ATI: Nurse Logic 2.0 (4 of 4)

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief?

Bargaining

A nurse is reinforcing a teaching to a client who has fractured ankle and is learning to walk up the stairs. Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait.

Bear weight on unaffected leg,transfer weight to crutches,advance unaffected leg,shift weight from crutches to unaffected leg,and go up stairs.

A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion?

Dullness

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed a dose of lorazepam preoperatively. Which of the following statement by the client indicates the medication has been effective?

I feel very relaxed now

A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform next?

Inspection

A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?

Lying on side

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?

Partial thickness skin loss

A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take?

Restrict fluid intake

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading?

Using a cuff that is too wide

A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?

¾ cup of canned tomato juice

A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle.

1 ½

A nurse in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose?

2 tsp

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the clients diet?

Grape juice, ice cream

A nurse is caring for a client who is receiving vancomycin for a beta hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?

Hearing loss

A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following?

Mood

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?

Sims

A nurse is preparing to transfer a client from a bed to a chair. The nurse should take which of the following actions to prevent a lift injury?

Stand close to the client

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While preforming a respiratory examination, the nurse hears the sound on the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds?

Stridor

A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes.

Toward the back of the neck

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways?

Vector