NUR 204: ATI Exam A

A nurse is preparing to instill ear drops to a 3-year-old child. Which of the following techniques should the nurse use? A. Pull the auricle down and back B. Pull the auricle down and out C. Pull the auricle up and back D. Pull the auricle up and out.

A. Pull the auricle down and back.

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for insertion of the suppository? A. Sim's position B. Prone position C. Lying on the right side D. Supine

A. Sim's position

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? A. Administer another nitroglycerin tablet. B. Initiate peripheral IV. C. Call the Rapid Response Team. D. Obtain an ECG.

A. Administer another nitroglycerin tablet.

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? A. "The spacer increased the amount of medication delivered to the oropharynx." B. "The spacer increases the amount of medication delivered to the lungs." C. "Inhale rapidly using the spacer with the MDI." D. "Cover exhalation slots of the spacer with lips when inhaling."

B. "The spacer increases the amount of medication delivered to the lungs."

A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene? A. Creating a 6mm (1/4in) bleb in the intradermal space of the forearm B. Withdrawing the needle and massaging the site gently C. Stretching the skin tightly before injection D. Visualizing the tip of the needle under the skin

B. Withdrawing the needle and massaging the site gently

A nurse is providing teaching to a client who has a stable angina and a new prescription for transdermal nitroglycerin. Which of the following instructions should the nurse include? (Select all that apply.) A. Apply the patch to a hairless area and rotate sites B. Apply a new patch each morning C. Remove the patch for 10 to 12 hr daily. D. Apply the patch to dry skin and cover the area with plastic wrap. E. Apply a new patch at the onset of anginal pain.

A. Apply the patch to a hairless area and rotate sites B. Apply a new patch each morning C. Remove the patch for 10 to 12 hrs daily.

A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply.) A. Erythema B. Damp dressing C. Throbbing D. Warmth at insertion site E. Streak formation

A. Erythema C. Throbbing D. Warmth at insertion site E. Streak formation

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client report that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first? A. Stop the infusion. B. Call the client's provider C. Elevate the head of the bed. D. Auscultate the clients breath sounds.

A. Stop the infusion

A nurse is teaching a client who has asthma about how to use an albuterol in haler. Which of the following actions by the client indicates an understanding of the teaching? A. The client holds his breath for 10 seconds after inhaling the medication B. The client takes a quick inhalation while releasing the medication from the inhaler C. the client exhales as the medication is released from the inhaler. D. The client waits 10 min between inhalations.

A. The client holds his breath for 10 seconds after inhaling the medication

A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the nurse include in the instructions? A. Losartan 50.0mg, PO, QD B. Metformin 500mg, 1 tablet, PO, daily C. Desmopressin .1mL, intranasal, qd D. Zolpidem, 5mg PO, HS

B. Metformin 500mg, 1 tablet, PO, daily

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client? A. Transdermal patch B. Sublingual C. Suspended-release D. Topical ointment

B. Sublingual

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instruction should the nurse include in the teaching? A. Expect ringing in your ears. B. Take the medication with food. C. Store the medication in the refrigerator D. Monitor for weight loss.

B. Take the medication with food.

A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide? A. Take the medication on an empty stomach to decrease gastrointestinal irritation. B. Take the medication with orange juice to enhance absorption. C. Take the medication with milk. D. Rinse the mouth before taking the iron.

B. Take the medication with orange juice to enhance absorption.

A nurse is preparing to administer heparin subcutaneously to a client who has a deep vein thrombosis. Which of the following techniques should the nurse use? A. Cleanse the skin with an alcohol swab, insert the needle, aspirate, and inject the heparin B. Cleanse the skin with an alcohol swab, insert the needle, aspirate, inject the heparin, and massage the site C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. D. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, aspirate, and observe for bleeding.

C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding

A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following action should the nurse plan to take? A. Check the unit of blood with an assistant personal (AP). B. Premeditate the client with an antiemetic. C. Plan to infuse the unit of blood over 6 hr. D. Remain with the client for the first 15 minutes of the transfusion.

D. Remain with the client for the first 15 minutes of the transfusion.

A nurse is providing teaching to a client who has stabile angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include? A. Take 1 capsule at the onset of anginal pain B. Stop taking the medication if side effects are troublesome C. Take medication with meals D. Swallow the capsules whole

D. Swallow the capsules whole

A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin? A. The client follows a low-fat diet to reduce cholesterol. B. The client drinks a glass of grapefruit juice every day. C. The client sprinkles flax seeds on food 1 hr before taking the anticoagulant. D. The client uses garlic to lower cholesterol levels

D. The client uses garlic to lower cholesterol levels.

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take? A. Give the ordered KCL as prescribed B. Omit the KCL dose and document that it was not given. C. Hold the prescribed dose and notify the provider of the serum potassium level. D. Call the lab to verify the client's results.

