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ATI
COMPREHENSIVE 2.
- Following abdominal surgery, a client's abdominal wound edges are
separating, and the wound is draining a large amount of serous drainage. Thenurse should place the client:
Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further
wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it can increase tension on thesuture line, and cause further wound separation and tearing (dehiscence). Correct: The semi-Fowler's position
decreases tension on the wound, and it may prevent further separation and tearing of the wound(dehiscence).Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further
wound separation and tearing (dehiscence).
flat on the back with legs straight.
in high-Fowler's position with legs straight.
in semi-Fowler's position with the knees slightly bent.
on the left side with knees bent.
- The PN is preparing to administer an enteral feeding to a client. To prevent
gastric cramping and discomfort due to the feeding, the nurse should:
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Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via gastrostomy tube,
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Encourage the use of cough suppressant syrup.
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Give frequent nebulization treatments.
Limit changing the child's position to conserve the child's need for oxygen.
Withhold the vaccine for pertussis.
- The nurse is caring for a client following insertion of a pacemaker. The client isplaced on continuous ECG monitoring because it will:
Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time of
insertion.Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker insertion.Correct:
The heart rate may change following pacemaker insertion because the pacemaker fails to maintain the pre-set heartrate. This problem can be detected immediately with continuous ECG monitoring.Incorrect: Fluoroscopy is used to
determine dislodgement of pacer leads after a pacemaker insertion. Dislodgement can be prevented with bedrest andminimal arm and shoulder activity.
allow the primary care provider to adjust voltage settings.
check placement of the pacer wires.
detect a dramatic change in heart rate.
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client's pain.Incorrect: Clients often place their hands over the painful area as a self-protective or guardingmechanism to prevent further pain.Correct: Many clients fail to report or discuss their pain or discomfort with nursesand other caretakers. Thus, the PN needs to assess clients for pain on a routine basis.
Clients experiencing pain may engage in social activities for distraction.
Clients from different cultures react to pain in the same way.
Clients in pain usually avoid touching the painful area.
Clients who are in pain may not report their pain to the nurse or other caretakers.
- A client is being discharged from same-day surgery following cataract
extraction from the right eye. The nurse will instruct the client to:
Correct: Lifting requires straining, which increases pressure in the eye and may disrupt suture
lines.Incorrect: The client should not bend forward or lower the head. This action increases pressure in the eye and
could disrupt suture lines.Incorrect: Mild pain is normal. However, moderate to severe pain should be reported to the
surgeon.Incorrect: The client should sleep on the unaffected (left side) to reduce pressure in the eye. Increased
pressure could disrupt the suture lines.
avoid lifting anything heavier than five pounds until cleared by the surgeon.
bend from the waist to pick up objects on the floor.
call the surgeon immediately if he has any discomfort.
sleep on his back or on his right side.
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- Substance abuse is diagnosed when the person's involvement with drugs oralcohol:
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Incorrect: This action is an unsafe practice, and it violates the five rights of medication
administration.Incorrect: Reporting the incident to the State Board of Nursing is not the first step in resolving theissue.Correct: The nurse needs to inform the nurse manager about the unsafe medication practice and incorrect
medication dosages. The nurse manager can then determine how to resolve this intradepartmental issue.Incorrect:
Resigning will not resolve the issue and it will allow the unsafe practice to continue.
give the dose that is available.
report the incident with documentation to the State Board of Nursing.
report this unsafe practice to the nurse manager.
resign due to unsafe practices.
- The nurse is teaching a client with tuberculosis about ways to reduce spreadof the disease to others. Teaching is effective when the client states:
Incorrect: Tuberculosis is spread by droplet nuclei, and not through contact with the skin of an infected
person.Incorrect: Tuberculosis is spread by droplet nuclei, and not through blood contact.Incorrect: Clients with
tuberculosis need to cover their mouths when they laugh to reduce spread of the disease.Correct: Tuberculosis is
spread by droplet nuclei. Thus, covering the mouth when coughing decreases the release of droplet nuclei into the
air, and the spread of the disease to other people.
"I can transmit tuberculosis to others by touching them."
"I can transmit tuberculosis to others through contact with my blood."
"I don't need to cover my mouth when I laugh."
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"I'll cover my mouth with a tissue when I cough."
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"Ask your doctor for an antibiotic that you can take."
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"Stay indoors during the height of cold and flu season."
"Wear a mask when going outdoors during cold and flu season."
"Wash your hands frequently during cold and flu season."
- The nurse is interviewing the wife of a client who is in the middle stage ofAlzheimer's. The wife tells the nurse that she wants to keep her husband at homeas long as possible. Which response by the nurse is most helpful?
Incorrect: This statement is not supportive of the wife. The wife may be quite capable of providing care,
especially with instruction and other assistance.Incorrect: Some clients with Alzheimer's disease become aggressive,
but not all. If aggression occurs, the client can be treated with medication or behavioral interventions.Correct: Withsupport and education, a family caregiver may be able to provide an appropriate home environment for the client with
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The boot is secured by three Velcro straps around the leg.
The client is lying with hips midline and shoulders to the left of midline.
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The traction footplate is resting 6 inches from the footboard.
Traction weights are hanging freely at the foot of the bed.
- What is the purpose of the Apgar score after birth?
Incorrect: Apgar scores do not correlate with the gestational age, and are not used for this purpose.Incorrect:
Although babies that score low on the Apgar may be transferred to the ICU, this is not the purpose of the
Apgar.Correct: The one-minute and five-minute Apgar is a ten-point scoring tool used to assess the need for
resuscitation systematically in the newborn. This score reflects the baby's physical condition at birth.Incorrect: Apgar
scores are not used to evaluate the baby for long-term health needs or health problems.
To estimate gestational age
To determine if the baby needs to be transferred to the intensive care unit (ICU).
To determine if the newborn needs resuscitation.
To predict if the baby will have long-term problems.
- A client with severe emphysema has a moon face and a buffalo hump related
to long-term steroid treatment. The client states, "I look so horrible." Whichresponse by the nurse is therapeutic?
Incorrect: This is a judgmental statement, it has no bearing on disease etiology in this case, and it does not
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The client's symptoms are related to long-term steroid use and not overeating. Also, the nurse is not addressing the
client's anxiety about a distressing change in appearance.Correct: This is a therapeutic response. This response
indicates that the nurse is receptive to listening to the client's feelings about distressing body imagechanges.Incorrect: This is not a therapeutic response. The nurse is not addressing the client's anxiety about a
distressing change in appearance.
"If you hadn't smoked all those years, this would not have happened."
"I will refer you to the dietician for a weight-loss diet."
"This must be very upsetting for you. Would you like to talk about it?"
"You must try to get used to your appearance as you need to take steroids."
- A client develops wheals as a result of an allergic reaction to a medication.
When documenting the reaction, the nurse correctly describes a wheal as:
Incorrect: This is a description of a macule, not a wheal. Freckles or flat moles are examples of
macules.Incorrect: This is a description of a papule, not a wheal. Warts or elevated nevi are examples of
papules.Incorrect: This is a description of scales, not wheals. Dandruff or dry skin are examples of scales.Correct:
This is the correct description of a wheal. Urticaria (or hives) is characterized by the development of wheals.
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a flat, nonpalpable, brown lesion with an irregular boarder.
