ATI practice A

a nurse is auscultating the anterior chest of client who was newly admitted to a medical-surgical unit.

normal breath sounds

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

notify the nursing manager

a nurse in a long term care facility is caring for a a client who dies during the nurse's shift. Identify the sequence in which the nurse should preform the following steps.

obtain the pronouncement of death from the provider. remove tubes and indwelling lines. wash the client's body. ask the client's family members if they would like to view the body. place a name tag on the body.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

pupil clarity. visual fields. visual acuity.

A nurse is preforming a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observation should the nurse identify as proper safety protocol?

the client identifies the location of a fire extinguisher

first clinic visit ... A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?

"I am limiting my sodium intake to 2 grams daily" "I am eating fewer potato chips and more fruit for snacks." "I know to call my doctor if I gain 3 pounds or more in 2 days."

A nurse is caring for a client who has a terminal illness and is at the end of life. the nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time."

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. 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 talking with an older adult who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"let's talk about how the change in your job status will affect you."

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"they indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

107 mL/hr

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

I am available to talk if you should change your mind

0800: heart rate 109/min ... Complete the following sentence by using the list of options

The nurse identify that the client might be experiencing extravasation as evidence by the client's IV catheter site

On entry into a client's room with discharge papers, client was found on the floor seizing.

The nurse should first address the client's physical safety followed by the client's positioning

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

We would give you oxygen through a tube in your nose

A nurse is preforming a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

a mole with an asymmetrical appearance

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

acupuncture

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in teaching?

administer the medication into the abdomen

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

administer the medication with the needle at a 45 degree angle

a nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

advocacy ensures client's safety, health, and rights

The assessment findings below that the nurse should report to the provider.

urinary output. reported pain level. vital signs.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

the client holds the cane on the stronger side of her body

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

subtract the amount of irrigation used from the client's urine output

client reports itching and anxiety. Client's face is flushed and has hive

the client has manifestations of allergic reaction as evidenced by the client's itching

A nurse is caring for a client who expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

reassure the client that this an expected response to grief

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min

A nurse is talking with a partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

role overload

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

situation, background, assessment, and recommendation

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

stand close to the cabinet when lifting it

Day 1: lactated ringer's at 100 mL/hr infusing into ... the nurse is assessing the client. Which of the following actions should nurse take?

stop IV infusion. elevate the client's left arm. apply heat to the client's left hand.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching.

"use the complete name of the medication magnesium sulfate."

a nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

make sure two fingers can fit under the sleeves

a nurse on a medical-surgical unit is caring who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

pad the client's wrist before applying the restraints

client admitted with a productive cough with thick yellow sputum ... select the 3 findings that require follow-up.

breath sounds. oxygen saturation. temperature.

a nurse is responding to call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

check the client for injuries

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

compare the client's home medications with the providers'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?

contact precaustions

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?

decrease in heart rate

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the nurse's priority?

determine the reasons why the client is refusing to use the incentive spirometer

The client states, "I am unable to eat anything without vomiting." ... select 3 tasks the nurse should delegate to an assistive personnel.

document the client's vital signs. measures the client's intake and output. transfer the client from wheelchair to bed.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

A nurse is admitting a client who is having an exacerbation of the heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process

temperature 36.2 C ... the nurse is providing teaching for a client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching.

eat probiotic intake of high-calcium food. avoid alcohol while experiencing diarrhea. avoid caffeine while experiencing diarrhea. follow a low-fiber diet.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm

a nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

examine personal values about the issue

a nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

have the client take sips of water to promote insertion of the NG tube into the esophagus

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

hydrocolloid

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?

is your pain sharp or dull?

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

make sure the client wears a mask when outside her room if there is construction in the area

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

place the client's arm in a dependent position

influenza with nausea, vomiting, and diarrhea for 3 days. ... complete the following sentence by using the list of options

the nurse should first review medications that might cause confusion followed by using other methods to keep the client safe

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

turn the client every 2 hr

a nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to client?

use a bed exit alarm system

a nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

use the planning step of the nursing process to prioritize client care delivery

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors

Client reports fever, chills, cough and night sweats for the past 2 weeks ... The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include?

wear an N95 when caring for the client. place a container for soiled linens inside the client's room. place the client in a negative airflow room. remove mask after exiting the client's room.