Adult health theory ATI practice quiz 1

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

schedule a follow-up visit by a home health nurse for dressing changes

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serous Purulent Sanguineous Serosanguineous

serogeneous

A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?

"Tell me what has been happening lately."

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Dysphagia

A nurse is caring for a young adult client who says he is experiencing increasing anxiety and the inability to concentrate. Which of the following is an appropriate response by the nurse?

"It sounds like you are having a difficult time."

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

"I will call for pain medication before the previous dose wears off."

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will walk briskly for 30 minutes before bedtime."

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

"Your husband should decide when more medication is needed."

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures? a. Nurses should focus on clients' cultures, rather than race, when providing care.b. Nonverbal communication is important in few cultures.c. Culture plays no role in determining when a client will seek medical care.d. Nurses should expect clients to adapt to the care provided regardless of culture.

A

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (select all that apply)

A client who has protein calorie malnutritionA client who has right sided heart failure and 4+ edema to the lower extremitiesA client who has postoperative delirium

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazards waste container

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?:

Give the client extra time to communicate needs

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?:

I see you have done some grooming today

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I watch television until I fall asleep at night

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

If I could lose about 50 pounds, I might stop having so many apneic episodes

A nurse is providing teaching to a client who take opioid medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates and understanding of the teaching

It might take up to 3 days for the medication to work

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

It's unfortunate that I have to be in the hospital for this treatment

An older adult client who lives alone tells a clinic nurse that he is unable to drive himself to the store and is afraid to cook on the stove. Which of the following community resources should the nurse recommend for this client?

Meals on Wheels

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently

A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?

Report the findings to a supervisor

A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BIPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client?

Respiratory therapist

A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?

Spending time sitting with the client

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain relief.Which of the following scenarios should the nurse document as the explanation for this situation?

The client developed a tolerance to the medications

A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?

Urinary Frequency

A nurse is planning care for an older adult client risk for developing pressure ulcers. Which of the following interventions should the nurse u se t o help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC count

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

apply the bag of 30 min at a time

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

respiratory rate

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personal (AP) while the client is sleeping should prompt the nurse to intervene?

flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder?

past history of childhood trauma