ATI Test 2 NSG 100

A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching? -"I can wear heels up to 2 ½ inches in height." -"I should sleep lying flat with my legs extended straight." -"I should increase high potassium foods in my diet." -"I should keep my weight within 10 percent of my ideal weight."

"I should keep my weight within 10 percent of my ideal weight."

A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification? -"I'll sit with my knees lower than my hips." -"I'll do exercises that strengthen my abdominal muscles." -"I'll wear low-heeled shoes from now on." -"I'll carry heavy objects close to my body."

"I'll sit with my knees lower than my hips."

A nurse is teaching a client who has a new prescription for docusate. Which of the following information should the nurse include in the teaching? -"Do not take this medication before bedtime." -"Take the medication with a full glass of water." -"Expect abdominal pain with this medication." -"Take this medication on an empty stomach."

"Take the medication with a full glass of water."

A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make? -"This test will tell your doctor how your kidneys are functioning." -"You'll have to ask your doctor." -"This test will tell if you have severe renal impairment or a disease." -"We'll find out if any medications, such as steroids, are interfering with your kidney function."

"This test will tell your doctor how your kidneys are functioning."

A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform? -Apply ice to the affected area. -Encourage range of motion of the foot. -Provide the client with a light snack. -Apply a compression bandage. -Elevate the foot.

-Apply ice to the affected area. -Apply a compression bandage -Elevate the foot.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? -Contractures of the extremities -Polyuria -Diarrhea -Crackles in the lungs -Pressure ulcers

-Contractures of the extremities -Crackles in the lungs -Pressure ulcers

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? -Excessive laxative use -Ignoring the urge to defecate -Inadequate fluid intake -Increased fiber in the diet -Increased activity

-Excessive laxative use -Ignoring the urge to defecate -Inadequate fluid intake

A nurse in a long-term care facility is caring for a client who had a stroke four weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? -A reddened area over the sacrum -Stiffness in the lower extremities -Difficulty moving the upper extremities -Difficulty hearing some types of sounds

A reddened area over the sacrum

A nurse is reviewing the lab results of an adolescent female client and notes WBC of 16,000/mm3 with increased immature neutrophils and normal monocytes. Which of the following is the appropriate analysis of the results? -An acute infectious process -Neutropenia -Allergic reaction -A resolving inflammatory process

An acute infectious process

A nurse on the med-surg unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? -An older adult client who is confused and has urinary frequency -A client with diabetes mellitus who has a leg ulcer -A client who is 1 day postoperative and has a nursing assistant helping him out of bed -An adolescent client who has a leg fracture and has been using crutches for the past 2 days

An older adult client who is confused and has urinary frequency

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength? -Ask the client how strong she feels today. -Ask the client to touch her finger to her nose. -Palpate the client's pedal pulses. -Ask the client to push her feet against the nurse's palms.

Ask the client to push her feet against the nurse's palms.

A clinical nurse educator is preparing an educational program about the transmission of MRSA in hospitalized clients. Which of the following should the nurse include in the program? -Place clients who have MRSA on airborne precautions. -MRSA can be effectively treated with an antiviral medication. -MRSA can live on the hands for 1 hr. -Bathe clients with water and chlorhexidine gluconate.

Bathe clients with water and chlorhexidine gluconate.

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the patient should the nurse anticipate because it is the most common reaction? -Identity crisis -Body image changes -Feelings of displacement -Loss of privacy

Body image changes

A nurse is caring for a older adult who has a UTI. Which of the following manifestations should the nurse identify as a finding specifically associated with this client? -Urinary retention -Low back pain -Incontinence -Confusion

Confusion

A nurse is teaching a client who has urolithiasis. The nurse should explain that which of the following conditions can increase the risk for renal calculi? -Protein in the urine -Dehydration -Iron deficiency -Obesity

Dehydration

A nurse is caring for a client who has BPH. The nurse should expect which of the following findings? -Urge incontinence -Critically elevated prostate-specific antigen (PSA) level -Difficulty starting the flow of urine -Painful urination

Difficulty starting the flow of urine.

While assessing a client who is receiving continuous IV therapy in his left arm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? -Discontinue the existing IV line. -Initiate a new IV line in the other extremity. -Apply a hot pack to the irritated site. -Determine if the client needs to continue IV therapy.

Discontinue the existing IV line

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? -Enforce strict bedrest for 3 days. -Apply fresh ice packs every 4 hr. -Elevate the affected leg on two pillows. -Apply antibiotic ointment to the wound with dressing changes.

Elevate the affected leg on two pillows.

