ATI – Testing and Remediation Advanced Test – Flashcards

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question
A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder?
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Unstable interpersonal relationships To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is a caring for a client who has borderline personality disorder. Question: Which of the following is a manifestation of the disorder? Person of Focus: The client who has borderline personality disorder Key Words: borderline personality disorder, manifestation So, the question is asking which manifestation is a characteristic of borderline personality disorder. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Unstable interpersonal relationships is correct. Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions.Test: Testing and Remediation Advanced Test
question
A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.)
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Blood stream, Urinary tract , Surgical wound, Respiratory tract To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Question: Which of the following sites should be included in the teaching? Person of Focus: The nurse who is assisting with the educational program Key Words: educational program, sites of health care associated infections, included, teaching, select all that apply So, the question is asking which sites are associated with health care infections. This is a positively worded, multiple response item, which means there are five or six options. Of these options, two or more are correct. Because the item included both correct and incorrect options, and you have to select only the correct options, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Urinary tract is correct. Health care associated infections are caused from health care delivery in a health care facility. These result from prescribed antibiotic administration, presence of multi-medication resistant organisms, breeches in infection control practices, and invasive procedures. The urinary tract is a common site for health care associated infections. Surgical wound is correct. Surgical wounds are a common site for health care associated infections. Musculoskeletal system is incorrect. While injuries can occur in the health care setting that affect the musculoskeletal system, this is not a common site for health care associated infections. Respiratory tract is correct. The respiratory tract is a common site for health care associated infections. Blood stream is correct. The blood stream is common site for health care associated infections.
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A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak?
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Oliguria
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A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning?
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Advocate
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A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider?
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A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L
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A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care?
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Identify one's own beliefs and values. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is from a culture different than his own. Question: Which of the following actions by the nurse is most important in the provision of culturally competent care? Person of Focus: The nurse caring for client who is from a different culture Key Words: culture, different, actions, most important, culturally competent care So, the question is asking which of the actions is most important for the nurse to take in the provision of culturally competent care. This is a positively worded, multiple choice item. The key word "most" in the question indicates this is a priority setting item, which means all four actions are important in the provision of culturally competent care, but one action is the most important. Next you should review each option and determine which should be performed first. Identify one's own beliefs and values is correct. To provide culturally competent care, it is essential to identify one's own cultural background, values, and beliefs, especially those that are related to health and health care. This is the most important action by the nurse.
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A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching?
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Soybeans To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching regarding foods containing complete protein to a client. Question: Which of the following should be included in the teaching? Person of Focus: The nurse who is reinforcing teaching about complete proteins Key Words: teaching, complete protein, foods, included So, the question is asking which of the foods are complete sources of protein and should be included in the teaching. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Soybeans is correct. Food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance. Soybeans are a source of complete protein and should be included in the teaching.
question
A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider?
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Slurred speech
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A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider?
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Tachycardia To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is admitted with acute alcohol withdrawal. Question: Which of the following findings should the nurse report to the provider? Person of Focus: The client admitted with acute alcohol withdrawal Key Words: acute alcohol withdrawal, findings, report to the provider So, the question is asking which of the findings the nurse should report to the provider. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Tachycardia is correct. Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.
question
A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril?
answer
Aspirin (Bayer) To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). Question: The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? Person of Focus: The nurse who is reinforcing teaching about captopril Key Words: captopril, reduce, antihypertensive effects So, the question is asking which of the medications should be reinforced to the client as having the potential to reduce the antihypertensive effect of captopril. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Aspirin is correct. Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.
question
A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations?
answer
Shakiness and diaphoresis To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's TPN is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. Question: The nurse should monitor the client for which of the following manifestations? Person of Focus: The client who has been off the unit for physical therapy Key Words: infusion pump, turned off, TPN So, the question is asking which manifestation the nurse should observe for when TPN has been abruptly stopped. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Shakiness and diaphoresis is correct. The nurse should observe the client for shakiness and diaphoresis. These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.
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A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching?
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"I should eat low carbohydrate foods."
question
A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.)
answer
Drooling is correct. Drooling is a clinical finding associated with epiglottitis. Stridor is correct. Stridor is a clinical finding associated with epiglottitis. Difficulty swallowing is correct. Difficulty swallowing is a clinical finding associated with epiglottitis. Croupy cough is incorrect. Croupy cough is a clinical finding associated with acute spasmodic laryngitis, and acute tracheitis, but it is not a clinical finding associated with epiglottitis. High-grade fever is correct. High-grade fever is a clinical finding associated with epiglottitis.
question
A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)
answer
To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is collecting data on a client who has appendicitis. Question: Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. Person of Focus: The nurse who is palpating for tenderness at McBurney's point Key Words: appendicitis, site, palpate, tenderness at McBurney's point So, the question is asking the location the nurse should palpate to determine the presence of tenderness at McBurney's point. This is a Hot Spot item, which means an image is provided with clickable "Hot Spots" in various locations on the image Next you should roll the cursor over the image to locate all Hot Spots and determine if each is probably correct, possibly correct, or probably incorrect. Then, you had to click on one of the Hot Spots to select it as the correct option. This is the site the nurse should palpate. McBurney's point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image; you had to identify the client's right side. (A)
question
A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse?
answer
Place client in knee-chest position.
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A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching?
answer
This illness will not recur because my child has now had it."
question
A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50 mg/kg IM. The infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?
answer
The nurse should administer 0.8 mL ceftriaxone IM. STEP 1: Determine the infant's weight in kg: 2.2 lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 17.6 lb / 1 kg. Cross multiply and x = 8 kg STEP 2: Find total of one-time dose: Amount prescribed x kg weight (mg x kg) = total daily dose; 50 mg x 8 kg = 400 mg STEP 3: What is the dose needed? Dose needed = Desired; Desired = 400 mg STEP 4: What is the dose available? Dose available = Have; Have = 500 mg STEP 5: Do the units of measure need to be converted? No (mg = mg) STEP 6: What is the quantity of the dose available? Quantity = 1 mL STEP 7: Set up an equation using knowledge about basic equivalents. Desired x Quantity / Have = Amount to be given; 400 mg x 1 mL / 500 mg = x mL; 400 x 1 = 400 ÷ 500 = 0.8 mL STEP 8: Reassess to determine if the amount to be given seems plausible. If there are 500 mg in 1 mL and the prescribed dose is 400 mg, it makes sense to administer 0.8 mL. The nurse should administer 0.8 mL ceftriaxone IM.
question
nurse in a pediatric provider's office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. Listen to the audio clip and determine which of the following responses by the nurse is appropriate. (Click on the audio button to listen to the telephone conversation.)
answer
Do not attempt to remove it."
question
A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.)
answer
Temperature 37.6º C (99.8º F)
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