ATI - NurseLogic - Testing and Remediation Beginner

1) A nurse is reinforcing to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further testing?

¾ cup of canned tomato juice Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the med has been effective?

"I feel very relaxed" Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective.

9) A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading?

Using a cuff that is too wide Using a cuff that is too wide can result in a false low blood pressure reading.

A nurse is preparing to administer an IM injection to an adult who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?

1 1/2 inch A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.

1st- to stand and bear weight on the unaffected leg 2nd- transfer body weight to the crutches 3rd- advance the unaffected leg between the crutches 4th- shift weight from the crutches to the unaffected leg 5th- align crutches on the stair

2) A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25 mg every 6hrs as needed. Available is Benadryl 12.5mg/5mL. How many teaspoons of Benadryl does the nurse instruct the parents to administer per dose?

2 tsp

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicated the client is in which of the following stages of grief?

Bargaining Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.

8) A nurse is performing a respiratory examination on a client whio has pneumonia. Which of the following sounds should be elicted over areas of consolidation during percussion?

Dullness Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.

3) A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (select all that apply)

Grape juice, ice cream

A nurse is caring for a client who is receiving Vancomycin for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?

Hearing loss Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect.

19) A nurse us collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? a) Inspection

Inspection Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting low-pitch diastolic murmur?

Left lateral recumbent position

5) A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following?

Mood St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety

6) A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?

Partial-thickness skin loss Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes.

Posterior side of neck, A While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.

A nurse on a rehab. unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? (Serum Lab Results - Hemoglobin: 15.4g/dL, Protein: 7.2g/dL, BUN 8mg/dL, Glucose 72 mg/dL A) Request prescription for iron supplement B) Administer 4 oz. of orange juice C) Restrict fluid intake D) Encourage bed rest

Restrict fluid intake

A nurse on a rehab unit is caring for a client who was admitted 3 days ago. Upon review of the client's med record, which of the follwoign actions should the nurse take?

Restrict fluid intake Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.

4) A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?

Sim's The left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?

Stand close to patient

7) A nurse on a Peds unit is caring for an infant who is diagnosed w/laryngotracheobronchitis. While performing a respiratory exam, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds?

Stridor

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis (croup). While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? A) Rochi B) Crackles C) Stridor 4) Wheezing

Stridor Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. The breath sound on the audio clip is an example of stridor.

A nurse is reinforcing teaching to a client who is newly diagnosed w/Lyme disease. The nurses should include that the disease is transmitted in which of the following ways?

Vector Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector.