ATI Communication and Fundamental Learning system RN 3.0 465 questions

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drop?

drop the eye medication into the lower conjuctiva sac.

a nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take

elevate the head of the client's bed to 45 degree before the feeding.

a nurse is assessing a client's respiratory system. which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

vesicular

A nurse is planning care for a client who has a would infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals would the nurse plan to increase in the client's die

vitamin C and zinc. c and zinc is important to fight a wound infection.

A nurse is caring for a client who has cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following?

1. stabilizing the position of the tube 2. preventing aspiration of secretion 3. preventing air leaks

a nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

gait

a nurse is explaining PIAGET's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. which of the following activities should the nurse include as an example of concrete operational thinking?

1. collecting and trading game cards.

A nurse is caring for a client who has tracheostomy and requires suctioning. which of the following actions should the nurse take

1. hyperoxygenate the client before suctioning 2. insert the catheter during inhalation 3. supply suctioning no more than 10 seconds

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states. "its too late for me to quite:" which of the following action should the nurse take?

Assist the client in finding local smoking cessation assistance program

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range

BP 145/90 mmHg

A nurse is caring for a client who has methicillin resistant staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. which of the following instructions should the nurse give to the dietary assistant?

Don glove when entering the room and use the hand sanitizer when exiting

a nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the ye. this manifestation is consistent with which of the following eye disorders?

Glaucoma.

a Nurse is teaching a client who is using patient controlled analgesia (PCA) pump to deliver morphine for pain management. which of the following statement should the nurse identify a san indication that the client understand the instruction?

I can still use my transcutaneous electrical nerve stimulation unit while i'm pushing PCA button

a nurse is using the braden scale to predict the pressure ulcer risk of a client in a long term care facility. using this scale, which of the following parameters should the nurse evaluate?

Nutreint, sensory percenption moisure activity mobility friction shear

a Nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

Pc- for after meals

A nurse is caring for a client who has gastric ulcer. the nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur

hyperglycemia, hypertension

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, " you are not putting that hose down my throat" which of the following statement should the nurse make?

i can see that this is upsetting you

A nurse is providing teaching about nutritious diets to a group of adult women. which of the following statements should the nurse include?

include 2.5 cups of vegetables in your daily diet

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. which of the following actions should the nurse take first?

ask the client about first aid performed at the scene.

a nurse is caring a client who has hearing loss. the nurse should plan which of the following intervention when communication with the client?

attract the client's attention before speaking.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) which of the following actions should the nurse take?

check the client's capillary blood glucose level every 4 hrs

a nurse is caring for postoperative client who has an indwelling urinary catheter for gravity drainage. the nurse notes no urine output in the past 2 hrs. Which of the following actions should the nurse take first?

check to determine if the catheter tubing is kinked

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. which of the following laboratory findings should the nurse expect

decreased calcium. - positive chovostek's sign is when facial muscle twitching by tapping the facial nurses in front of the clinet's ear. - indicates hypocalcemia

a nurse is caring for a client who has BMI of 29 and expressess a desire to lose weight. which of the following action should the nurse take first?

determine the client's intention to change current eating habits.

a nurse is providng preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. the client expresses concern about the risk of acquiring an infection form the blood transfusion. which of the following statements should the nurse share with the client?

donate autologous blood before surgery. ( 나중에 자기가 다시 받는거임)

a nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take?

insert the tip of the tubing 8 cm ( 3.1 inches) (usually 7-10 cm) lubricate 5-8 cm position patient on the left side in the Sims' position hold enema container a mx of 45cm above the rectum

fidelity

keeping promises with patient

a nurse is planning care for a client who has anorexia and nausea due to cancer treatment. which of the following interventions should the nurse include?

limit drinking liquids with food.

a nurse is caring for client who has fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

oil retension.

A nurse is assessing the client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

peripheral pulses 1. bilaterally symmetric, equal, and strong in all 4 extremities.

a nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

a nurse is caring for a semiconscious client who had a small bore NG tube placed yesterday for the administration of enteral feeding. Which of the following method should the nurse use to verify correct tube placement? select all (3)

1. verify the initial x ray examination 2. measure the length of the exposed tube 3. Determine the pH of aspirated lfuid

a nurse is teaching an assistive personnel (AP) how to obtain a capillary finger- stick blood sample. which of the action by the AP requires the nurse to intervene?

elevating the finger above the heart level the nurse should intervene if the client elevates the finger above the level of the heart. holding finger below level of the heart, in a dependent position; will help increase blood flow to the area and ensure an adequate specimen for collection.

a nurse is proving teaching about food choices to a client who has prescription for a clear liquid diet. which of the following selections by the client indicates an understanding of the teaching?

gelatins. food allowed on a clear liquid diet are clear and liquid at room temperature.

a nurse is providing teaching to a group of unit nurses about would healing by secondary intention which of the following pieces of information should the nurse include in the teaching?

granulation tissue fills the wound during healing

a nurse is leading an education session about disposing of biohazards materials, which of the following instruction should the nurse include in the teaching

place soiled linen in a single linen bag. use chlorine beach to clean blood spills empty blood bags return to the blood bank incase reaction occurs

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take

place the client in the Trendelenburg position

A nurse is monitoring a client's laboratory result. Which of the following results should the nurse report to the provider 1. sodium 140 2. potassium 3 3. chloride 100 4. magnesium 2.0

potassium 3m Eq/L potassium too low- need to prevent muscle weakness that affect respiration

a nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feel warm. Which of the following action should the nurse take?

remove the Iv Catheter

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500-600 mL occurs each day through which of the following organs?

skin. the skin can excrete approximately 5-600 mL of insensible fluid loss. this type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin

A nurse is caring for a client who is exhibiting confusion the nurse should identify that which of the following laboratory values cn cause confusion

sodium 123mEQ/L . low sodium can cause confusion and lead to seizures, coma, and death.

a nurse is caring for a client who has xerostomia with lack of saliva. which of the following nutreitns will be affected by the lack of salivery amylase?

starch

a nurse in emergency department is caring for a client who has abdominal trauma. which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

tachycardia

the hospice nurse visiting with the family member of a client. The family member states that the client has insomnia almost nightly. which of the following practices should the nurse identify as contributing to the client's insomnia?

the client watches television in her bed during the day. use the bed only for sleep or sexual activities

a nurse is caring for a client who has a new diagnosis of breast cancer. The client becomes quiet and withdrawn and says to the nurse, " what do you think people will say about me when i'm gone?" which of the following responses should the nurse make?

the thought of having breast cancer may seem hopeless.

a nurse is teaching. a client who has urinary incontinence about bladder retraining. which of the following instruction should the nurse include

try to block the urge to urinate until the next scheduled time

safest injection site for intramuscular injection to a young adult

ventroguteal.