ATI Questions 4

A nurse is caring for a client who has a prescription for acetaminophen 325mg PO for an oral temp above 38.4 C. What Fahrenheit temp is this?

101.1 F

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document?

Average reflexes range on a scale of 0 to 4+. Active/expected are 2+

During a physical exam of a client, the nurse suspects strabismus. What test should the nurse use to gather more info?

Corneal light reflex

A nurse is reinforcing teaching for a client who has a new prescription for home oxygen therapy. What instruction should the nurse include?

Do not use any materials containing oil or alcohol when using oxygen

A nurse is caring for a client who is dehydrated. What lab value should the nurse expect?

Hct 55%

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. What action should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse is assisting with the initiation of seizure precautions for a client with a seizure disorder. What should the nurse have at the bedside?

Oxygen equipment

A nurse is caring for a group of client's who are receiving 02 therapy. Who should the nurse see first?

a client who has heart failure and is receiving 100% 02 via a partial rebreather mask

A nurse is evaluating a client for conductive hearing loss. Using the Rinne test, what result indicates that the client has conductive hearing loss of the left ear?

air conduction is less than bone conduction in the left ear

A nurse is caring for a client who has MRSA. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray?

don gloves when entering the room, and use hand sanitizer when exiting.

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. What factor is a source of this sound?

excessive wax in the ear canal

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The guard asks the nurse about the client's HIV status. What should the nurse do?

instruct the guard to ask the inmate

A nurse is caring for a client who is dehydrated. An insensible fluid loss of 500 to 600mL occurs through which organ?

skin

A nurse on a med-surg unit is washing her hands prior to assisting with a surgery. What is correct?

the nurse washes with her hands held higher than her elbows

A nurse is preparing to administer an intramuscular injection to a client who is overweight. What site should the nurse select?

the side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is post-op following a vaginal hysterectomy and asks for a drink. Her post-op diet prescription reads "clear liquids; advance diet as tolerated" What response should the nurse make?

"I am going to listen to your abdomen"

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. What statement indicates understanding?

"I will clip each suture close to the skin and pull it through the other side"

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care"

A nurse is reinforcing teaching with a client about how to use an albuterol metered-dose inhaler. After removing the cap and shaking the canister, in what order should the nurse instruct the client?

1. Hold the mouth piece 1 to 2 in infront of your mouth 2. tilt your head back slightly and open your mouth wide 3. depress the canister while taking a slow, deep breath 4. hold your breath for 10 seconds

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating is what? Select all that apply

Stabilizing the position of the tube Preventing aspiration of secretion Preventing air leaks

A nurse is caring for a client who has mixed aphasia. What strategy should the nurse use?

ask simple, short questions

A nurse is collecting data from a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. What eye disorder is this?

glaucoma

A client who has which of the following devices can safely undergo an MRI?

hearing aids b/c they can be removed

A nurse is collecting data from a client who reports nausea and vomiting for 2 days. What finding indicates fluid volume deficit?

increased HR

A nurse is caring for a client who requires a protective environment. What precaution should the nurse take?

make sure the client wears a mask when outside his room