J1 ATI Final
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning." "It is difficult to read the instructions because my glasses are at home." "I'm wondering why I need to learn this." "You will have to talk to my wife about this."
"I can concentrate best in the morning." (CORRECT) The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn. "It is difficult to read the instructions because my glasses are at home." (Incorrect) The client's statement indicates the client is not ready to learn. He has to have the tools he needs to learn and comprehend the information. "I'm wondering why I need to learn this." (Incorrect) The client's statement indicates a reluctance to learn information he thinks he might not need to know. "You will have to talk to my wife about this." (Incorrect) With this statement, the client is redirecting the nurse's attempt to teach toward someone else, indicating that he is not ready to learn.
A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine." "I have a specimen in the bathroom from about 30 minutes ago." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." "I drink a lot, so I will fill up the bottle and complete the test quickly."
"I had a bowel movement, but I was able to save the urine." (Incorrect) For a 24-hr urine collection, the client should collect urine that is free of feces. "I have a specimen in the bathroom from about 30 minutes ago." (Incorrect) For a 24-hr urine collection, the client should place any urine in the container immediately and keep it on ice or in a refrigerator. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." (CORRECT) For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. "I drink a lot, so I will fill up the bottle and complete the test quickly." (Incorrect) For a 24-hr urine collection, there is no specified amount. The collection takes place over a 24-hr period.
A nurse is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses would the nurse make? "I'll get a blood sample from you and send it for a screening test." "Beginning at age 60, you should have a colonoscopy." "You should have a fecal occult blood test every year." "The recommendation is to have a sigmoidoscopy every 10 years."
"I'll get a blood sample from you and send it for a screening test." (Incorrect) - Blood tests do not detect colorectal cancer. One option for screening is a double-contrast barium enema every 5 years. "Beginning at age 60, you should have a colonoscopy." (Incorrect) - Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. "You should have a fecal occult blood test every year." (CORRECT) - Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually. "The recommendation is to have a sigmoidoscopy every 10 years." (Incorrect) - One option for screening is a flexible sigmoidoscopy every 5 years.
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." "I'll use a woolen blanket if I get chilly while I'm using my oxygen." "I'll check the wires and cables on my TV to make sure they are in good working order." "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."
"I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." (Incorrect) Oxygen is a highly flammable gas. The client's visitors should smoke outside the house. "I'll use a woolen blanket if I get chilly while I'm using my oxygen."(Incorrect) Oxygen is a highly flammable gas. Woolen and synthetic materials can create sparks, so the client should use a cotton blanket during supplemental oxygen therapy. "I'll check the wires and cables on my TV to make sure they are in good working order." (CORRECT) Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." (Incorrect) The client should keep her oxygen tank upright and secure in its holder at all times.
A nurse is preparing to administer an injection of opioid medication to a client. The nurse draws out 1mL of the medication from a 2mL vial. Which of the following action should the nurse take? Ask another nurse to observe the medication wastage. Notify the pharmacy when wasting the medication. Lock the remaining medication in the controlled substances cabinet. Dispose of the vial with the remaining medication in a sharps container.
Ask another nurse to observe the medication wastage. (CORRECT) A second nurse must witness the disposal of any portion of a dose of a controlled substance. Notify the pharmacy when wasting the medication. (Incorrect) Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. Lock the remaining medication in the controlled substances cabinet. (Incorrect) The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. Dispose of the vial with the remaining medication in a sharps container. (Incorrect) The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.
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 his condition is a contraindication for which of the following therapies? Biofeedback Aloe Feverfew Acupuncture
Biofeedback (Incorrect) Biofeedback is a complementary and alternative therapy used by clients for disease processes such as stroke recovery, smoking cessation, and headache disorders. The use of this mind-body technique is not known to be contraindicated for a client who has herpes zoster. Aloe (Incorrect) Aloe is a complementary and alternative therapy used by clients for skin disorders and can have wound healing effects. This type of therapy is not known to be contraindicated for a client who has herpes zoster. Feverfew (Incorrect) Feverfew is a complementary and alternative therapy used by clients for wound healing. It should not be taken by clients who are prescribed warfarin or other blood thinners, but this type of therapy is not known to be contraindicated for a client who has herpes zoster. Acupuncture (CORRECT) The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection.
