ATI #1
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?
I'll just sit here with you for a few minutes then
A nurse is caring for a client who is dying. The client says "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
I wonder if you are fearful of dying alone
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
Increased heart rate Increased blood pressure Increased respiratory rate
A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?
Instruct the client to tighten muscle groups for a short period, and then relax
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
It sounds like you're having a difficult time
A nurse is caring for a client on the med-surge unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
Explain the risk the client faces if she leaves the facility?
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up". Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Encouraging the client to drink 2-3 L of water daily
A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?
Silvery, white scales
A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following foods is a good source of high-quality protein?
Soybeans
A nurse reports an incident of suspected elderly abuse. One of the children of the elder becomes upset and demands to know the reason for the nurse's action. which of the following responses by the nurse is appropriate?
As a nurse, I am required by law to report suspected abuse
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which fo the following instructions should the nurse include?
Avoid lifting anything heavier than 4.5kg (10lb) to 1 week
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
pH: 7.25, HCO3-: 19, PaCO2: 30
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?
Protein
A client is admitted to the emergency room with a respiratory rate of 7/min. ABG reveal the following values. Which of the following is an appropriate analysis of the ABG? pH: 7.22 PaCO2: 68 Base excess: -2 PaO2: 78 Saturation 80% Bicarb 26
respiratory acidosis
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client?
Dyspnea Barrel chest Clubbing of the fingers
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
Eating a high fiber diet will reduce my risk for developing skin cancer
A nurse is caring for a client who is taking lisinopril. which of the following outcomes indicates a therapeutic effect of the medication?
Decreased Blood pressure
A nurse is instructing a group of clients regarding nutrition. Which of the following is a good source of omega-3 fatty acids that the nurse should include in the teaching?
Fish
A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide. Which of the following statements by the nurse best describes the action of glipizide?
Glipizide stimulates your pancreas to release insulin
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 caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
Obtain a pair of slipper-socks for the client
A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer?
Overexposure to ultraviolet light previous skin injury genetic predisposition
A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?
Prepare to administer acyclovir
A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects?
Adrenocortical insufficiency
A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a health BMI?
A client with a weight of 150lb and height of 68 inches
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
Impaired tissue perfusion
A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan?
Many clients experience pain the affected area for weeks after the lesions have resolved
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion?
More difficulty seeing due to a greater sensitivity to glare Decreased cough reflex Decreased bladder capacity Dehydration of intervertebral discs
A nurse is caring for a client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone order on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?
Regular insulin
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 members 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 instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates?
Rice, potatoes, oranges
A nurse us assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?
Serosanguineous
A nurse is teaching a client who has psoriasis about possible treatment options. Which of the following treatments should the nurse include in the teaching?
Tar preparation Corticosteroids Ultraviolet light therapy
A nurse is instructing a group of adult client about nutrition. The nurse should include which of the following as the recommended amount of vegetables servings per day?
2 1/2 cups
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia?
Blurred vision Tachycardia Moist, clammy skin
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
Check the catheter tubing for kinks or twisting
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
Cigarette smoking
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 coworker puts an arm around a nurse and says "I bet you are a great lover." Which of the following is an appropriate response by the nurse
Speaking to me like that makes me uncomfortable
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
Sputum culture for acid-fast bacillus
A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?
The client holds his breath for 10 sec after inhaling the medication
A nurse is caring for a client who has heart failure and a prescription for digoxin 125mcg PO daily. Available is digoxin PO 0.25 mg/tablets. How many tablets should the nurse administer per dose?
0.5
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. after administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
0745
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is private, negative-pressure airflow room; room 212 is a semi private, positive pressure airflow room; 214 is a negative pressure, semi private room and room 216 is a private, positive pressure airflow room. To which of the following rooms should the nurse asking the client?
208
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?
A client who sustained a head injury and is having periods of confusion
A nurse is assessing a lesion on a client who has a basal cell carcinoma. The nurse should expect which of the following findings?
A pearly, shiny nodule
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Lock the wheels of the bed and the wheelchair
A nurse is assessing a client who reports a nevus that has increased in size and an irregular shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses?
Malignant melanoma
A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?
A small, translucent papule with rolled borders
A nurse is caring for a client who has active pulmonary tuberculosis. The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
Have a client wear a mask
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?
Heparin does not dissolve clots. It stops new clots from forming
A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching.
I should apply sunscreen prior to going outside, even in the winter months
A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension. Which of the following statements by the client indicates an understanding for the teaching?
I will store the medication at room temperature
A nurse is providing dietary teaching to a client who has chronic kidney disease. The nurse should instruct the client to limit which of the following nutrients?
Protein Phosphorus Sodium
A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?
Prothrombin (PT)
A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?
Provide mittens for the client to wear at night
A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
Pull the curtain around the client's bed
A nurse is caring for a client who has a malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion?
Purplish in color
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?
The client will walk for 30 min 5 days a week