ATI-Correct

A nurse is caring for a toddler at a well child visit when the mother calls< "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

inability to cry or speak

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expressess concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

"The dietitian will help you choose foods you are use to that also meet your health needs."

A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client who has diarrhea. Select 4 instructions that the nurse should include in the teaching.

1. Eat probiotic foods, such as yogurt 2. Avoid alcohol while experiencing diarrhea 3. Avoid caffeine while experiencing diarrhea is correct 4. Follow a low-fiber diet

A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client?

1. Hold the mouthpiece 1 to 2 inches in front of your mouth. 2. Tilt your head back slightly and open your mouth wide. 3. Depress the canister while taking a slow, deep breath. 4. Hold your breath for 10 seconds.

The nurse is placing the client on isolation precautions (tuberculosis). Which of the following interventions should the nurse include? select all that apply

1. Wear an N95 when caring for the client 2. Place a container for soiled linens inside the client's room 3. Place the client in a negative airflow room 4. Remove mask after exiting the client's roome

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

145/90

A nurse is assessing the pH of a client's gastric fluid to confirm placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? a. 6 b. 2 c. 10 d. 8

2

A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? (Fill in the blank with the numeric value only.)

48 132/2.2=60 kg 60 kg x 0.8g = 48 g

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

Gelatin

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Administering high-flow oxygen prior to the procedure

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies

A nurse on a medical surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? a. b. Plan of care c. Nursing interventions performed d. Evaluation of progress

Assessment

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission based precautions. Which of the following actions by the newly licensed nurse indicates understanding of droplet precautions? a. Shaking soiled linen before putting it in a hamper b. removing a face mask when standing 0.5 m (1.6 ft) from the client c. Assigning another client with the same infection to share the room with the client d. Allowing the client to visit a family member in the lobby of the facility

Assigning another client with the same infection to share the room with the client

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take?

Assist the client in finding local smoking-cessation assistance programs

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching.

Clients who are 65 or older are reluctant to report pain.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. Protective environment b. Airborne precautions c. Droplet precautions d. Contact precautions

Contact precautions

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the clients weight?

Weigh the client on arising

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief. a. Acceptance b. Bargaining c. Anger d. Denial

Denial

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. Increase in hematocrit b. Increase in respiratory rate c. Decrease in heart rate d. Decrease in capillary refill time

Decrease in heart rate

A nurse is providing 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 from the blood transfusion. Which of the following statements should the nurse share with the client?

Donate autologous blood before the surgery

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?

Evacuate the client from the room

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? a. hold the irrigator 1.25 cm (0.5 in) above the eye b. Direct the irrigation solution up toward the upper eyelid c. Exert pressure on the bony prominences when holding the eyelids open d. Direct the irrigation from the outer canthus to the inner canthus of the eye

Exert pressure on the bony prominences when holding the eyelids open

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bed. Which of the following actions should the nurse take?

Hold the sterile drape above the waist away from the body

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. Is your pain constant or intermittent? b. What would you rate your pain on a scale of 0-10? c. Does the pain radiate? d. Is your pain sharp or dull?

Is your pain sharp or dull?

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

It might help me to listen to music while I'm lying in bed

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering device is the best choice for the nurse to use to decrease skin irritation? a. abdominal binder b. Montgomery straps c. hypoallergenic tape d. plastic tape

Montgomery straps

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? a. Identify goals for client care b. Obtain client information c. Document nursing care needs d. Evaluate the effectiveness of care

Obtain client information

A nurse is planning to collect a stool specimen for ova and parasites for a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15mg/dL b. Creatinine 0.8 mg/dL c. Sodium 143 mEq/L d. Potassium 5.4 mEq/L

Potassium 5.4 mEq/L

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level to the bed.

A nurse is preparing to insert a NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

Raise your index finger if you need to pause during the insertion

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restrains within 24 hr

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? a. scoliosis b. lordosis c. torticollis d. kyphosis

Scoliosis

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the privider?

Sodium 150 mEq/L

A nurse is teaching range of motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? a. The client holds the hand with the palm up. b. The client holds the hand with the palm down. c. The client points the fingers toward the floor. d. The client point the fingers toward the ceiling

The client holds the hand with the palm up.

A nurse is administering an IM injection to a 5 month old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect.

absent bowel sounds with distention

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following should the nurse perform immediately following the transfer? a. administer pain medication b. check the client's vital signs c. instruct the client to use the incentive spirometer ever 1 hr d. provide ice chips as per provider prescription

check the client's vital signs

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

compare the medical record number and name on the MAR with the client's identification band

A nurse is teaching a middle aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routing health screening?

eye examination every 2 years

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with; butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a bake potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. The client's diet is deficient in which of the following groups? a. dairy b. vegetables c. fruits d. grains

grains

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? a. sit beside the client during the interview b. make sure the device is functioning c. make sure lighting in room is soft d. provide a lengthy interview process to allow adequate time to answer questions

make sure the device is functioning

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 inserting an NG tube into a client who begins t cough and gag. Which of the following actions should the nurse take? a. remove the ng tube b. advance the ng tube quickly c. pull the ng tube back slightly d. ask the client to tilt his head backward

pull the NG tube back slightly