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse prepare to take? Dissolve each medication in 5 mL of sterile water. Draw up medications together in the syringe. Push the syringe plunger gently when feeling resistance. Flush the tube with 15 mL of sterile water.
Dissolve each medication in 5 mL of sterile water. (Incorrect) The nurse should dissolve each medication in at least 30 mL of warm, sterile water. Draw up medications together in the syringe. (Incorrect) The nurse should draw up medications separately and not mix them together. Push the syringe plunger gently when feeling resistance. (Incorrect) If the nurse encounters resistance when administering medications, he should stop and contact the provider. Flush the tube with 15 mL of sterile water. (CORRECT) The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? Drink a cup of hot cocoa before bedtime. Exercise 1 hr before going to bed. Use progressive relaxation techniques at bedtime. Reflect on the day's activities before going to bed.
Drink a cup of hot cocoa before bedtime. (Incorrect) Cocoa contains caffeine, which is a stimulant that can interfere with sleep. Exercise 1 hr before going to bed. (Incorrect) Exercising within 2 hr of bedtime can interfere with sleep. Use progressive relaxation techniques at bedtime. (Correct) Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension. Reflect on the day's activities before going to bed. (Incorrect) Reflecting on the day's activities can cause stress and worry, which can interfere with sleep.
A nurse is assessing an adult client who has been immobile for the past three weeks. The nurse should identify which of the following findings requires further intervention? Erythema on pressure points Lower-extremity pulse strength of 2+ Fluid intake of 3,000 mL per day A bowel movement every other day
Erythema on pressure points (CORRECT) Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown. Lower-extremity pulse strength of 2+ (Incorrect) A lower-extremity pulse strength of 2+ is an expected finding. Fluid intake of 3,000 mL per day (Incorrect) Clients should drink 2,500 to 3,000 mL of fluid per day. A bowel movement every other day (Incorrect) Bowel movements less frequent than three per week indicate constipation and the need for intervention.
Which of the following foods are not apart of a mechanical soft diet? Tomato juice Banana Pancakes Fried eggs
Fried eggs
A nurse is prepping to administer 0.5mL of an oral single dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration. Transfer the medication to a medicine cup. Place the client in a semi-Fowler's position prior to medication administration. Verify the dosage by measuring the liquid before administering it.
Gently shake the container of medication prior to administration. (CORRECT) - The nurse should gently shake the liquid medication to ensure the medication is mixed. Transfer the medication to a medicine cup. (Incorrect) - The nurse should not transfer prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose. Place the client in a semi-Fowler's position prior to medication administration. (Incorrect) - The nurse should place the client in a high-Fowler's position when administering an oral liquid medication to reduce the risk of aspiration. Verify the dosage by measuring the liquid before administering it. (Incorrect) - The nurse should not transfer prepackaged liquid medication to a measuring device to reduce the risk of altering the premeasured dose.
A nurse is caring for a client with Tuberculosis. Which of the following actions should the nurse take? Place the client in a room with negative-pressure airflow Wear gloves when assisting the client with oral care Limit each visitor to 2-hr increments Wear a surgical mask when providing client care Use antimicrobial sanitizer for hand hygiene
Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever her hands might come in contact with a client's body fluids, such as saliva, and the mucous membranes in the mouth. Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and have him wear a surgical mask when he does leave the room. Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions. Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. The nurse should also wash her hands with soap and water when her hands have visible soiling.
