nonproductive cough
c. sore throat
d. bronchospasms: d. bronchospasms
32. A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should
the nurse ensure are in the clients room? (select all that apply)
a. Oxygen equipment
b. incentive spirometer
c. pulse oximeter
d. sterile dressing
e. suture removal kit: a. Oxygen equipment
c. pulse oximeter
d. sterile dressing
33. A nurse is caring for a client following a thoracentesis. Which of the fol- lowing manifestations should the
nurse recognize as risks for complications? (select all that apply)
a. dyspnea
b. localized bloody drainage on the dressing
c. fever
d. hypotension
e. report of pain a the puncture site: a. dyspnea
c. fever
d. hypotension
34. A nurse is monitoring a group of clients of increased risk for developing pneumonia. Which of the
following cleints hsould the expect to be at risk? (select all the apply)
a. client who has dysphagia
b. client who has AIDS
c. client who was vaccinated for pneumococcus and influenza 6 months ago
d. client who is postoperative and has received local anesthesia
e. client who has a closed head injury and is receiving ventilation
f. client who has myasthenia gravis: a. client who has dysphagia
b. client who has AIDS
e. client who has a closed head injury and is receiving ventilation
f. client who has myasthenia gravis
35. A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not
recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?
a. obtain baseline vital signs and oxygen saturation
b. obtain a sputum culture
c. obtain a complete history from the client
b. I need to avoid drinking fluids if I develop symptoms c. I need a flu shout every 2 years because of the different flu strains d. I should cover my mouth with my hand when I sneeze: a. I should wash my hands after blowing my nose to prevent spreading the virus
39. A nurse in the emergency department is caring for a client who is having an acute asthma attack. which of
the following assessments indicates that the respiratory status is declining? (select all that apply)
a. SaO2 95%
b. wheezing
c. retraction of sternal muscles
d. pink mucous membranes
e. premature ventricular complexes (PVCs): b. wheezing
c. retraction of sternal muscles e. premature ventricular complexes (PVCs)
40. A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audilbe wheezes,
and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer?
a. antibiotics
b. beta-blocker
c. antiviral
d. beta2 agonist: d. beta2 agonist
41. A nurse is providing discharge teaching to a client who has a new pre- scription for prednisone for asthma.
Which of the following client statements indicates an understanding of the teaching? a. i will decrease my fluid intake while taking this medication b. i will expect to have black, tarry stools c. i will take my medication with meals d. i will monitor for weight loss while on this medication: c. i will take my medication with meals
42. A nurse is assessing a client who has history of asthma. Which of the following factors should the nurse
identify as a risk for asthma?
a. gender
b. environmental allergies
c. alcohol use
d. race: b. environmental allergies
43. A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the
following client statements indicates an under- standing of the teaching?
a. this medication can decrease my immune response
b. i take this medication to prevent asthma attacks
c. i need to take this medication with food
d. this medication has a slow onset to treat my symptoms: b. i take this med- ication to prevent asthma attacks
44. A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol.
which of the following statements by the client indicates an understanding of the teaching?
a. this medication can increase my blood sugar levels
b. this medication can decrease my immune response
47. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the
client indicates an understanding of the teaching? a. I will place the adapter on my finger to read my blood oxygen saturation level b. I will lie on my back with my knees bent c. I will rest my hand over my abdomen to create resistance d. I will take in a deep breath and hold it before exhaling: d. I will take in a deep breath and hold it before exhaling
48. A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following
should the nurse include in the plan of care?
a. take a quick breathe upon inhalation
b. place you hand over your stomach
c. take a deep breath in through your nose
d. puff your cheeks upon exhalation: c. take a deep breath in through your nose
49. A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse
increases the clients oxygen per protocol. Which of the following actions should the nurse take first?
a. obtain the client's weight
b. assist the client into high-fowler's position
c. auscultate lungs sounds
d. check oxygen saturation with pulse oximeter: b. assist the client into high-fowler's position
50. A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg
daily. Which of the following foods should the nurse recommend for the client? (select all that apply) a. 1 slice cheddar cheese
b. 1 medium beef hot dog
c. 3 oz Atlantic salmon
d. 3 oz roasted chicken breast
e. 2 oz lean baked ham: a. 1 slice cheddar cheese
c. 3 oz Atlantic salmon
d. 3 oz roasted chicken breast
51. A nurse is completing the admission assessment of a client who has sus- pected pulmonary edema. Which of
the following manifestation are expected findings? (select all that apply)
a. tachypnea
b. persistent cough
c. increased urinary output
d. thick, yellow sputum
e. orthopnea: a. tachypnea
b. persistent cough
e. orthopnea
52. A nurse is completing discharge teaching with a client who has heart failure and is encouraged to
increased potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium?
a.1 medium apple
b.1 medium baked potato
