ATI Break Quiz 3
a nurse in the emergency department is assessing a client with heroin intoxication. which of the following findings should the nurse expect? -seizure activity -respiratory depression -hypersensitivity to pain -increased mental alertness
respiratory depression
a nurse is caring for a client whose surgeon informed him postoperatively that he has a metastasizing malignant neoplasm in the colon. which of the following statements by the client should the nurse identify as an indication that the client understands this information? -"i have cancer of the colon that has begun to spread" -"i have growths in my bowel that the doctor can treat easily" -"as long as my tumor doesn't get any bigger, i'll be okay" -"there is not much point in having more treatments"
"i have cancer of the colon that has begun to spread"
a nurse is providing teaching to a client who has a new prescription for buspirone. which of the following statements by the client indicates an understanding of the teaching? -"i need to watch for signs of dehydration" -"i need to have my kidney function monitored while taking this medication" -"i should take this medication on an empty stomach" -"i might not notice the effects of this medication for several weeks"
"i might not notice the effects of this medication for several weeks"
a client is scheduled for a lumbar puncture to rule out bacterial meningitis. she tells the nurse that she is fearful of becoming paralyzed from the needle pacement in her spinal column. which of the following responses should the nurse offer? -"let's not focus on the negative. let's focus on getting better" -"why are you feeling so anxious about this procedure" -"the needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends" -"your doctor is very skilled at this procedure. everything will be all right."
"the needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends."
A nurse in an acute mental health facility is caring for a client who has schizophrenia. the client asks the nurse, "can i vote in the upcominh presidential election?" which of the following responses should the nurse offer? -"why do you want to vote while you are in the hospital?" -"i wouldn't worry about voting right now" -"we can work together to find out how you can get a mail-in ballot" -"you'll have a lot more opportunities to vote after you get better"
"we can work together to find out how you can get a mail-in ballot"
the adult child of a client arrives to take his parent home from the facility following a colon resection. the client's son tells the nurse, "i don't know how i am going to take care of my mom now." which of the following responses should the nurse make? -"a home health nurse will be stopping by tomorrow. if you have any questions, you can ask the nurse" -"your mother has been taught to care for the colostomy independently" -"what part of your mother's care are you concerned about?" -"your job is quite simple. i'll make sure that the colostomy bag is clean before your mother leaves"
"what part of your mother's care are you concerned about?"
a nurse is providing teaching to a client who has type 2 diabetes mellitus. the client states, "i eat pasta every day. i can't imagine giving it up." which of the following responses should the nurse provide? -"let's discuss this with your doctor; giving up daily pasta may not be necessary" -"is there another favorite dish you can substitute?" -"you don't have to give up pasta; just adjust the amount you eat" -"you can use no-added-salt tomato products on your pasta"
"you don't have to give up pasta; just adjust the amount you eat"
a nurse is palnning care for a client who is postoperative following a gastrectomy. which of the following strategies should the nurse include to help prevent dumping syndrome? -have the client drink plenty of water with meals -eliminate simple sugars and sugar alcohols from the client's diet -limit the client's intake to 2 meals per day -offer the client meals that are low in protein or protein-free
eliminate simple sugars and sugar alcohols from the client's diet
a nurse is observing the behavior of a 2-year-old child. which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? -playing a simple game with another child -engaging in play near other children -sharing crayons with another toddler -jumping on 1 foot without help
engaging in play near other children
a nurse is providing education for the parent of a premature infant on interventions to promote optimal development. which of the following actions should the nurse instruct the parent to perform? -maintain bright lighting to enable close observation of the infant at all times -place the infant in a prone position with arms and legs extended -rouse the infant every 1-2 hr to provide auditory and visual stimualtion -provide kangaroo care for the infant
provide kangaroo care for the infant
a nurse is caring for a client who is unconscious. which of the following actions should the nurse take when providing oral care for the client? -test for the presence of the client's gag reflex -place the client in the supine position -use a firm toothbrush for tooth and gum care -use 2 gauze-wrapped fingers to hold the mouth open
test for the presence of the client's gag reflex
a charge nurse is planning a performance appraisal for a newly hired assistive personnel (AP). which of the following factors should the charge nurse take into consideration when planning a performance appraisal interview for the AP? -the performance appraisal interview should be friendly and informal -aside from the charge nurse, no one should have input regarding the AP's appraisal -a nursing administrator who does not know the AP should conduct the interview to promote fairness -the AP should have a copy of the performance standards before the appraisal interview