A nurse is receiving fluid through an IV peripheral catheter. Which of the following findings at the IV site should the nurse identify as infiltration? Purulent exudate Warmth Skin blanching Bleeding
Purulent exudate (Incorrect) Exudate indicates infection rather than infiltration. Warmth (Incorrect) Warmth indicates phlebitis rather than infiltration. Skin blanching (CORRECT) Skin blanching, edema, and coolness at the IV site indicate infiltration. Bleeding (Incorrect) Bleeding can have a mechanical cause or can occur as a result of anticoagulation. It is not a sign of infiltration.
A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? Side-lying Supine Semi-Fowlers Trendelenburg
Side-lying (Incorrect) Positioning the client on her side does not promote full expansion of the lungs. Supine (Incorrect) Placing the client in the supine position does not promote full expansion of the lungs. Semi-Fowler's (CORRECT) Positioning the client in semi-Fowler's or high-Fowler's position allows for maximum expansion of the lungs. Trendelenburg (Incorrect) Positioning the client with her head below her feet does not promote full expansion of the lungs.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? Suction the client's airway. Administer a bronchodilator. Increase the humidity in the client's room. Assist the client to an upright position.
Suction the client's airway. (Incorrect) - The nurse might have to remove pulmonary secretions to ease the client's breathing; however, the nurse should use a less invasive intervention first. Administer a bronchodilator. (Incorrect) - The nurse might have to administer a bronchodilator to open the client's airway and facilitate breathing; however, the nurse should use a less invasive intervention first. Increase the humidity in the client's room. (Incorrect) - The nurse might have to increase the humidity in the client's room to thin secretions that can limit airflow; however, the nurse should use a less invasive intervention first. Assist the client to an upright position. (CORRECT) - When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed to the semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? Tell the client which food she should eat first. Provide small-handle utensils for the client. Thicken liquids on the client's tray. Use a clock pattern to describe food on the client's plate.
Tell the client which food she should eat first. (Incorrect) - The nurse should allow the client to decide for herself the order in which she consumes food. Provide small-handle utensils for the client. (Incorrect) - Large-handle adaptive utensils are easier for the client to grip and allow for greater independence during meals for clients who have vision loss. Thicken liquids on the client's tray. (Incorrect) - Clients who have dysphagia, not vision loss, require thickening of liquids to facilitate swallowing without choking. Use a clock pattern to describe food on the client's plate. (CORRECT) - Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals.
A nurse is preparing a client who has right-sided weakness from the bed to the chair. In what order should the nurse take the following actions to assist the client? Ask the client if he can bear weight. Use the stand-and-pivot technique to move the client to the chair. Position the chair on the left side of the bed. Have the client sit and dangle his feet at the bedside.
The first action the nurse should take is to assess the client to determine if he can bear weight and assist with his transfer. Next, the nurse should position the chair on the side of the bed closest to the client's stronger side for easy access. Next, the nurse should have the client sit and dangle his feet at the bedside to allow him to adjust to sitting up and prevent dizziness when transferring. Finally, the nurse should use the stand-and-pivot technique to move the client to the chair.
The nurse is evaluating the client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. When walking, the client moves the cane 46 cm (18 in) forward. The client holds the cane on the stronger side of her body. The client moves her stronger limb forward with the cane.
The top of the cane is parallel to the client's waist. (Incorrect) The top of the cane should be parallel to the client's greater trochanter. When walking, the client moves the cane 46 cm (18 in) forward. (Incorrect) To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. The client holds the cane on the stronger side of her body. (CORRECT) The client should hold the cane on the stronger side of her body to increase support and maintain alignment. The client moves her stronger limb forward with the cane. (Incorrect) The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.
A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly Riding a bicycle Performing isometric exercises Engaging in high-impact aerobics
Walking briskly (CORRECT) Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. Riding a bicycle (Incorrect) Cycling has no weight-bearing advantages; therefore, it does not help prevent osteoporosis. Performing isometric exercises (Incorrect) Isometric exercises have no weight-bearing advantages; therefore, they do not help prevent osteoporosis. Engaging in high-impact aerobics (Incorrect) High-impact aerobics can injure bones that have lost density; therefore, the nurse should not recommend these exercises for the client who is at risk for developing osteoporosis.
