Ticket To Class ATI Questions
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? 1. "I will call for pain medication before the dose wears off" 2. "I will call for pain medication as my pain starts to increase again" 3. "I will wait for you to evaluate my pain before asking for more medication." 4. "I will ask for less medication to avoid addiction"
"I will call for pain medication before the previous dose wears off"
A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching? 1. "It might take up to 3 days for the medication to work" 2. "It will take the medication for diarrhea" 3. "I should drink 4 ounces of water when I take the medication" 4. "I can take this medication along with mineral oil"
"It might take up to 3 days for the medication to work."
A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply) 1. offer the client a back rub 2. remind the client to use incisional splinting 3. Identify the clients pain level 4. Assist the client to ambulate 5. Change the clients position
1, 2, 3, 5
A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply) .1. Have a parent stay with the child during procedures 2. Cluster invasive procedures whenever possible 3. Perform the procedure as quickly as possible 4. Allow the child to keep a toy from home with her 5. Use mummy restraints during painful procedures
1,3,4
A nurse is teaching a client who has asthma how to use a metered dose inhaler. The nurse identifies the sequence of steps the client should follow.
1. Inhale deeply and then exhale completely 2. Place her lips firmly around the mouthpiece 3. Breath in deeply over 2 to 3 seconds while pushing down on the canister 4. Hold her breath for 10 seconds 5. Exhale slowly through pursed lips 6. Wait 60 seconds between each puff
A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply) 1. Use of analgesics will eventually lead to addiction 2. Each clients expression of pain may be different and individualized 3. Patient controlled analgesia (PCA) offers a constant level of opioids within the therapeutic range 4. Pain level and pain tolerance can be assessed using a scale from 0-10 5. The client will express the feeling of pain both verbally an nonverbally
2,3,4
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply) 1. Genetic predisposition 2. Hypercholesterolemia 3. Hypertension 4. Obesity 5. Smoking
2,3,4,5
A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? a. 6.3% b. 7.8% c. 8.5% d. 10%
6.3%
A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home?
A straight backed chair with an elevated seat
A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicates a need for clarification ? a. I will enjoy eating cantaloupe for my morning snack b. I can easily add baked potatoes to my diet c. Eating yogurt will be an new experience d. Adding pecans will be a change I can readily make
Adding pecans will be a change I can readily make
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? a. Initiating oxygen therapy b. Providing immediate rest for the client c. Positioning the client in high- Fowler's d. Administering a nebulized beta-adrenergic
Administering a nebulized beta-adrenergic
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching?
Aging, obesity, smoking
A nurse is caring for a client who is scheduled to have a magnetic resonance imaging scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? 1. An MRI scan is not distorted by movement, so you don't have to lie still 2. An MRI scan is a short procedure and should take no longer than 30 minutes 3. The MRI contrast dye contains iodine and can cause your skin to itch 4. An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner
An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? 1. Determine the time the client last received pain medication 2. Measure the client's vital signs, including temperature 3. Ask the client to rate her pain on a scale from 0-10 4. Reposition the client and offer her a back rub
Ask the client to rate her pain on a scale from 0-10
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? a. ausculatate lung fields b.Assess pulse and respirations c. Assess characteristics of her sputum d. Instruct to slowly exhale with pursed lips
Ausculate lung fields
A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?
Auscultate for wheezing
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of following should be the nurse's priority intervention?
Count the respiratory rate.
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light brown serious drainage. Which of the following actions should the nurse perform first? 1. Check the client's vital signs 2. Assess the clients pain level 3. Cover the wound with a moist, sterile gauze dressing 4. Obtain a culture and sensitivity of the wound drainage
Cover the wound with a moist, sterile gauze dressing
A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? a. Place the client in a supine position postoperatively b. encourage ambulation once fully awake c. Offer the client ice cream postoperatively d. instruct the client not lift over 4.5 kg
Encourage ambulation once fully awake
A nurse is caring for a client who has COPD. The client tells the nurse, " I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following action should the nurse take to help this client with tenacious bronchial secretions? 1. Maintaining a semi-Fowlers position as often as possible 2. Administering oxygen via nasal cannula at 2 L/min 3. Helping the client select a low-salt diet 4. Encouraging the client to drink 2 to 3 L of water daily
Encouraging the client to drink 2 to 3 L of water daily
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident 3 weeks ago. Which of the following foals should the nurse include in the client's rehabilitation program? 1. Establish the ability to communicate effectively 2. Compensate for loss of depth perception 3. Learn to control impulsive behavior 4. Improve left-side motor function
Establish the ability to communicate effectively
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching? a. I am to take my blood sugar reading after meals b. Insulin allows me to eat ice cream at bedtime c. A weight reduction program will make me hypoglycemic d. I give the insulin injections in my abdominal area
I give the insulin injections in my abdominal area
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? 1. A weight loss program can decrease my LDL cholesterol level 2. Exercising regularly will increase HDL cholesterol levels 3. Adding foods containing omega-3 fatty acids to my diet can lower my risk 4. Increasing my intake of foods containing trans-fatty acids can lower my risk
Increasing my intake of foods containing trans-fatty acids can lower my risk
A nurse is reviewing the providers prescriptions for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take? a. administer an antacid b. Provide bulk forming agent c. Insert nasogastric tube d. Apply a truss
Insert a nasogastric tube
A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?
