ATI

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? A. Activate alarm B. Extinguish the fire C. Evacuate the client D. Confine the fire

C

A home health nurse is performing a follow up visit for a client wh ohas a gastrostomy tube through which they receive intermittent feedings and meds. The client has developed diarrhea. Which finding should the nurse identify as a possible cause? A. Client is receiving formula at room temperature. B. The feedings infuse at a slow, continuous drip over 8 hr each night. C. The client's caregiver washes out the feeding bad with warm water once every 24 hr. D. The client's caregiver flushes the tubing with water before and after administering meds.

C

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? A. I'll get a blood sample from you and send it for a screening test. B. Beginning age 60, you should have a colonoscopy. C. You should have a fecal occult blood test every year. D. The recommendation is to have a sigmoidoscopy every 10 years.

C

A nurse is caring for a client who is post operative. When the nurse prepares to change her dressing, she says "Every time you change my bandage, it hurts so much." Which of the following is the priority? A. Encourage deep breaths during dressing change. B. Educate client about importance of the dressing change to precent infection. C. Assist client to a comfortable position for the dressing change. D. administer pain meds 45 mins prior to change.

D

A nurse has accepted a verbal prescription for "three tenths of a milligram of levothyroxine STAT" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's med record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

b

A nurse is preparing to administer 0.9% NaCl 750 mL IV to infuse over 7 hours. The nurse should set the infusion pump to deliver how many mL / hr?

107 mL/hr

A nurse is preparing a heparin infusion for a client who was admitted to the facility with DVT. The prescription reads: 25,000 units of heparin in 0.9% NaCl 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

8 mL/Hr

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. When descending stairs, I will first shift weight to the right leg. B. I should place crutches 12 inches in front and to the side of each foot. C. As I sit down, I will hold one crutch in each hand. D. I will make sure the shoulder rests are snug against my armpits.

A

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Select all that apply. A. check cords for frays/tearing B. Keep unit at least 4 feet away from a gas stove. C. Consider purchasing a generator for power backup. D. Observe for hypoxia E. Select synthetic clothing/bedding

A C D

a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? Select all that apply. A. Assist with bed bath B. Measure BP C. Test swallowing ability by providing thickened liquids. D. Use communication board to ask what they want for lunch. E. Irrigate indwelling catheter.

A, B, D

A nurse is caring for a client who has TB. Which of the following actions should the nurse take? Select all that apply. A. Place the client in a room with negative air flow. B. Wear gloves when assisting with oral care. C. Limit each visitor to 2 hour increments. D. Wear surgical mask. E. Use antimicrobial sanitizer for hand hygiene.

A, B, E

a nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert at 45º angle B. Place arm in dependent position C. Shave excess hair from site D. Initiate IV therapy with veins of the hand.

B

a nurse is assessing an older adult risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? select all that apply A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctiva D. Visual fields E. Visual acuity

B, D, E

A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting

D

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following should nurse expect? A. Numb extremities B. Bradycardia C. Positive Chvostek's sign D. Abdominal cramping

D

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D

What transmission precautions is pharyngeal diphtheria?

droplet

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer SQ. Determine correct order of steps for this procedure.

1. Inject 10 units of air into bottle of NPH insulin. 2. Inject 5 units of air into bottle of regular insulin. 3. Withdraw correct dose of regular insulin. 4. Withdraw amount of NPH insulin.

To obtain an accurate blood pressure measurement, the nurse should inflate the cuff

30 mm Hg beyond the point at which the nurse was last able to palpate the pulse.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. Ausculate lung sounds B. Measure urine Output C. Monitor BP D. Monitor electrolyte levels

A

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragus B. Pack small piece of cotton deep into ear canal. C. Move client's auricle down and back toward her head. D. Tilt the client's head backward for 5 min.