A. Give the ordered KCL as prescribed

A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is contraindication for the client receiving the live attenuated influenza vaccine (LAIV)? A. The client's age is 62. B. The client smokes one pack of cigarettes a day. C. The client has a history of myocardial infarction. D. The client has recently traveled to Europe.

A. The client's age is 62.

A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching? A. "Clients who have glaucoma should not take warfarin." B. "Clients who have rheumatoid arthritis should not take warfarin." C. "Clients who are pregnant should not take warfarin." D. "Clients who have hyperthyroidism should not take warfarin."

C. "Clients who are pregnant should not take warfarin."

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following should the nurse identify as an indication that client understands the teaching? A. "I will remove the old patch and apply a new on in the same location." B. "I will press the patch securely in place on my forearm." C. "I will clean and dry the area before applying the patch." D. "I will use the lotion on irritated skin before applying a new patch in that area."

C. "I will clean and dry the area before applying the patch."

A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? A. Recap the needle. B. Place the cape on the bedside table and slide the needle into the cap. C. Wrap the needle with gauze. D. Dispose of the needle uncapped

D. Dispose of the needle uncapped.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.) A. Bounding pulse B. Pitting edema C. Swelling at the IV site D. Urine-specific gravity greater than 1.030 E. Crackles upon auscultation

A. Bounding pulse B. Pitting edema E. Crackles upon auscultation

A nurse is obtaining a medical history from a client who is to start warfarin therapy and currently uses herbal supplements at home. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin? A. Feverfew B. Black cohosh C. Echinacea D. Flaxseed

A. Feverfew Rationale: The nurse should instruct the client to avoid taking feverfew while taking warfarin because it will increase the anticoagulant effect.

A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide? A. Wash the affected area with soap and water before applying cream. B. Increase intake of fluids while using this medication. C. The medication might cause temporary blurred vision. D. Apply the cream to large areas around the infection

A. Wash the affected area with soap and water before applying cream

A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client's history, the client tells the nurse that she takes the herb feverfew for migraine headaches. Which of the following actions should the nurse take? A. Tell the client that she should take over-the-counter analgesic instead. B. Explain to the client that she should not take this herb while she is pregnant. C. Ask the client why she would take an herb during pregnancy D. Suggest that the client ask her herbalist within the next few weeks about taking it while pregnant.

B. Explain to the client that she should not take this herb while she is pregnant

A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? A. Omeprazole B. Vancomycin C. Ondansetron D. Diphenhydramine

B. Vancomycin Rationale: an antibiotic

A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take? A. Use a 22-gauge needle to inject the medication. B. Use a 1-inch needle to inject the medication. C. Inject the medication into the abdomen above the level of the iliac crest. D. Massage the injection site after administration of the medication

C. Inject the medication into the abdomen above the level of the iliac crest

A nurse withdraws morphine 2 mg from a 4-mg/mL vial to inject IM for a client. Which of the following actions should the nurse take for wasting the excess medication? A. Place the excess medication in the sharps container. B. Save the excess medication for the next administration. C. Return the excess medication to the secure cabinet. D. Have the second nurse witness the disposal of the excess medication.

C. Return the excess medication to the secure cabinet.

A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give? A. "Gradually decrease the dose once tolerance to the effect is reached." B. "Distribute the doses evenly throughout the day." C. "Take most of the daily dose at bedtime." D. "Take the medication with meals."

C. "Take most of the daily dose at bedtime."

A nurse is teaching a client who has diabetes mellitus and a new prescription of glimepiride. The nurse should teach the client to avoid which of the following drinks while taking this medication? A. Grapefruit juice B. Milk C. Alcohol D. Coffee

C. Alcohol

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? A. Planning B. Evaluation C. Assessment D. Implementation

C. Assessment

A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include? A. Discard the NPH solution if it appears cloudy. B. Shake the insulin vigorously before loading the syringe. C. Expect the NPH insulin to peak in 6 to 14 hr. D. Freeze unopened insulin vials.

C. Expect the NPH insulin to peak in 6 to 14 hr.

The nurse is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction. Which of the following interventions is priority? A. Collect a urine specimen. B. Administer 0.9% sodium chloride through the IV line. C. Stop the transfusion. D. Notify the blood bank.

C. Stop the transfusion.

A nurse at an ophthalmology clinic is proving 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? A. The medication is to be applied when the client is experiencing eye pain. B. The medication will be used until the client's introoccular pressure returns to normal. C. The medication should be applied on a regular schedule for the rest of the client's life. D. The medication is to be used approximately 10 days, followed by a gradual tapering off.

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

A nurse is preparing a presentation about echinacea to a group of clients. Which of the following information should the nurse include in the teaching? A. "Echinacea blocks testosterone receptors." B. "Echinacea boosts the immune system." C. "Echinacea is used to treat vertigo." D. "Echinacea increases the ability to walk further distances for clients who have PAD."

D."Echinacea increases the ability to walk further distances for clients who have PAD."