ATI Skills Sheets #1

naomisdonaldson's version from 2014-01-10 05:20

Section !

Question Answer
"1. When collecting data, the nurse identifies these signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?""1. Impaired physical mobility"
"2. Each morning, the nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. the next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the tasks should have been completed anyway. Which leadership style is the nurse-manager exhibiting?""2. Authoritarian"
"3. A nurse who's assigned the care of six clients is administering a tube feeding to a client when breakfast trays arrive. A client who needs assistance with meals helps herself to her tray and spills hot coffee on her chest and abdomen. How should the nurse intervene?""3. Stop administering the tube feeding and assist the client with changing her wet clothing, assess the burns, and notify the charge nurse."
"4. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?""4. Identifying one way to increase social interaction"
"5. Which statement best describes an expected outcome?""5. Goals that the client should reach as a result of planned nursing interventions"
"6. A physician becomes angry when he sees not recent vital signs documented on the client's graphic vital sign record. How should the nurse intervene?""6. Obtain vital signs and report the findings to the physician."
"7. After collecting data on a client, the nurse helps formulate relevant nursing diagnoses. Which of the following is a complete nursing diagnosis statement?""7. Ineffective airway clearance related to mucus plugs and nonproductive cough"
"8. Which of the following is an approved nursing diagnosis?""8. Impaired gas exchange"
"9. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital sign, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?""9. Data collection"
"10. A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?""10. Evaluation"
"11. A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?""11. Deficient fluid volume related to nausea and vomiting"
"12. During the planning step of the nursing process, the nurse performs which activity?""12. Develops goals of care"
"13. A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client to rate his level of pain using a pain scale. Which step of the nursing process is the nurse using?""13. Evaluation"
"14. What is a common goal of discharge planning in all care settings?""14. Teaching the client how to perform self-care activities"
"15. A client is admitted with acute chest pain. When obtaining the health history, which question would be most helpful for the nurse to ask?""15. How would you rate your pain on a scale of one to ten, with ten being the worst pain imaginable?"


Question Answer
"16. A 65-year-old client comes to the physician's office for a follow-up appointment after having a basal cell lesion removed from his face. The nurse teaches the client to inspect his skin for signs of melanoma. For which sign should the nurse tell him to look?""16. Black or purple irregularly shaped nodules"
"17. The following statement appears on a client's plan of care 'Client will ambulate in the hall without assistance withing 4 days.' This statement is and example of""17. A client outcome."
"18. The nurse is providing care for a client who underwent heart surgery. The best example of a measurable outcome goal is for the client to""18. walk from his room to the end of the hall and back before discharge."
"19. Professional regulations and laws that govern nursing practice are in place for which of the following reasons?""To protect the safety of the public"
"20. Which intervention is an example of primary prevention?""Administering a measles, mumps, and rubella immunization to an infant"
"21. A client with a weak left leg is learning how to ambulate with a can; however, he has difficulty remembering to hold the can with his right arm. Which statement by the nurse would be most helpful to this client?""Remember to hold the cane with the hand on the opposite side of your weak leg."
"22. While driving home from work, nurse realizes that she failed to communicate to the oncoming nurse that a client asked for more information about advance directives. which action would be appropriate for the nurse to take?""22. Phone the nurse caring for the client and inform her of the client's request."
"23. The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families?""Escort the family who received the discouraging news to a private area."
"24. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be""24. administering pain medication."
"25. A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best?""25. Notify the charge nurse and nursing supervisor of the incident."
"26. The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?""26. Evaluation"
"27. Which statement reflects appropriate documentation in the medical record of a hospitalized client?""Client's skin is moist and cool."
"28. A client is admitted with the following vital sign; temperature, 102 F (38.9 C); heart rate, 144 beats/minute and irregular; and respiratory rate, 22 breaths/minute. Which nursing diagnosis takes highest priority when planning when this client's care?""28. Decreased cardiac output"
"29. A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?""29. Deficient fluid volume"
"30. A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written outcome for this nursing diagnosis?""30. Before discharge, the client correctly identifies three potassium-rich food sources."


Question Answer
"31. After her shift, a nurse remembers that she failed to document a medication that she administered. What should the nurse do?""31. Return to the client care area and document the medication as given."
"32. The nurse assists in developing a list of nursing diagnoses for a client. This list should include""32. factors influencing the client's problem."
"33. A client who speaks and understands minimal English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?""33. Demonstrating the procedure and having the client perform a return demonstration."
"34. A client complains that he's uncomfortable lying in the hospital bed and can't sleep. The nurse checks the client's the client's medication administration record and there's no sleep medication prescribed. How can the nurse best help this client?""34. Provide a gentle backrub to promote relaxation an sleep."
"35. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is""35. keeping the bed in the lowest possible position."
"36. A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?""36. Notify the charge nurse so she can notify the physician of the missed dose."
"37. What should the nurse do with linens that have been soiled by a client with hepatitis?""37. Place them in a plastic bag that has a contamination symbol."
"38. A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she see that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?""38. Voice her concerns about continuity of care with the charge nurse."
"39. An elderly client becomes extremely agitated and attempts to remove his endotracheal tube. The physician orders physical restraints. Which action indicates that the nurse has applied the restraints correctly?""39. A quick-release knot is used to tie the restraint."
"40. A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, 'He is rude. His patients always end up with infections.' the nurse is at risk of being accused of which of the following?""40. Slander"
"41. The nurse is caring for a client whose cultural background is different from her own. Which of the following actions are appropriate for the nurse to take? Select all that apply.""41. Respect the client's cultural beliefs - Ask the client is he has cultural of religious requirements that should be considered in his care - Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures."
"42. A client is diagnosed with diabetes mellitus. Which data collection finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?""42. Crying whenever diabetes is mentioned"
"43. Erikson described the psychosocial tasks of the young adult (ages 18 to 24) is""43. intimacy versus isolation"
"44. As the nurse helps a client to the bathroom, the client says, 'When you get to the point where you can't even go to the bathroom by yourself,you might as well be dead.' Which response by the nurse would be most therapeutic?""44. You sound really discouraged today."
"45. The nurse enters the room of a client who is visibly shaken. The nurse states, 'You seem upset." The client does't respond so the nurse sists down with the client and remain silent. By using this therapeutic communication technique the nurse is exercising her knowledge that science is""45. a means of allowing the client space in which to respond an a way of communicating patience."


Question Answer
"46. Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of ""46. poor boundaries"
"47. The nurse is trying to establish rapport with a newly admitted client. Which technique blocks effective communication with a client?""47. Giving advice"
"48. A 74-year-old client has grown children who each have families of their own. The client is retired and looks back on his life with satisfaction. According to Erickson, the nurse concludes that the client is in a stage of""48. ego integrity"
"49. Before preparing a client for surgery, the nurse assist in developing a teaching plan. What is the primary purpose of preoperative teaching?""49. To reduce the risk of postoperative complications"
"50. Which intervention is best to help a 2-year-old child adapt to hospitalization?""50. Ask one or both parents to stay with the child"
"51. A 13-year-old boy admitted with a fractured femur had an open reduction and internal fixation 2 days ago and is currently in traction. He asks the nurse what would happen to him if a terrorist decided to bomb the hospital. What's the nurse's best response?""51. "What do you think might happen if terrorists attacked?""



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