A nurse is planning care for a female who has T4 spinal cord injury and is at risk for acquiring UTI's. Which of the following actions should the nurse include inn the client's plan of care? -Cleanse the perineum from back to front. -Obtain a prescription for an indwelling urinary catheter. -Encourage fluid intake at and between meals. -Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? -Trochanter roll -Sheepskin heel pad -Abduction pillow -Footboard

Footboard

A nurse is caring for a client who is two days post-op following an above the knee amputation. Which of the following is an appropriate nursing intervention for the client at this time? -Elevate the foot of the bed. -Encourage the client to sit up as much as possible. -Elevate the client's residual limb on a pillow. -Have the client lie prone every 3 hr for 20 min at a time.

Have the client lie prone every 3 hours for 20 minute at a time.

During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect? -Poor circulation -Pressure from the cast -Uneven cast drying -Infection

Infection

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? -Gloves -Goggles -Gown -Mask

Mask

A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an AP? -Perform wound irrigation for a client. -Evaluate pain relief for a client following the administration of a pain medication. -Measure and record intake and output for a client. -Teach a client about low-sodium foods.

Measure and record intake and output for a client

A nurse is caring for a client with C. Diff infection. Which of the following cleansing agents should the nurse use for hand hygiene? -Chlorhexidine -Povidone-iodine -Nonantimicrobial soap -Alcohol-based hand rub

Nonantimicrobial soap

A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? -Enuresis -Anuria -Nocturia -Oliguria

Oliguria

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder is distended and palpable . The nurse should associate these findings with which of the following types of urinary incontinence? -Stress incontinence -Urge incontinence -Overflow incontinence -Reflex incontinence

Overflow incontinence

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? -Changing the client's bed linens each day -Encouraging the client to consume a high-protein diet -Performing hand hygiene before, during, and after direct contact with the client -Placing the client in a room with positive-pressure airflow

Performing hand hygiene before, during, and after direct contact with the client

A nurse is assessing a client who has required strict bed rest for one week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate? -Needs assistance raising her legs to put on socks -Demonstrates mild dyspnea when eating breakfast -Performs active range-of-motion (ROM) exercises of all extremities -Develops fatigue when assisting with morning hygiene care

Performs active range-of-motion (ROM) exercises of all extremities

A nurse is planning care for a client who has C. Diff. Which of the following actions should the nurse plan to take? -Place a surgical mask on the client during transport. -Place the client on contact precautions. -Use an alcohol-based agent to perform hand hygiene when caring for the client. -Obtain a blood specimen to test for C. difficile.

Place the client on contact precautions.

A nurse is caring for a client who receives furosemide to treat HF. Which of the following lab values should the nurse monitor for this client due to this medication? -Potassium -Albumin -Cortisol -Bicarbonate

Potassium

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders? -Scoliosis -Kyphosis -Lordosis -Torticollis

Scoliosis

A nurse in a long term care facility is caring for an older adult who has dementia and begins to have episodes of urinary incontinence. After the provider determine no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? -Remind the client to tell the nurse when he has to urinate. -Use adult diapers to prevent frequent clothing changes. -Take the client to the bathroom every 2 hr. -Request a prescription for an indwelling urinary catheter.

Take the client to the bathroom every 2 hr.

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? -The client faces the direction of movement when sliding an object across the floor. -When pushing an object, the client moves his front foot backward. -When moving an object to one side, the client puts his weight on his heels. -The client stands with his feet close together when lifting an object.

The client faces the direction of movement when sliding an object across the floor.

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching? -The client should drink two to three 8 oz glasses of water each day. -The client should follow a high-fiber diet to establish bowel regularity. -The client should try to take in all of the required dietary fiber with the morning meal. -The client should be taught that the goal of therapy is to have a bowel movement daily.

The client should follow a high-fiber diet to establish bowel regularity

A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain? -Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club -Has ankle pain after running a 16 km (10 mile) race -Twisted his foot while running bases during a baseball game -Was hit by another soccer player on the field

Twisted his foot while running bases during a baseball game

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? -Urinary tract infection -Urinary incontinence -Urinary frequency -Urinary retention

Urinary tract infection

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? -Report the incident to the charge nurse. -Wash the area of the puncture thoroughly with soap and water. -Complete an incident report. -Go to employee health services.

Wash the area of the puncture thoroughly with soap and water.

A nurse is caring for a client who has MRSA in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? -Wear an N95 respirator mask. -Wear sterile gloves. -Wear clean gloves. -Wear protective eyewear.

Wear clean gloves