ATI

A nurse is performing at home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations to the nurse identify as proper safety protocol?

The client is non-acetone nail polish remover

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

droplet

A nurse is caring for a client who has 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 - Use antimicrobial sanitizer for hand hygiene

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

Check the client for injuries

Are nurses in Moneta client was having an exacerbation of her failure. And planning this clients care, when should the nurse initiate discharge planning?

During the admission process

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

Ensure the bladder of the blood pressure cuff's surrounds 80% of the clients arm

A nurse is assessing an adult client who has been in Mobil for the past three weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points

A nurse is preparing to administer multiple medications to a client who has an android feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water

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 except in the event of serious illness

The nurse providing discharge teaching to a client will self administering heparin. Which of the following instructions to the nurse include in the teaching?

Administer the medication into the abdomen

A nurse is administering 1 L of 0.9% sodium chloride to a client is postoperative and has fluid volume deficit. Which of the following changes to the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

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

Pad the clients wrist before applying the restraints

A nurse is talking with the partner of a client who has dementia. The clients 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 dress?

Role overload

A nurse is using an open irrigation technique to irrigate a clients enroll in urinary catheter which of the following actions should the nurse take?

Subtract the amount of arrogant used for the clients urine in output

A nurse has excepted a verbal prescription "for three tenths of a milligram of level thyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record?

0.3 mg

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over seven hours. The nurse should set the infusion pump to deliver how many milliliters per hour.

107

A nurse is calculating a clients food intake over the past eight hours which of the following items to the nurse plan to document on the client intake and I'll put record as 120 mL of fluid?

8 ounces of ice chips

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

A nurse is caring for a client who has a sodium level of 125 mEq per liter. Which of the following findings should the nurse expect?

Abdominal cramping

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

Acupuncture

A nurse is caring for a client who is postoperative period when the nurse prepares to change her dressing she says, "every time you change my bandage, it hurts so much." Which of the following interventions is the nurses priority action?

Administer pain medication 45 minutes before changing the clients dressing.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as a priority?

Auscultate lung sounds

A nurse is giving a change of shift report about a client admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward

A nurse under the clients room and find her on the floor. The client reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements of the nurse document about this incident?

Client found lying on the floor

A nurse is a marina client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?

Droplet

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 a 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

I flushed what I urinated at 7 AM and have saved all urine since.

A nurse is reviewing a clients medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription to the nurse verified with the provider?

Medication dose

Nurses in ministering and otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear

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

Reassure the client that this is an expected response to greif

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

SBAR

A nurse is lifting a bedside cabinet to move it closer to the client was sitting in 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

A nurse is caring for a client who has an NG tube and is receiving inner minute feeding through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30°

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 the airway. which of the following actions should the nurse take?

Turn the client every 1 hours.

A nurse is 1 million a client who has an of Domino one with a large amount of prevalent drainage. Which of the following types of transmission precautions to the nurse take?

contact precautions

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

Administer the medication with a needle at a 45° angle

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

Advocacy insurance clients safety, health, and rights

A nurse has just an certain NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube about the pylorus

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care the assist the client with feeding?

Arrange food in a consistent pattern on the clients plate

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

Ask another nurse to observe the medication wastage

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling

A nurse on a medical unit is preparing to discharge a client home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received while at the facility

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

Compare the client of medications of the providers prescriptions

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

Determine the reasons were the client is refusing to Use the incentive spirometer

A nurse is assessing a client received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of Fluid volume excess?

Distended neck veins

A nurse is preparing to administer 0.5 mL of 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

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 address in for a client who has a stage to pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid

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

I am available to talk should you change your mind

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an internal feeding through a gastrostomy tube

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is sleeping

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 clients vital signs every 15 minutes and report back in one hour. Which of the following actions should the nurse take next?

Notified nursing manager

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

People in middle adulthood often find satisfaction in nurturing and guiding young people.

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 clients arm in a dependent position

A nurse is reviewing evidence-based practice principles about administration of the 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 per minute

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings of the IV site for the nurse identify as indicating infiltration?

Skin blanching

A home health nurse is completing an Admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

The caregiver insists on remaining in the room

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 home health nurse is performing a follow up visit for a client who has a gastrostomy tube through which they receive Internet feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse indicate as a possible cause of the diarrhea?

The clients caregiver washes out the feeding bag with warm water once every 24 hours

A charge nurse is observing a newly licensed nurse prepare a sterile field for dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse place is the Of a bottle of sterile saline solution on the sterile field

A nurse is caring for a client who reports pain. When documenting the quality of the patient's pain in initial assessment, the nurse should record which of the following client statements?

The pain is like a dull ache in my stomach

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

Use a bed exit alarm system

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

Use the complete name of the medication magnesium sulfate

A nurse is planning strategies to manage 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 clients tracheostomy at home. Which of the following instruction should the nurse include in the teaching?

