ATI

A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicates that the client understands the teaching? A. "I'll call the doctor's office if my fingers get colder on the arm with the cast." B. "If I have any itching under the cast, I'll try to reach the area with a cotton swab." C. "If my fingers swell, I should put a heating pad on them and rest." D. "If I have any tingling under my cast, I'll know I need to move my fingers more."

A. "I'll call the doctor's office if my fingers get colder on the arm with the cast."

A nurse in an acute care clinic is talking with a client who reports that the osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches to help relieve her pain. Which of the following interventions should the nurse suggest? A. Applying warm compresses to sore joints B. Decreasing the daily intake of dietary protein C. Keeping joints in extension during rest periods D. Limiting sleep to 6 to 7 hr per night

A. Applying warm compresses to sore joints

A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss

A. Aspiration

A nurse in the emergency department is caring for a client who has a fruity breath odor, a dry mouth, and extreme thirst. Which of the following assessments should the nurse make? A. Blood glucose level B. Pupillary reaction to light C. Deep tendon reflexes D. Liver function test

A. Blood glucose level

A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure? A. Calcium B. Sodium C. Potassium D. Phosphorous

A. Calcium

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia

A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is the nurse's priority? A. Performing hand hygiene before and after contact with the client B. Reducing the client's anxiety due to isolation procedures C. Assisting the client in making nutritional choices D. Monitoring the client's intake and output

A. Performing hand hygiene before and after contact with the client

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine

A. The client's ability to clear oral secretions

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower the head of the client's bed D. Advance the catheter approximately 2.5 cm (1 in) further

A. Turn the client from side to side

A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the following actions should the nurse take? A. Warm the dialysate solution prior to administration B. Cleanse the catheter site using a back and forth motion, beginning at the end of the catheter and moving inward C. Place the drainage bag at the level of the client's chest D. Apply clean gloves and cleanse the client's catheter site with cold water

A. Warm the dialysate solution prior to administration

A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following client statements should the nurse provide further teaching? A. "I drink at least 2 L of fluid per day." B. "I prefer taking tub baths to showering." C. "I urinate before and after sexual relations." D. "I wipe from front to back after urinating."

B. "I prefer taking tub baths to showering."

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly

B. Crackles in the lung bases

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left-sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body

B. Difficulty with speech

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the drainage bag on the client's abdomen when transferring from a bed to cart B. Empty the drainage bag when half-full of urine C. Rest the drainage bag on the floor when closing the drainage spigot during emptying D. Disconnect the drainage bag when obtaining a urine specimen

B. Empty the drainage bag when half-full of urine

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis

B. Fat embolism syndrome

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? A. Administer an analgesic to the client B. Check the client's electrolyte values C. Measure the client's weight D. Restrict the client's protein intake

B.. Check the client's electrolyte values

A nurse is providing discharge teaching about foot care to a client who has diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I can use a heating pad on my feet to keep them warm." B. "I can go barefoot as long as I stay inside the house." C. "I will wash my feet daily and apply lotion, except between my toes." D. "I will trim my toenails every morning by rounding the corners."

C. "I will wash my feet daily and apply lotion, except between my toes."

A nurse is preparing a client who is postoperative following total hip arthroplasty for discharge. Which of the following statements indicates that the client understands the instructions? A. "I'll use alcohol pads to clean my incision each day." B. "When I'm doing my exercises, I'll include bent-leg raises." C. "I'll use a reacher to help me pick up anything I drop on the floor." D. "When I can walk without my walker, I can stop attending physical therapy."

C. "I'll use a reacher to help me pick up anything I drop on the floor."

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse include in the teaching? A. "PCP is sexually transmitted from person to person." B. "You were most likely exposed to a contaminated surface such as a drinking glass." C. "PCP results from an impaired immune system." D. "You might have contracted PCP from a family pet."

C. "PCP results from an impaired immune system."

A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. Which of the following assessments is the nurse's priority? A. Measure the client's vital signs B. Perform a neurological examination C. Check airway patency D. Assess the client for injuries

C. Check airway patency

A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. Elevated temperature B. Swollen cervical lymph nodes C. Inspiratory stridor D. Purulent nasal discharge

C. Inspiratory stridor

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hr. Which of the following actions should the nurse take? A. Instruct the client to attempt to void around the indwelling urinary catheter B. Increase the rate of irrigation fluid instillation C. Irrigate the indwelling urinary catheter with a syringe D. Prepare to administer a diuretic

C. Irrigate the indwelling urinary catheter with a syringe

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? A. Urine negative for ketones B. Distended neck veins C. Kussmaul respirations D. Elevated blood pressure

C. Kussmaul respirations The nurse should expect this client with DKA to experience Kussmaul respirations. These deep and rapid respirations are the body's attempt to exhale carbon dioxide to reverse the metabolic acidosis that occurs with DKA.

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis

A nurse is caring for client who has human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? A. Protective isolation B. Droplet precautions C. Standard precautions D. Airborne precautions

C. Standard precautions

A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness

C. Weakness of the lower extremities

A nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. Which of the following instructions should the nurse include in the teaching? A. "Consume at least 4 oz of fluid with meals." B. "Take a short walk after each meal." C. "Use honey to flavor foods such as cereal." D. "Eat protein with each meal."

D. "Eat protein with each meal."

A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following pieces of information should the nurse include about osteoarthritis? A. "Osteoarthritis is caused by autoimmune processes." B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." C. "Osteoarthritis affects other organ systems." D. "Osteoarthritis can impair a joint on a single side of the body."

D. "Osteoarthritis can impair a joint on a single side of the body."

A nurse in the emergency department is caring for a client who has Addison's disease and reports nausea, vomiting, diarrhea, and abdominal pain. To prevent an Addisonian crisis, the nurse should prepare to administer which of the following medications? A. Calcium B. Potassium C. Iodine D. Hydrocortisone

D. Hydrocortisone

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

D. Iron toxicity

A nurse enters a client's room and notes smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Attempt to extinguish the fire C. Activate the facility's fire alarm system D. Transport the client to an area away from the smoke

D. Transport the client to an area away from the smoke