A

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? A. Droplet B. Airborne C. Contact D. Protective

A

A nurse in a surgical unit notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Ensure sterile nondisposable items with ethylene oxide. B. Wrap monitoring cords with stockinette and tape them in place. C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medicaiton. D. Wear hypoallergenic latex gloves with powder.

B

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings thru an open system. which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30º C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol.

B

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? A. Drink a cup of hot cocoa before bedtime. B. Maintain a consistent time to wake up each day. C. Exercise 1 hour before going to bed. D. Watch a television program in bed before going to sleep.

B

A nurse is caring for a client who reports pain. when documenting the quality of the client's pain, the nurse should record what statement? A. I'm having mild pain. B. The pain is like a dull ache in my stomach C. I notice the pain gets worse after I eat. D. The pain is making me feel nauseous.

B

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? A. Describe procedure. B. Witness signature on consent form C. Inform client of alternatives. D. Tell the client which team members will assist with the procedure

B

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resusitation bag with 80% oxygen prior to procedure B. Select catheter half the size of the lumen. C. Place the end of the catheter in water soluble lube. D. Adjust wall suction to 170 mmHg

B

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site indicates infiltration. A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

C

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? A. Touch the face with a cotton ball. B. Apply a vibrating tubing fork to the client's forehead. C. Have the client stand with their arms at the sides and their feet together. D. Perform direct percussion over kidneys

C

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth everyday."Which of the following components of the prescription should the nurse verify with the HCP? A. Medication name. B. Route of administration, C. Medication dose. D. Frequency of admin

C

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place client in side lying position. B. Instill 15 mL of irrigation fluid in to catheter with each fluid C. Subtract amount of irrigant used from client's output. D. Perform the irrigation using a 20 mL syringe.

C

The nurse is caring for a client who has an indwelling catheter. Which of the following findings indicates that the catheter requires irrigation? A. Urine has an unusual odor. B. Urine specific gravity is 1.035 C. Bladder scan shows 525 mL of urine D. Urine is positive for ketones.

C

a nurse enters a client's room and finds her on the floor. The clients roommate reports the client was trying to get out of bed and fell over the side rail. Which statement should the nurse document? A. Incident report completed. B. Client climbed over side rail. C. Client found lying on floor. D. Client was trying to get out of bed.

C

a nurse is administering 1 L of 0.9% NaCl to a client who is post operative and has fluid volume defecit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Increased hemtocrit B. Increased RR C. Decrease HR D. Decrease cap refill

C

a nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing the old dressing. B. Warm the irrigation solution to 105 F. C. Cleanse the wound from center outward. D. Use a 20 mL syringe to irrigate.

C

a nurse is caring for a client who requires a 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. I had a BM, but was able to save the urine. B. I have a specimen in the bathroom from about 30 mins ago. C. I flushed what I urinated at 7 am and have saved all urine since. D. I drink a lot so I will fill up the bottle and complete the test quickly.

C

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? A. Hypotension B. Weak thready pulse C. Slow cap refill D. Distended neck veins

D

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of the assistive device? A. "This type of hearing aid does not allow for fine tuning of volume." B. I shouldn't have trouble keeping the hearing aid in place during exercise. C. I expect to hear a whistling sound when I first insert the aid. D. I will be sure to remove my hearing aid before the shower.

D

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? A. You should have an eye exam every 2 years B. You should receive a tetanus booster every 5 years. C. You should receive a shingles vaccine when you are 70 years old. D. you should receive a pneumococcal vaccine when you are 65.

D

A nurse is preparing to apply a pressure inury for a client who has a stage 2 pressure injury. which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? A. Seal unused meds from the facility in a plastic bag. B. Evaluate client's ability to self-administer meds. C. Report an identified discrepancy to Joint Commission. D. Compare prescriptions with meds received at facility.

D

a nurse is preparing to administer multiple meds to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? A. Dissolve each med in 5 mL of sterile water. B. Draw up meds together in a syringe. C. Push the syringe gently when feeling resistance. D. Flush tube with 15 mL of sterile water.

D