Use tracheostomy covers when outdoors

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity which of the following types of activities at the nurse recommend?

Walking briskly

Nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client request information about advance directives. Which of the following responses to the nurse make?

We can talk about advanced directive's, and I can also give you some brochures about them

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 have difficulty breathing?" Which of the following responses should nurse make?

We would give you oxygen through a tube in your nose

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

When descending stairs, I will first shift my weight to my right leg

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility?

Witness the clients signature on the consent form

A nurse is it Moreno client who has been having frequent tonic clonic seizures. Which of the following actions should the nurse add to the clients plan of care?

Wrap blankets around all four sides of the bed

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

check the IV tubing for obstruction

Nurse is Assessing an older adult clients risk for falls. Which of the following assessments should the nurse used to identify the client safety needs? SATA

- pupil clarity - visual fields - visual acuity

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

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

A mole with asymmetrical appearance

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar for repositioning

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following clients statement indicates an understanding of herbal use?

I can take echinacea to improve my immune system

A nurse is caring for a client who was recently started using a behind the ear hearing aid. Which of the following statements to the nurse identify as an indication that the client understands the use of the assistive device?

I will be sure to remove my hearing aid before taking a shower

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

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

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following question should the nurse take when assessing the quality of the patient's pain?

Is your pain sharp or dull?

A client who is postoperative is verbalizing pain as a two on a pain scale of 0 to 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 laying in bed

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day

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

Make sure the client wears a mask on outside her room if there's construction in the area.

A nurse is planning care for a client who has a stroke, resulting in aphasia and dysphasia. Which of the following tasks should the nurse assigned to an assistive personnel? SATA

- Assist the client with a partial bed bath - Measure the client's bP after the nurse administers an antihypertensive medication -Use a communication board to ask what the client wants for lunch

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions to the nurse implement for this client?

Wear a gown when caring for the client

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client partner wants the client to have a blood transfusion. Which of the following actions should the nurse take?

With hold the blood transfusion

Nurse is completing an admission assessment for a client reports vomiting and diarrhea for the past three days. Which of the following findings should the nurse expect?

Rapid heart rate

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

N95 Respirator

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen concentrator. Which of the following instructions to the nurse provide to the client and his family? SATA

-Check the cord routinely for phrase or tearing - Consider purchasing a generator for power back up -Observe for signs of hypoxia

There's a long-term care facility is caring for a client and dies during the nurse a chef. Identify the sequence in which the nurse should perform the following steps.

-Obtain the pronouncement of death from the provider. -Remove tubes and indwelling lines - Wash the clients body - Ask the clients family members if they would like to view the body -Place a name tag on the body

A nurse is caring for a group of clients on a medical surgical unit. And which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of her recent cancer diagnosis ask the nurse if she has cancer, and the nurse responds affirmatively

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPPA guidelines?

A nurse asked a nurse from another unit to assist with documentation for a client

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension

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 partner indicates effective coping?

I am relying on support from my family during this time

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 is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Place a client who has tuberculosis in a room with negative pressure airflow

A nurse is caring for a client who has a respiratory infection. Which of the following techniques to the nurse use when performing nasotracheal suctioning for the client?

apply intermittent suction when withdrawing the catheter

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ass to me. Which of the following methods should the nurse use as a psycho motor approach to learning?

Practice sessions

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures?

Apply and ankle foot orthotic device to the clients feet

A nurse is reviewing a clients fluid and electrolyte status. Which of the following financial the nurse report to the provider? -BUN 15 mg/dL - Creatinine 0.8 mg/dL - Sodium 143 mEq/L - Potassium 5.4 mEq/L

Potassium 5.4 mEq/L

A nurse in a surgical suite notes documentation on a clients medical record that he has a latex allergy. In preparation for the clients procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place

A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

A nurse is talking with an older adult client 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 response it should the nurse make?

Let's talk about how the change in your job status will affect you

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

You should receive a pneumococcal immunization every 10 years

A nurse in the clinic is caring for a middle of a 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 should the nurse make?

You should have a fecal occult blood test every year

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility which of the following documentation should the nurse include?

Current medications

A client who is non-ambulatory notifies the nurse that his trashcan is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take?

Evacuate the client

A nurse is performing a Rhomberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have a client stand with their arms at their sides and their feet together

A charge nurse is discussing the responsibility of nurse is caring for clients who have clostridium Dificil infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting

A nurse is assessing the clients readiness to learn about insulin self and ministration which of the following statements to the nurse identify as an indication that the client is ready to learn?

I can concentrate best in the morning

A nurse is caring for a client who has terminal liver cancer. Which of the following statements to the nurse identify as an indication that the client is experiencing spiritual distress?

What could I have done to deserve this illness