ATI learning system RN

a nurse in the ED is caring for a client who has fruity breath odor, 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 tests

a.

a nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. which of the following instructions should the nurse include in the teaching? a. use pursed-lip breathing during periods of dyspnea b. limit fluid intake to 1,500mL per day c. practice chest breathing each day d. wear home oxygen to maintain an SaO2 of at least 94%

a.

a nurse is providing discharge teaching to a client who has a new permanent pacemaker. which of the following statements by the client indicates an understanding of the teaching? a. "i should check my HR at the same time each day" b. "i don't have to take my antihypertensive meds now that i have a pacemaker" c. "i should keep a pressure dressing over the generator until the incision is healed" d. "i can't stand in front of our new microwave oven when it's on"

a.

a nurse is reviewing a client's lab report. the client's ABG levels are pH 7.5, PaCO2 32 mm HG, and HCO3- 24 mEq/L. the nurse should determine that the client has which of the following acid-base imbalances? a. respiratory alkalosis b. metabolic acidosis c. respiratory acidosis d metabolic alkalosis

a.

a nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. which of the following PPE should the nurse don prior to providing client care? (select all that apply) a. gown b. gloves c. mask d. hair cover e. goggles

a., b.

a nurse is providing teaching to a client who has gout and urolithiasis. the client asks how to prevent future uric acid stones. which of the following suggestions should the nurse make? (select all that apply) a. take allopurinol as prescribed b. exercise several times a week c. limit intake of foods high in purine d. decrease daily fluid intake e. avoid citrus juices

a., b., c.

a nurse is caring for a client who has an upper GI bleed and a hematocrit of 24%. prior to initiating a transfusion of packed RBCs, which of the following actions should the nurse take? (select all that apply) a. assess and document the clients vital signs b. restart the IV with a 22-guage needle c. verify with another nurse the blood type and Rh of the packed RBCs d. hang a bag of lactated Ringer's IV solution e. change IV tubing to a set that has a filter

a., c., e.

a nurse in an emergency department is assessing a client who sustained a fall off of a roof. which of the following findings should the nurse identify as an indication of a basilar skull fracture? a. a depressed fracture of the forehead b. clear fluid coming from the nares c. motor less on one side of the body d. bleeding from the top of the scalp

b.

a nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. which of the following findings should the nurse expect? a. kussmaul respirations b. diaphoresis c. decreased skin turgor d. ketonuria

b.

a nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. which of the following actions should the nurse take? a. elevate the residual limb on a soft pillow b. assist the client to a prone position every 4 hr c. reapply a bandage to the residual limb every 12 hr d. apply dressings to the site in a proximal-to-distal direction

b.

a nurse is planning dietary teaching for a client who has diabetes mellitus. which of the following actions should the nurse plan to take first? a. obtain sample menus from the dietitian to give to the client b. ask the client to identify the types of foods she prefers c. identify the recommended range for the clients blood glucose level d. discuss long term complications that can result from non adherence to the dietary plan

b.

a nurse is providing teaching to a client who has stomatitis due to chemo and radiation therapy. which of the following statements by the client indicates a need for further teaching? a. "i'll use a soft toothbrush of foam swab for oral care" b. "i'll use lemon and glycerine swabs after meals" c. "i'll remove my dentures except while eating" d. "i'll rinse my mouth frequently with hydrogen peroxide"

b.

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 PPE c. check the client's pain level d. place a waterproof pad under the client's extremeity

c.

a nurse is preparing to care for a group of clients after receiving change-of-shift report. which of the following clients should the nurse assess first? a. a client who has BPH and reports dysuria b. a client who has ulcerative colitis and reports diarrhea c. a client who has emphysema and reports dyspnea d. a client who has esophageal cancer and reports painful swallowing

c.

a nurse is caring for a client following a hip arthroplasty. the nurse places an abduction pillow on the client for which of the following purposes? a. raising the bed linens off the client's feet to prevent plantar flexion b. keeping the client's heels off the bed to prevent pressure ulcers c. positioning the client off of the operative site while in bed d. preventing dislocation of the hip during position changes or movement

d.

a nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. which of the following actions should the nurse take first? a. provide oxygen b. place the client in a side-lying position c. provide privacy d. lower the client to the floor

d.

a nurse is proving postoperative care for a client who has 2 chest tubes in place following a lobectomy. the client asks the nurse the reason for having 2 chest tubes. the nurse should inform the client that the lower chest tube is placed for which of the following reasons? a. removing air from the pleural space b. creating access for irrigating the chest cavity c. evacuating secretions from the bronchioles and alveoli d. draining blood and fluid from the pleural space

d.

a nurse is teaching a client how to perform a breast self exam (BSE). the nurse should identify which of the following findings as an indication of breast cancer? a. lumps that are mobile and tender upon palpation prior to a menstrual period b. multiple round masses that are tender and found in both breasts c. bilaterally darkened areolas d. a nontender, hard lump that is palpated in one breast

d.