ATI Fundamentals Adaptive Quizzez

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I need to place a towel between the heating pad and my skin" -The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns.

A nurse on a surgical unit is receiving a client who had abdominal surgery from the post-anesthesia care unit. Which of the following assessments should the nurse make first?

Airway. -ABCs

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decreased estrogen and testosterone production. -Both estrogen and testosterone levels start to decrease in. middle age.

How often should restraints be moved in order for ROM exercises to be preformed?

Every 2 hours

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of info must the nurse verify w/ another nurse prior to the administration? (Select all that apply.) A. The client's ID number B. The client's room number C. The client's name D. ABO compatibility E. Rh compatibility

A. The client's ID number C. The client's name D. ABO compatibility E. Rh compatibility -Nurses should never use a client's room number as an identifier because clients can change rooms.

A client who has glaucoma of the right I self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after installation. -The client should apply gentle pressure over the nasolacrimal duct to prevent the medication from flowing into the nasal passages where systemic absorption could result.

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

Lactose

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher. -Locking the wheels prevents the client from falling on the floor by not allowing the cart of bed to move apart or away from the client.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision. -Acting as the client advocate, thte nutrse

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

Place the client in a left Sims' position. -The nurse should place the client into a left Sims' position for the insertion of an enema. The left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time. -The nurse should remove one restraint at a time for a client who is violent or noncompliant.

A nurse is caring for an older client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time. -The nurse should remove one restraint at a time for a client who is violent or noncompliant.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum. -The nurse should process priority-setting framework to plan client care and prioritize nursing actions. Each step builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. The priority nursing acting is for the nurse to collect more data by assessing the area of irritation.

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?

Hearing aids. -A client who has hearing aids can undergo MRI because the hearing aids can be removed. The powerful magnetic field of the MRI system could damage the hearing, so they should be removed prior to the client undergoing MRI.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45-degree angle to the bed. -Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required.

The nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch. -A client who has. taut skin around the IV site that is cool to touch might have an infiltration IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration).

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side. -The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability.

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level.

A nurse is caring for a client who has type 1 diabetes mellitus and us resistant to learning how to self-inject insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome tour fear of giving yourself injections." -This response illustrates the therapeutic communication technique of clarifying and offering self. The nurse should allow the client to express feelings and fears and support the client in learning how to give the injections.

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data?

Corneal light reflex. -The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses.

The nurse rates a client's biceps muscle strength as a 2+. Which of the following characteristics should the nurse document about the client's reflexes?

Average -Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+.

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

"Keep the rubber crutch tip securely in place." -The client should never use crutches w/o the rubber crutch tips. The client should inspect the tips regularly, replace then when they show signs of wear, and remove and dry them throughout w/ paper towels if they become wet.

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. -Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.

The nurse is removing personal protective equipment (PPE). Which item should be removed first?

Gloves -According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least contaminated piece of PPE.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic. -A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

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

Hold the sterile drape above the waist and away from the body. -Contamination occurs when the nurse holds any object that will be part of the sterile field below the waist or allows it to touch anything other than a sterile object.

A nurse is preparing to administer a partial dose of a pre-filled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record. -Two nurses should sign the controlled substance inventory record to document the amount of medication wasted.

A hospice nurse is 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 TV in her bed during the day. -To promote sleep, the client should avoid watching TV in bed. She should use the bed only for sleep or sexual activities.

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative form is the client's. -The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will preform the procedure to obtain consent by explaining the procedure along with the associated risks and benifits.

A nurse is obtaining a capillary blood sample to determine A client's blood glucose level. The nurse prepares and punctures The client's finger for the procedure but it's not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

Wrap the clients finger in a warm washcloth. -Warmth helps increase the blood flow to the client's finger.

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus. -The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle.

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

Clean the drain site from the center outward. -The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound.

A new resident provider asks the charge nurse for an access code to review clients online records. The resident is not scheduled to attend the facilities orientation computer class until next week. Which of the following actions should the nurse take?

Explain that is against policy to share access codes and refer the resident to his supervisor. -Staff members should never share access codes and passwords or allow people who do not have their own access code to use the system. Allowing unauthorized access is a breach of federal guidelines for data security in client confidentiality.

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside?

O2 equipment. -The nurse should have O2 equipment at the bedside of a client who is on seizure precautions, The nurse should be able to apply O2 via mask or nasal cannula to a client who experiences a seizure.

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

Raise the level of the bed. -The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury.