ATI Fundamentals I questions #3

A nurse is caring for a client who has dysthymia. Which of the following techniques should the nurse use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following action should the nurse take?

Don clean gloves to remove the old dressing

A nurse is measuring at the blood pressure of several clients. Which of the following results within the expected reference range for blood pressure

142/85 116/70 130/76 124/82. Correct ANS: 116/70

A nurse is teaching the parent of a child who is to take 30 mL Of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct a parent to give the child?

2 tablespoons 15ml= 1 T= 30mL/ ? T. 15X= 30 X=2

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells ; procedure that carries risk therefore the client must sign a consent form prior to the procedure

A nurse is caring for a semi conscious client who has a small bore NG tube placed yesterday for the administration of internal feeding. Which of the following methods should the nurse used to verify correct to placement? Select all that apply

A. Auscultate injected air B. Verify the initial x-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Checked the aspirated fluid for a glucose B,C,D

A nurse in a urgent care center is caring for a 15-year-old client who symptom suggest a sexual transmitted infection (STI). The client parent is unavailable, but the clients grandmother accompanied the client to the clinic. Which of the following actions would the nurse take?

Ask the adolescent to sign the consent form

A nurse is caring for a client who is immobile. The nurse should recognize that and mobility places the client at risk of which of the following health alterations?

Decreased cardiac output

A nurse is caring for a client who has transferred to the surgical unit by stretcher from in the PACU. Which of the following action should the nurse perform immediately following the transfer?

Check the client vital signs

A nurse is teaching in assistive personnel AP how to obtain a capillary fingerstick blood sample. Which of the following actions by the AP requires a nurse to intervene?

Elevating the finger above the heart level

A nurse is auscultating a clients lungs and identifies rhonchi over the trachea and bronchi. Which of the following action should the nurse take?

Encourage the client to cough

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

Reduced level of consciousness

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings as an indication of infiltration?

Edema at the infusion

A nurse is collecting health history data from a client who has deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following action should the nurse take when working with the interpreter

Pace speech to allow time for the interpreter to convey the words

A nurse is responding to a patient question about his infants expected physical development during the first year of life. Which of the following pieces of information should the nurse include?

A 10 month old infant can pull up to a standing position

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults Primary prevention includes health education about disease prevention

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following action should the nurse take?

Establish client outcomes

A nurse is communicating with a group of clients about what to expect during the post operative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

Feedback is provided

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and ask for a drink. Her post operative diet prescription states "clear liquids: advance diet as tolerated." which of the following responses should the nurse make?

I am going to listen to your abdomen.

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client stated, "you are not putting the hose down my throat." Which of the following statements should the nurse make?

I can see that this is upsetting you

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously

A nurse is caring for a client who is unconscious. Which of the following action should the nurse take when providing oral care for a client?

Test for the presence of the clients gag reflex

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis in his on transmission based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with a client

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following action should the nurse take when selecting the specimen?

Place the stool specimen collection container in a biohazard bag

A nurse is caring for a client who is receiving a fluid infusion through a purple IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following action should the nurse take?

Remove the IV catheter; The client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV immediately. The nurse should then apply warm compresses to the site.

And a adolescent client in a outpatient mental health facility tells the nurse that he struggles to follow his treatment plan because his friends discourage him. Which of the following statements should the nurse make?

Tell me more about how your friends discourage you

A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following action should the nurse take?

Keep the client's bed linens dry

A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 cal more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 pounds)?

10 weeks ; 1 pound of body fat is equivalent to 3500 cal, consuming 500 extra calories each day for seven days would lead to a total of 3500 cal and a 1 pound gain per week. At the rate of 1 pound per week, the client would gain 10 pounds in 10 weeks

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

Supports self-determination; The nurse must honor the clients autonomy and ability to make healthcare decisions. The client has the right to refuse treatment: as the clients advocate, the nurse must support that right.