ATI
How many breaths should a client repeat every hour while awake to prevent atelectasis and pneumonia?
10 to 20 breaths
After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure?
2mm
How should a nurse document 2+ pedal edema?
A 4 mm indentation after applying and removing pressure
How should a nurse document 3+ pedal edema?
A 6 mm indentation after applying and removing pressure
A nurse is preparing to provide discharge teaching to an older adult client. Which of the following teaching considerations should the nurse include?
Allow frequent rest periods during teaching
How should a nurse document 4+ pedal edema?
An 8 mm indentation after applying and removing pressure
What should the nurse do if the client is losing consciousness and might fall to the floor?
Assist the client to the floor
What font size should the nurse use for older adult clients' written materials?
At least 14-point font size
A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?
Can you explain the concerns you are having right now?
A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?
Darken the lights
A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?
Evacuate the client from the room
A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?
Fowler's
A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?
Fowler's
How should the nurse open the airway to look for a foreign object if the client is choking and unable to speak or cough strongly?
Head-chin tilt
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?
Hold breath for 5 sec after goal volume is reached
A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.
Hypertension Diabetes mellitus Hyperlipidemia Tobacco smoking
A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?
I will be on a special shower table
How should a nurse instruct a client to breathe to reach the goal volume and prevent alveoli collapse?
Inhale slowly
A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?
Instruct the client to apply pressure to the inside corner of the eye after instillation
A nurse is providing teaching for a client following a below-the-knee amputation. Which of the following pieces of information should the nurse include in the teaching?
Instruct the client to lie prone in bed Sleep on a firm mattress Push down on the limb while in bed Wrap with elastic bandage to prep for prosthesis
What should the nurse do with small blisters on burn victims?
Leave them intact
Position to promote venous circulation and postural drainage
Lowering head of the bed with foot raised in a straight incline
Position not ideal for lung expansion in clients with dyspnea
Lying on their back
A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take?
Observe the client closely
What should the nurse do with large blisters on burn victims?
Open them
What action should the nurse take if the client is choking and unable to speak or cough strongly?
Perform an abdominal thrust
Best position for maximum lung expansion
Side-lying position
At what reading level should the nurse present discharge information?
Sixth to eighth-grade
A nurse is planning care for a client who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend?
Social worker
What should the nurse use to scrub and debride wounds of burn victims?
Soft washcloths or gauze
Tip for migraine headache: Avoid trigger foods
The nurse should instruct the client to avoid foods that can trigger migraines such as caffeinated beverages.
Tip for migraine headache: Avoid scents
The nurse should instruct the client to avoid scents that can increase the severity of a migraine.
Tip for migraine headache: Cool cloth on forehead
The nurse should instruct the client to place a cool cloth on the forehead to reduce migraine pain.
Why should a client breathe normally for short periods between breath cycles?
To reduce hyperventilation and fatigue
What temperature of water should the nurse use during hydrotherapy for burn victims?
Warm water
What type of paper should the nurse use for discharge instructions to avoid glare?
White or buff-colored paper with a matte finish