Muscle spasms
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following order when notifying the provider of this finding? 1. Obtain a venous duplex ultrasound 2. Obtain impedance plethysmography 3. Monitor Homan's sign 4. Apply cold therapy to the affected leg
Obtain a venous duplex ultrasound
A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? a. bowel sounds b. Surgical dressing c. Temperature d. Oxygen saturation
Oxygen saturation
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/84 mm Hg places him in which of the following categories. 1. Within the expected reference range 2. Prehypertension 3. Stage 1 hypertension 4. Stage 2 hypertension
Prehypertension
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? a. Propranolol b. Theophylline c. Montelukast d. Prednisone
Propranolol
A nurse is planning a diet for a client who is iron deficient. which of the following foods high iron should the nurse include in the plan? a. oranges b. cashews c. Red meat d. Yogurt
Red meat
A nurse is teaching the partner of a client who had an acute myocardial infarction about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? 1. these tests help determine the degree of damage to the heart tissues 2. cardiac enzymes will identify the location fo the MI 3. These tests will enable the provider to determine the heart structure and mobility of the heart valves 4. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion
These tests help determine the degree of damage to the heart tissues
A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? 1. To convert atrial fibrillation to sinus rhythm 2. To dissolve clots in the bloodstream 3. To slow the response of the ventricles to the fast atrial impulses 4. To reduce the risk of stroke in clients who have atrial fibrillation
To reduce the risk of stroke in clients who have atrial fibrillation
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease. The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid? a. nonfat milk b. chocolate c. apples d. oatmeal
chocolate
A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment finding is a manifestation of pneumonia in the older adult client? a. Bradycardia b. Night sweats c. Confusion d. Narrowed pulse pressure
confusion
A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? a. Unequal pupils b.Hypertension c. Tympany upon chest percussion d. Confusion
confusion
A nurse is providing teaching for a client who has GERD about ways to manage his condition. Which of the following instructions should the nurse include? a. Sleep on your left side b. Drink milk to soothe your stomach c. Eat four small meals each day d. Wait to go to bed for 1 hour after eating
eat four small meals each day
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? a. Graham crackers b. 1 tsp c. 4 oz diet soda d. 4 oz skim milk
graham crackers
A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect? a. Decreased creatinine level b. Hyperkalemia c. Hypomagnesaemia d. Increased glomerular filtration rate
hyperkalemia
A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect? a. hypoglycemia b. nephropathy c. hyperglycemia d. ketoacidosis
hypoglycemia
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? 1. difficulty reading 2. inability to recognize his family members 3. Right hemiparesis 4. Aphasia
inability to recognize his family members
A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? 1. Insert a padded tongue blade into the clients mouth 2. Place a pillow under the clients head 3. Gently restrain the clients extremities 4. Apply a face mask for oxygen administration
place a pillow under the clients head
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? 1. Insert a tongue blade in the clients mouth 2. Place the client on his side 3. Hold the client's arms and legs from moving 4. Place the client back in bed
place the client on his side
A nurse is providing dietary teaching to a client who has chronic kidney disease. The nurse should instruct the client to limit which of the following nutrients? a. protein b. Calcium c. Calories d. Phosphorous e. Sodium
protein, phosphorous, sodium
A nurse is caring for a. client who has chronic kidney disease and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I just take the antacid magaldrate my husband has at home?" The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following? a. Serum phosphorus levels b. Serum potassium levels c. Serum magnesium levels d. Serum calcium levels
serum phosphorous levels
A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? a. decreased urine specific gravity b. Decreased Hgb c. Increased BUN d. Increased urine ketones
Increased BUN
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Dehydration b. Polyphagia c. Hyperglycemia d. Bradycardia
dehydration
A nurse is a assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? a. Fatty-stools b. Straw-colored urine c. Tenderness in the left upper abdomen d. Ecchymosis of the extremities
fatty-stools
A nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? a. I will be able to eat solid food when I wake up from anesthesia b. I will have a glass of juice in the morning of my surgery c. I understand what risks I can expect with this surgery d. I will take time to relax if I get nervous the night before surgery
i will be able to eat solid food when I wake up from anesthesia
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor for the client for which of the following manifestations of peritonitis? a. Hyperactive bowel sounds b. Nausea and vomiting c. Brady cardia d. Increased urinary output
Nausea and vomiting
A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? 1. Pigeon 2. Funnel 3. Kyphotic 4. Barrel
Barrel
A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the client to watch for and report which of the following adverse effects?
