Final ATI Challenge

A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include?

Report any numbness or pain in your toes.

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?

"Keep your head up and straight."

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

"I need something for the pain in my eye. I can't stand it."

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I will clean the hearing aids with alcohol wipes."

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find I have cancer." Which of the following responses should the nurse make?

"I'm hearing that you are concerned that it might turn out that you have cancer."

A nurse is providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching?

"Rest frequently with your foot elevated."

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching?

"Without treatment, glaucoma can cause blindness."

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium?

3 oz canned salmon

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

Acute compartment syndrome

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Administer antibiotics to the client.

A nurse is caring for a client with a new diagnosis of Paget's disease. The nurse anticipates the provider will prescribe which of the following medications for this client?

Alendronate

A nurse is teaching a client about diagnostic vision tests. The nurse should include that which of the following tests is performed to diagnose macular degeneration?

Amsler grid

A nurse in an emergency department is caring for a client who has abdominal pain. A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include?

Increase daily exercise, increase fluid intake to 1500 ml daily, include probiotic foods in the daily diet are all correct.

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the technician to take x-rays, which of the following actions should the nurse take? (Select all that apply.)

Apply ice to the ankle is correct. Apply a compression bandage is correct Elevate the foot is correct

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?

Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.

A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include in the plan?

Avoid reading and writing.

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Bathe a client who had an amputation 2 days ago, assist a client to ambulate using a gait belt, feed a client who had a stroke 3 months ago are all correct

A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?

Renal stones

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

Inability to flex the toes of the casted foot

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Check the tubing for kinks.

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?

Checking capillary refill distal to the cast

A nurse is discussing a client's needs at an interdisciplinary team conference. The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care. Which of the nursing competencies is the nurse demonstrating?

Collaborator

A nurse is admitting a client who has hip fracture from recent fall at home. During the admission interview, the client's partner, who is frail, informs the nurse that they will be the client's caregiver upon discharge to home. Which of the following actions should the nurse take?

Consult case management

An occupational health nurse is discussing social determinants of health with staff members in the clinic. Which of the following does the nurse suggest the team use when searching for a non-profit resource to provide information about socioeconomic factors in the local community?

County health rankings

A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include?

Decreased ability to hear high frequency sounds

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

Difficulty starting the flow of urine

A nurse is discussing the revision of care plans with a newly licensed nurse. During which of the following steps of the Clinical Judgment Action Model (CJAM) should revisions take place?

Evaluating Outcomes

A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include?

Examine the testicles after a bath or shower.

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Fever

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?

Footboard

A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. Which of the following is an appropriate nursing intervention for this client at this time?

Have the client lie prone every 3 hr for 20 min at a time.

A nurse is caring for a client in the emergency department (ED). Select the 4 assessment findings on day 2 that require immediate follow-up.

Heart rate, edema, urine color, and pedal pulses are all correct

A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?

Hold the wrist at a 90-degree flexion.

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate from 18 to 44/min.

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema

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?

Infection

A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?

Initiate the use of a PCA pump for pain control.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes.

A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?

Isosorbide

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider? (Select all that apply.)

Jaw pain, blurred vision, and dysphagia

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?

Localized erythema

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

Macular degeneration

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

Monitor peripheral pulses in the affected extremity is correct. Examine the skin under the traction splint is correct Assess the temperature of the affected extremity is correct.

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?

Notify the surgeon.

A nurse is teaching a class about the roles and responsibilities of a case manager. Which of the following responsibilities should the nurse include?

Organizes client services following discharge

A nurse is caring for a client who has a prescription for a bone densitometry test. The nurse should identify that this test is used to assess for which of the following conditions?

Osteopenia

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

Pale pink

A nurse is teaching a client who has a fractured femur about fat emboli syndrome. Which of the following findings should the nurse include as a manifestation of a fat embolism?

Petechiae on the chest

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?

Pitting edema around the stump dressing

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Place suction equipment at the client's bedside.

A nurse is assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings?

