ATI Funds Final

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number).

29

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? A. Vesicular B. Bronchial C. Rhonchi D. Bronchovesicular

A. Vesicular

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? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. Nutrition

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test

Perform a blanch test

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? A. Fat breaks down into amino acids. B. Protein serves as an energy source when other sources are inadequate. C. Glucose breaks down into ammonia. D. Carbohydrates provide 9 cal/g of energy.

Protein serves an emergency source when other sources are inadequate

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? A. A 2-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test

D. Romberg test

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A. "We miss our daughter so much that we are going to move closer to her" B. "I think this year I can plan on managing the funding at church" C. "I really wish I could lose some of this weight" D. "I find I am spending more time at work now that my son is at college"

A. "We miss our daughter so much that we are going to move closer to her"

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation

A. Auscultation

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally". The nurse should document this finding when a client's pulses have which of the following qualities? A. Bounding B. Full C. Variable D. Weak

A. Bounding

A nurse is caring for a postop client who has an indwelling catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked

A nurse is caring for a client who is postop following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

A. Cover the incision with a moist sterile dressing

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? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium

A. Decreased calcium

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 drops? A. Drop the eye medication into the lower conjunctival sac B. Apple gentle pressure to the outer opening of the eye for 2 min C. Hold the eye dropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration

A. Drop the eye medication into the lower conjunctival sac

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? A. Independent moral development B. Acceptance of body changes C. Strengthening ties with the family of origin D. Development of concrete reasoning

A. Independent moral development

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber

A. Romberg

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia

A. Sanguineous

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion> A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

A. Sodium 123 mEq/L

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A. Vitamin C and zinc

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? A. "I'm in no hurry to get married. I think I'll enjoy single life." B. "I go home on the weekends to be with my family because I do not have any good friends here on campus." C. "I am interested in politics and may consider becoming an elected official.: D. "I am looking forward to finishing school and going to work for my family's business."

B. "I go home on the weekends to be with my family because I do not have any good friends here on campus."

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? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young clients. B. Clients who are age 65 or older are reluctant to report pain. C. Clients who are age 65 or older should not receive opioid narcotics. D. Clients who are age 65 or older experience a shorter duration of action with medications than young clients.

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

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

B. Edema at the infusion site

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30 or 45 degrees C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

B. Elevate the head of the bed to 30 or 45 degrees

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec

B. Faint pedal pulses

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min B. Fill the bad 2/3 full with ice C. Place the ice bag uncovered on the client's ankle D. Tell the client that numbness is expected when the ice bag is in place

B. Fill the bad 2/3 full with ice

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A. Heart B. Lungs C. Thyroid gland D. Skin

B. Lungs

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0

B. Potassium 3.0 mEq/L

A nurse is reviewing the lab data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEq/L

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia

B. Stereognosis

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D/ Medial thigh

B. lower abdomen

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10 mL syringe B. Attach a 22-gauge catheter to the syringe C. Warm the irrigating solution to 37 degree Celsius D. Administer an analgesic 10 min before the irrigation

C. Warm the irrigating solution to 37 degree Celsius

A nurse is assessing a client's thyroid gland. Which of the following instruction should the nurse give the client before inspecting and palpating the thyroid gland? A. "Tilt your head slightly forward" B. "Keep your head straight and look ahead of you" C. "Tilt your head back and swallow" D. "Turn your head to the side against my hand"

C. "Tilt your head back and swallow"

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report B. Notify the prescribing provider C. Assess the client D. Notify the charge nurse

C. Assess the client

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level d. Place a waterproof pad under the client's extremity.

C. Check the client's pain level

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A. Select a vein in the client's dominant arm B. Choose the most proximal vein in the extremity C. Choose a vein that is soft on palpation D. Select a site distal to previous venipuncture attempts

C. Choose a vein that is soft on palpation

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D. Snellen chart

C. Cotton wisps

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse exepect? A. Muscle tremors B. Positive Chvostek's sign C. Depressed deep-tendon reflexes D. Numbness around the mouth

C. Depressed deep-tendon reflexes

A nurse is caring for a client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

C. Depression

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of the tubing to be inserted

C. Explain the procedure to the client

A nurse is caring for a client who had a stroke and is at risk for falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints

C. Monitor the client at least once every hour

A nurse is caring for a client who is receiving intermittent feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

C. Provide more water with feedings

A nurse is inserting an NG tube into a client who begins to 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 backwards

C. Pull the NG tube back slightly

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 feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

C. Remove the IV catheter

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims

C. Supine

A nurse in the 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? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

C. Tachycardia

A 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? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? A. The deceased was a close friend B. The client lived far from the deceased C. The death was sudden D. The client has not visited the deceased in a long time

C. The death was sudden

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgement B. Short-term memory C. Attention span D. Abstract reasoning

D. Abstract reasoning

A nurse is preparing to insert an indwelling catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received the dose B. Give the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage

D. Call the provider to clarify the dosage

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? A. Managing a home B. Establishing a sense of self in the adult world C. Forming new friendships D. Ceasing to compare personal identity with others

D. Ceasing to compare personal identity with others

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

D. Clamp the tubing below the collection port

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait

D. Gait

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue w/a granular appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin

D. Halo of erythema on the surrounding skin

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 400 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could case which of the following adverse effects? A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver damage

D. Liver damage

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.24, PaCO2 40, and HCO30- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

D. Metabolic acidosis

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation

D. Palpation

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bad every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate D. Request a prescription for an isotonic enteral nutrition formula

D. Request a prescription for an isotonic enteral nutrition formula

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum

D. Second intercostal space to the right of the sternum