Black, tarry stools
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? ( Select all that apply) a. Polyuria b. Blurred vision c. Polydipsia d. Tachycardia e. Moist, clammy skin
Blurred vision, tachycardia, moist, clammy skin
A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following? 1. Cabbage 2. Cantaloupe 3. Green beans 3. White beans
Cabbage
The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? 1. Carvedilol 2. Fluticasone 3. Captopril 4. Isosorbide dinitrate
Carvedilol
A nurse is caring for a client who has suspected cholecystits. The nurse should expect the client's urine to appear which fo the following colors? a. Pale yellow b. Greenish-brown c. Red d. Dark and foamy
Dark and foamy
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? 1. Reposition the client 2. Administer the medication 3. Determine the location of the pain 4. Review the effects of the pain medication
Determine the location of the pain
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? a. Drink 3 L of fluid everyday b. Take 3,000 mg of vitamin C daily c. Restrict calcium intake to one serving per day d. Eat 12 oz of animal protein daily
Drink 3 L of fluid everyday
A nurse is caring for a client who had emphysema. Which of the following findings should the nurse expect to access in this client? (Select all that apply) - Dyspnea - Bradycardia - Barrel Chest - Clubbing of the fingers - Deep respirations
Dyspnea, Barrel Chest
A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? a. hypokalemia b. Metabolic alkalosis c. Hypercalcemia d. Elevated BUN
Elevated BUN
A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson Pratt drain? a. Measure the drainage every hour for the first 8 hr postoperative b. Secure the drain to the clients bed sheet c. Expel the air from the JP bulb after emptying to re-establish suction d. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze
Expel the air from the JP bulb after emptying to re-establish suction
A nurse is caring for a 6 month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infants pain level? 1. FLACC 2. Oucher 3. FACES 4. Visual Analog Scale
FLACC
A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis for diabetes mellitus? a. HbA1c 5.5% b. 2 hr blood glucose 170 mg/dL c. Fasting blood glucose 155 mg/dL d. Casual blood glucose 180 mg/dL
Fasting blood glucose 155 mg/dL
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
Flu-like symptoms and night sweats
A nurse on the day shift is preparing to change a client's total parenteral nutrition solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? a. Hang dextrose 10% in water until the TPN solution is delivered b. Saline lock the IV catheter after discontinuing the TPN soltution c. Hang the IV fat emulsion solution d. Call the provider for new TPN orders
Hang dextrose 10% in water until the TPN solution is delivered
A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching?
I can use either heat or ice to help relieve the discomfort
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? a. I drink at least 2 quarts of fluid every day b. The last time I voided it was painful and red-tinged c. My period ended 2 days ago d. I don't eat shellfish because it gives me hives
I don't eat shellfish because it gives me hives
A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions? a. I will lie on my left side to sleep at night b. I will lie on my right side to sleep at night c. I will sleep on my back with my head flat d. I will sleep on my stomach with my head flat
I will lie on my right side to sleep at night
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicated a need for further teaching? a. I will rest for a least 30 minutes before eating b. I will take my bronchodilators after meals c. I will eat five or six small meals each day d. I will choose foods that are not gas-forming
I will take my bronchodilators after meals
A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? a. I will wear sandals in warm weather b. I will put lotion between my toes after drying my feet c. I will check my feet every day for sores and bruises d. I'll soak my feet in cool water every night before I go to bed
I'll check my feet every day for sores and bruises
A nurse is caring for a client who is 1-day postoperative following a total hip athroplasty. It is 0830 and the client is schedule for physical therapy at 0900. Which of the following interventions should the nurse take?
