ATI FUNDAMENTALS 5
After assessing a client, the nurse documents 1+ pedal edema bilateral. This indicates that the nurse observed an indentation of which of the following depths after applying pressure?
2 mm
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. which of the following action should the nurse take?
Advise the client to perform range of motion exercises while in bed
A nurse is assessing a client for conductive hearing hearing loss. When using the Rinne test, which of the following results should the nurse identify as a indication that the client has conductive hearing loss of the left ear?
Air conduction is less then bone conduction into the left ear
A nurse on a telemetry unit is caring for a client who had a Myocardio infarction. The client states, all this equipment is making me nervous. Which of the following responses should the nurse offer?
All of this equipment can be frightening: This statement is therapeutic because the nurse is reflecting the clients statement. The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more.
A nurse is preparing to insert an indwelling urinary catheter. Which of the following instruction should the nurse give the client to ease the passage of the catheter through the urinary meatus?
Bear down; The nurse should ask the client to "bear down" gently as if to avoid. This can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter. This will ease the passage of the catheter through the urinary meatus.
A nurse is performing a focus assessment of a clients peripheral vascular. Which of the following location should the nurse palpate the posterior tibial pulse?
Below the medial malleolus
A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate a understanding of the teaching. select all that apply
C. Black beans D. Whole-grain bread
A nurse is caring for a client who has major fecal incontinence and reports irritation and the perineal area. Which of the following action should the nurse take first?
Check the client's perineum
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking?
Collecting and trading game cards
A nurse is preparing to administer medication's to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client bedside and perform which of the following verification procedures?
Compared the medical record number and name on the MAR with the clients identification band.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statement should the nurse share with the client?
Donate autoLogous blood before the surgery
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?
Encourage the client to listen to soft music
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces information should the nurse include in the teaching?
Granulation tissue fills the wound during healing
A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following action should the nurse take?
Hold the sterile drape above the wrist and away from the body
A nurse in a rehab facility is observing a assistive personnel AP help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse said the AP understand how to perform this task?
Locking the brakes on the bed and the wheelchair before moving the client
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following action should the nurse take first?
Lower the client to the floor: if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect the client from injury
A nurse in the emergency Department is assessing a client who has a deep, rapid respirations. Aerial arterial blood gas analysis includes the following values: pH 7.25, PACO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?
Metabolic acidosis
A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke in his coughing strongly. Which of the following action should the nurse take?
Observe the client closely: the nurse should observe the client closely at this point in time. As long as the client is able to cough strongly, the nurse does not need to intervene
A nurse is planning to document care provided for a client. Which of the following abbreviation should the nurse use?
PC for after meals
A nurse is leading in education session about disposing of bio hazardous materials. Which of the following instruction should the nurse include in the teaching?
Play soiled linen in a single lined bag: soiled linen should be placed in a single bag that is tightly secured to reduce the risk of transmission of microorganisms.
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following intervention should the nurse include in the plan of care?
Renew the prescription for the use of restraints within 24 hours
A nurse is preparing to administer a unit of packed RBCs to a client who when she discovers that the IV line is no longer patent. The IV team informed her that someone can come to initiate a In 30 minutes. Which of the following action should the nurse take?
Return the blood to the laboratory
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following action should the nurse take first?
Start chest compressions
A nurse is preparing to administer a Medication to a client. Which of the following a ministration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible?
Stat prescription
A nurse is providing discharge teaching for a client who has type two diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?
The dietitian will help you choose foods you are used to that also meet your Health needs.
A nurse is caring for a client who has a prescription for a chest restraint. Which of the following action should the nurse take?
Tie the restraint with a quick-release knot
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following question should the nurse asked to encourage discussion with the client?
What do you think caused the onset of your pain? Open ended question that allows the client to respond with a wide range of information by using more than a few words
A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet?
Whole milk: fat soluble vitamins A, D, E, and K require fatty substances or tissues to be dissolved and also require the presence of bile in the small intestine for absorption. Whole milk contains vitamin a and K and is often fortified with vitamin D
A nurse is teaching a client how to perform range of motion exercises of the wrist. To perform add duction, which of the following instructions should the nurse include?
With your palm facing down, move your wrist sideways toward your thumb
A charge nurse is teaching adult cardio pulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following action should the charge nurse teach as the first response in CPR?
Confirm unresponsiveness