Positive Phalen's sign

A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

Provide high-flow oxygen.

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Realign the client's position.

A nurse is teaching a newly license nurse about the function of red bone marrow. Which of the following information should the nurse include?

Red bone marrow produces white blood cells

A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Remind the client he might feel a constant urge to void.

A nurse is discussing Russell's traction with a newly licensed nurse. Which of the following statements about this form of traction should the nurse include in the teaching?

Russell's traction uses a sling under the knee to treat a fracture of the femur.

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Scatter rugs are present in the kitchen.

A nurse in a provider's office is providing teaching to a client about modifiable risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.)

Sedentary lifestyle, carbonated beverages, caffeine intake, and smoking tobacco products are all correct

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

Slight pain at the insertion site, serous drainage on the dressing, minimal edema around the pin are all correct

A nurse is performing discharge teaching with a client who has a wound that requires home health care. Which of the following team members should the nurse contact for consultation?

Social worker

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

Sudden pain relief

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take?

Talk slowly when speaking to the client

A nurse is teaching a client about how to instill eye drops. The nurse asks the client to explain the procedure in their own words. Which of the following types of teaching methods is the nurse using?

Teach back

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?

The medication should be applied on a regular schedule for the rest of the client's life.

A nurse on a medical-surgical unit is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should medicate the client for bladder spasms and irrigate the urinary catheter because the client is most likely experiencing an obstructed urinary catheter. Clots and tissue debris can pass through and block the flow of urine through the catheter. If the urinary catheter becomes obstructed, the nurse should irrigate the indwelling catheter to maintain the flow of irrigation and urine. The nurse should also medicate the client for bladder spasms that can occur as a result of obstruction of the catheter. The nurse should closely monitor the client's urine output to ensure that further obstruction to the catheter does not occur. The nurse should also frequently monitor the client's blood pressure and pulse to detect if bleeding is occurring because this is a risk factor of a TURP procedure. The nurse should monitor the client's hemoglobin and hematocrit levels and urine output because a complication of a transurethral resection of the prostate is bleeding from bladder spasms or movement. Also, the nurse should monitor the color, consistency, and amount of the client's output to detect any further obstruction and bleeding.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

This service began with the client's admission to the hospital.

A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?

Thyroid hormones

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Tugging on the affected ear lobe

A nurse is caring for a client in the provider's office. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

Upon recognizing and analyzing the client's cues of sudden loss of vision, increase in the number of floaters, seeing "bright flashing lights" and "a curtain coming down" in the right eye, the nurse's priority hypotheses is that this client is most likely experiencing a retinal detachment. It is important to generate solutions and take actions to prevent further detachment. The nurse should advise the client to have someone drive them to their eye doctor immediately and anticipate emergency eye surgery to repair the client's retina. Following surgery, the nurse should monitor the client for sudden eye pain and change in pupil size which can indicate complications and should notify the provider immediately.

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?

Vertigo

A nurse is providing teaching for a client who is postoperative following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for would healing?

Vitamin C

A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

Walking briskly

An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency care? (Select all that apply.)

Wrap the part in dry sterile gauze is correct. Put the severed part in a dry, waterproof plastic bag is correct. Elevate the extremity is correct Prevent contact of the severed part with water is correct

A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?

Wrap the residual limb with an elastic bandage in a figure-eight configuration.

A nurse is caring for a client. For which of the following interprofessional team members should the nurse anticipate a provider's referral? Select all that apply.

case manager, respiratory therapist, physical therapist, and occupational therapist

A nurse is caring for a client who is postoperative following repair of a right femur fracture. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

constipation, and oxycodone prescription

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report

having a decreased ability to perceive colors.

A nurse is caring for a client. A nurse is reviewing a client's medical record. Select the 3 findings that place the client at risk for hearing impairment.

occupation, furosemide, and naproxen

A nurse on a mental health unit is caring for a client whose plan of care includes learning work-related skills. Which of the following members of the interprofessional team is appropriate for this client?

occupational therapist