ATI Critical Thinking Practice

1. A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

• Shakes the soiled linen to remove any toilet paper remnants

• Places the soiled linen on the floor before bagging it

• Holds the soiled linen against her body while carrying it to the linen bag

• Places clean linen that touched the floor in the soiled linen bag

2. A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse’s priority before the transfusion begins?

• skin color

• fluid intake

• temperature

• hemoglobin level

A nurse is preparing a sterile field. Which of the following actions should the nurse take first?

•    A. Grasp the outer edge of the innermost flap and lay it on the table.

•    B. Center the sterile pack on the work surface.

•    C. Open the outermost flap away from the body.

•   D. Grasp the side flap by the outer edge and lay it on the work surface.

While disposing of a needle after administering a subcutaneous injection to a client, a nurse punctures her finger. Which of the following actions should the nurse take first?

• A. Initiate post-exposure pharmacological prophylaxis.

•    B. Flush and wash the exposed area with warm water and soap.

•  C. Obtain a blood sample from the client.

•    D. Complete an incident report.

6. A nurse is caring for a client who has an IV pump that begins to alarm. Which of the following actions should the nurse take?

• A. Silence the alarm.

•    B. Plug the pump into another outlet.

•    C. Discontinue the IV infusion.

•    D. Tag the pump and notify engineering.

A nurse in an acute care mental health facility is caring for a client who begins to yell and scream at staff members. Which of the following actions is the nurse’s priority?

•    A. Administer haloperidol IM to the client.

  
  

•    B. Place the client in restraints.

  
  

•    C. Move the client to a seclusion room with continuous observation.

  
  

•    D. Ask the client to talk about his feelings.

  
  

8. A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow.

   - A. Open the innermost flap of the package toward the body.

   - B. Perform hand hygiene.

   - C. Use the inner surface of the package as a sterile field.

   - D. Open the side flaps of the package.

   - E. Place the sterile package on the work surface.

   - F. Open the outermost flap of the package away from the body.

9. A nurse is exiting the room of a client who is placed on droplet precautions. Identify the sequence the nurse should follow when removing personal protective equipment.

   - A. Perform hand hygiene.

   - B. Remove goggles.

   - C. Remove N95 mask.

   - D. Remove gown.

   - E. Remove gloves.

10. A nurse enters a client's room and finds the client on the floor. Which of the following actions should the nurse take first?

•     A. Collect data on the client.

  
  

•     B. Fill out an incident report.

  
  

•     C. Notify the client's provider.

  
  

•     D. Place the client back into bed.

  
  

11. A nurse is caring for a client who is confused and has been placed in wrist restraints. Which of the following actions should the nurse take while caring for this client?

•     - A. Document client care every 15 min.

  
  

•     - B. Request that the provider prescribe the restraints as PRN.

  
  

•     - C. Ensure that the client's wrists are padded.

  
  

•     - D. Check that the client's restraints are secured with a half-bow knot.

  
  

•     - E. Loosen the restraints once every 4 hr.