ATI Questions 3
A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A lab result within the expected range for what substance indicates adequate protein intake and synthesis?
albumin
A nurse is preparing to administer a TB skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?
circle the area of the injection site with a pen
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling cath. What action should the nurse take?
clamp the tubing below the collection port
A nurse is reviewing the lab results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant entercocci (VRE). What precautions should the nurse take?
contact
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
exert slight pressure on the bony prominences when holding the eyelids open
A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facilities computer orientation class until next week. What action should the nurse take?
explain that sharing access codes is against policy and refer the resident to the supervisor.
A nurse is teaching a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. What should the nurse include in the teaching?
granulation tissue fills the wound during healing
A nurse is reinforcing teaching about body mechanics with AP. Which of the following instructions should the nurse include? Select all that apply
sit with your back supported keep your knees at hip level use an ergonomically designed computer keyboard
A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure?
use the index finger to insert the suppository
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation
Montgomery straps
A nurse at a screening clinic is collecting data for 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?
Second intercostal space to the right of the sternum
A nurse in an urgent-care center is caring for a 15 year old client whose symptoms suggest a STI. The client's parent is unavailable, but the grandmother accompanied the client to the clinic. What action should the nurse take?
have the adolescent sign the consent form
As a nurse is preparing to administer liquid medication from a bottle to a client. What action should the nurse take?
hold the med bottle with the label against the palm of the hand while pouring
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which action should the nurse take?
hyperoxygenate the client before suctioning
A nurse is collecting a specimen for culture from a clients infected wound. Which of the following actions should the nurse take?
cleanse the wound with 0.9% sodium chloride irrigation
A nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?
2
A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. What action indicates understanding?
administering high-flow oxygen prior to the procedure
A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age?
eye exam every 2 years
A nurse in a providers office is collecting data from an older adult client. What finding should the nurse expect?
increased cerumen
A nurse is assisting with planning care for a client who has anorexia and nausea due to cancer treatment. What intervention should the nurse suggest?
limit drinking liquids when eating food
A nurse is performing a physical exam of a client. To evaluate the client's skin moisture, the nurse should use what technique?
palpation
A nurse is collecting data from a client. Which of the following actions should the nurse take to determine the clients tissue perfusion?
perform a blanch test
A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. What heart sounds should the nurse document?
pericardial friction rub
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications?
plasma volume expanders
A nurse is collecting data from a 5 year old client during a routine exam. Which activity should the nurse expect the client to perform?
ride a bicycle with training wheels
A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?
peripheral pulses bilaterally symmetric, equal, and strong in all four extremities
A nurse is reinforcing teaching about nutrition with a middle adult client who has a sedentary job. What factor should the nurse consider?
the basal metabolic rate could decrease
A nurse is evaluating a client's use of crutches. What action indicates safe usage?
the client has slightly flexed elbows when ambulating with crutches
A nurse is reinforcing teaching about ROM exercises with a client who has osteoarthritis. Which of the following positions indicates the client's correct understanding of supination of the hand?
the client holds the hand with palm up -palm down would be pronation