Identify the client's pain level and medicate if needed
A nurse on a medical surgical unit is performing an admission assessment of a client who had COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? a. Respiratory alkalosis b. Increased anteroposterior diameter of chest c. Oxygen saturation leve l96% d. Petechiae on chest
Increased anteroposterior diameter of the chest
A nurse is performing pulmonary hygiene for a client who had pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this postion? a. Lateral segment of the left lower lobe b. Lateral segment of the right lower lobe c. Posterior segment of the right middle lobe d. posterior segment of the right lower lobe
Lateral segment of the right lower lobe
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? a. Have and eye examination once per year b. Examine your feet carefully everyday c. Wear compression stockings daily d. Maintain stable blood glucose levels
Maintain stable blood glucose levels
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism. The nurse should instruct the client to avoid which of the following unsafe actions? 1. Elevating her feet 2. Massaging her legs 3. Flexing her ankles 4. Ambulating soon after surgery
Massaging her legs
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? a. Give the client 15 to 20 g of carbohydrate b. Monitor the client for hypoglycemia c. Complete an incident report d. notify the nurse manager
Monitor the client for hypoglycemia
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity. 1. I am gaining weight 2. I am constipated 3. My vision seems yellow 4. My tongue is red and beefy
My vision seems yellow
A nurse is caring for an adolescent client who has a long history of diabetes melliutus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? a. NPH insulin b. Insulin glargine c. Insulin detemir d. Regular insulin
Regular insulin
A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? 1. Blood pressure 2. Apical heart rate 3. Respiratory rate 4. Temperature
Respiratory rate
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? a. Review the clients electrolyte values b. Check the client's perianal skin integrity c. Investigate the client's emotional concerns d. Obtain a dietary history from the client
Review the client's electrolyte values
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? a. Maintenance of ideal weight b. Annual influenza immunization c. Smoking cessation d. Regular moderate exercise
Smoking cessation
A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in. the teaching? 1. Expect ringing in your ears 2. Take the medication with food 3. Store medication in the refrigerator 4. Monitor for weight loss
Take the medication with food
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? 1. The client needs total nursing care 2. The client is alert and oriented 3. The client is in a deep coma 4.Indicates stable neurologic status
The client needs total nursing care
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? a. the client who has been NPO since midnight for endoscopy b. The client who has left-sided heart failure and has a brain natruiretic peptide level of 600 pg.mL c. The client who has end-stage renal failure and is scheduled for dialysis today d. The client who has gastroenteritis and is ferbrile.
The client who has gastroenteritis and is febrile
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? 1. Vital sign measurement 2. The clients self-report of pain severity 3. Visual observation for nonverbal signs of pain 4. The nature of invasiveness of the surgical procedure
The clients self-report of pain severity.
A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? a. Renal function is reestablished b. BUN and creatinine levels decrease c. Urine output is less than 400 mL per 24 hr d. The glomerular filtration rate recovers
Urine output is less than 400 mL per 24 hr.
A nurse is planning care for a client who is to start receiving total parenteral nutrition . Which of the following interventions should the nurse include in the plan of care? a. Use a 1.2 micron filter when infusing TPN with fat emulsions added. b. Allow for 18 hr for the lipids to infuse when not mixed with the TPN solution c. Change the TPN solution after 36 hr d. Change the TPN tubing every 48 hr
Use a 1.2 micron filter when infusing TPN with fat emulsions added
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme linked immuosorbent assay results, it will use which of the following tests to confirm the diagnosis?
Western blot analysis
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident. Which of the following parameters should the nurse use first in order to assess the clients pain level? 1. pulse and blood pressure findings 2. behavioral indicators and effect 3. scheduled treatments and client illness 4. a self-report pain rating scale
a self-report pain rating scale
A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition at home. Which of the following instructions should the nurse include? a. Keep the TPN refrigerated when not in use b. Infuse 10 percent dextrose and water if the solution runs out c. Shake the TPN bag with fat emulsion if precipitate is present d. Stop using TPN once weight gain is achieved e. Maintain TPN infusion rate when behind schedule
a,b,e
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? a. Nausea b. Dysphagia c. Agitation d. Hypotension
agitation
A client who has a history of myocardial infarction is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? 1. analgesic 2. anti-inflammatory 3. anti-platelet aggregate 4. antipyretic
anti-platelet aggregate
A nurse is teaching a client about strategies to manage gastroesophageal reflux disease. Which of the following statements should the nurse include? a. elevate the head of your bed by 18 inches b. Avoid snacking between meals c. Limit foods that are high in fiber d. avoid eating 2 to 3 hours before bedtime
avoid eating 2 to 3 hours before bedtime
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? a. include foods high in starch and proteins b. include foods high in fiber c. avoid foods high in fat d. avoid foods high in sodium
avoid foods high in fat
A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury? a. Atorvastatin b. Metformin c. Nitroglycerin d. Carvedilol
metformin
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? 1. Obtain a venous duplex ultrasound 2.Obtain impedance plethysmography 3. Monitor Homan's sign 4. Apply cold therapy to the affected leg
obtain a venous duplex ultrasound
A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? a. oranges b. cashews c. red meat d. yogurt
red meat
A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? a. shallow respirations b. hypertensive crisis c. diarrhea d. hyperreflexia
shallow respirations
A nurse is in a client's room when the client begins having a tonic- clonic seizure. Which of the following actions should the nurse take first? 1. Turn the client's head to the side 2. Check the clients motor strength 3. Loosen the clothing around the clients waist 4. Document the time the seizure began
turn the clients head to the side
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? a. Vitamin b12 injections b. Iron supplements c. Blood transfusions d. Vitamin B6 supplements
vitamin b12 injections
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following should the nurse expect? a. hyperactive reflexes b. extreme thirst c. weak, irregular pulse d. hyperactive bowel sounds
weak, irregular pulse
