ATI trad 2

A nurse is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an intervention that the nurse should complete?

Pinch up a fold of skin to check for turgor

A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this as being done to resolve the following condition:

Diarrhea

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Discard the tablet and obtain another dose of medication

Diabetic ketoacidosis (DKA) is a life threatening condition caused by insulin deficiency. Select all symptoms that apply to DKA

Fruitey (acetone) breath Polyuria Nausea & vomiting May appear drunk

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

4.o

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

90 degrees

A nurse is preparing an in service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of 2/10 of a milligram. Which of the following should the nurse use to show appropriate transcription of this dosage?

0.2 mg

A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?

Abdominal bloating might occur

What is the process by which a drug is transferred from its site of entry into the body to the bloodstream?

Absorption

A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

Ask the client to agree to talk to the nurse whenever she feels the urge to exercise

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first:

Assess the client

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment

A nurse is preparing to administer a prepackaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

At the client's bedside before administration

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the orthodox jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher tray

A nurse is helping an older adult client ambulate in the hallway for the 1st time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

Check to see if the elbow restraint is in place for an infant who is post op from a surgical correction of cleft palate.

A nurse is caring for a client who is 1 day post op following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Chovstek's sign

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain

A nurse is caring for a client who is post op following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse is caring for a child who is 2 hr post op following a tonsillectomy. Which of the following fluid items should the nurse offer to the child at this time?

Crushed ice

A nurse is reviewing a client's prescription for 1,000 mL of D5W IV to infuse over 8 hr. What does D5W and IV mean?

Dextrose in 5% water & intravenous

Coronary artery disease (CAD) encompasses a group of diseases & conditions that affect the heart and blood vessels. Which diet is more recommended for patients with heart disease and HTN?

DASH diet

A vial is a plastic or glass bottle with a self-sealing stopper through which multi dose medications are removed. A nurse attempts to withdraw 3 cc from an open multi dose vial of saline. What documentation on the vial is necessary for use?

Date Time Initials of first user Expiration date

A nurse is preparing a presentation at a senior center about age related musculoskeletal changes. Which of the following changes should the nurse plan to include?

Decreased muscle mass

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Dysrhythmias

A nurse is caring for a pt who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation, SAA

Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further learning?

I will wear synthetic clothing and woolen socks when using my oxygen

A nurse is assessing an 85 yo client who has fluid overload. Which of the following findings should the nurse expect? SAA

Increased HR Increased BP Increased RR

A nurse is reviewing information about HIPAA w a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

Information about a client can be disclosed to family members at any time

A nurse is providing pre op teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in this demonstration?

Inhale slowly and evenly through her nose

A nurse is providing teaching for a client who has diabetes and a new prescription for insulin glargine. Which of the following instructions should the nurse provide regarding this type of insulin?

Insulin glargine has a duration of 18-24 hrs

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a hunchback curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?

Kyphosis

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Measure the circumference of both upper arms

Which domain of complementary and alternative therapies uses a variety of techniques designed to enhance the mind's ability to affect bodily function and symptoms?

Mind body medicine

A type of medication referred to semisolid preparation containing a drug to be applied externally: also called an unction

Ointment

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Provide the client w a diet high in protein

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed

A nurse is performing tracheostomy care for a client & suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction 2-3 times with a 60 second pause between passes

Allopathic medicine has been dominant for 100 years and has spearheaded remarkable advances in which of the following? SAA

Surgical interventions Diagnostic tools Pharmaceutical approaches

A nurse is providing teaching for a client on diuretic therapy & has a new prescription for potassium chloride (KCl) 20 mEq extended release PO daily. Which of the following instructions should the nurse provide about the new prescription?

Take the extended release tablets whole

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Tell the client to blow her nose gently before instillation

A nurse is caring for a client in a long-term care facility who is receiving enteral feeding via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate

A nurse is preparing to administer amoxicillin 100 mg PO every 8 hr to a toddler who weighs 20kg. The recommended dosage range is 20-25 mg/kg/day. Which of the following actions by the nurse is appropriate?

The nurse determines the prescription is insufficient to achieve the desired effect

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says: "go away, no one can help me." What should the nurse document?

Upon approaching the pt in the hall the pt stated "go away, no one can help me."

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Urine output of 175mL in the past 8 hr.

A nurse arrives for her shift and is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?

Verify that the amount of each medication she counts match the amounts of the inventory needed

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?

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

A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as a priority to address?

We buy the prescriptions we can afford