the AP should have a copy of the performance standards before the appraisal interview
a hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. which of the following pieces of information should the nurse include in the teaching? -toddlers will react to the parents' anxiety and sadness -toddlers view death as punishment for bad behavior -toddlers view death as permanent and irreversible -toddlers have a realistic concept of death
toddlers will react to the parents' anxiety and sadness
a nurse is preparing to administer an intramuscular injection to a young adult client. which of the following injection sites is the safest for this client? -vastus lateralis -dorsogluteal -deltoid -ventrogluteal
ventrogluteal
a nurse is providing discharge teaching to a client who is recovering from lung cancer. the provider instructed the client that he could resume lower-intensity activities of daily living. which of the following activities should the nurse recommend to the client? -sweeping the floor -shoveling snow -cleaning windows -washing dishes
washing dishes
a nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP) which of the following pieces of information should the nurse include in the teaching? -"PCP is sexually transmitted from person to person" -"you are most likely exposed to a contaminated surface such as a drinking glass" -"PCP results from an impaired immune system" -"you might have contracted PCP from a family pet"
"PCP results from an impaired immune system"
a nurse on a telemetry unit is caring for a client who had a myocardial infarction. the client states, "all this equipment is making me nervous." which of the following responses should the nurse offer? -"you won't need the equipment for very long" -"all of this equipment can be frightening" -"why does the equipment bother you?" -"let me tell you about what each machine each"
"all of this equipment can be freightening"
a nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIs). which of the following statements by the adolescent indicates a possible cause of the UTIs? -"i have bowel movements every 4 to 5 days" -"my mom taught me to wipe from front to back after going to the bathroom" -"i urinate every 2 to 3 hr during the day" -"i don't wear nylon underwear"
"i have bowel movements every 4 to 5 days"
a nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. which of the following statements indicates that the client understands the teaching? -"i'll call the doctor's office if my fingers get colder on the arm with the cast" -"if i have any itching under the cast, i'll try to reach the area with a cotton swab" -"if my fingers swell, i should put a heating pad on them and rest" -"if i have any tingling under my cast, i'll know i need to move my fingers more"
"i'll call the doctor's office if my fingers get colder on the arm with the cast"
a nurse is teaching a client who has asthma and a prescription for a fluticasone dry powder inhaler (DPI). which of the following instructions should the nurse include in the teaching? -"this medication should be taken at the start of your symptoms" -"rinse your mouth after administering this medication" -"shake the canister prior to administering this medication" -"this medication relaxes your airways to decrease your symptoms"
"rinse your mouth after administering this medication"
a nurse is caring for a group of clients on a medical-surgical unit. which of the following tasks should the nurse delegate to an assistive personnel (AP)? -collecting a stool specimen -providing instructions about using a spirometer -measuring oral intake -providing postmortem care -changing a sterile dressing
-collecting a stool specimen -measuring oral intake -providing postmortem care
a nurse is teaching a client who has chronic stable angina pectoris and a prescriptuon for sublingual nitroglycerin tablets. what sequence of instructions should the nurse tell the client to use if he experiences chest pain? -call 911 if the pain is not relieved -wait 5 min -place a tablet under the tongue -stop activityq
1. stop activity 2. place a tablet under the tongue 3. wait 5 min 4. call 911 if the pain is not relieved
a nurse is measuring the blood pressure of several clients. which of the following results is within the expected reference range for blood pressure? -142/85 mmHg -116/70 mmHg -130/76 mmHg -124/82 mmHg
115/70 mmHg
a nurse is caring for a group of clients on a medical-surgical unit. which of the following clients should the nurse attend to first? -a client who is receiving metoclopramide and reports diarrhea -a client who is receiving tamsulosin and reports feeling dizzy -a client who is receiving cephalexin and reports dyspnea -a client who is receiving erythromycin and reports epigastric pain
a client who is receiving cephalexin and reports dyspnea
a nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. the nurse should anticipate a prescripton for which of the following medications? -zoster vaccine -acyclovir -amoxicillin -infliximab
acyclovir
a nurse is caring for a client who has emphysema. the client has not stopped smoking cigarettes and states, "it's too late for me to quit." which of the following actions should the nurse take? -assist the client in finding local smoking-cessation assistance programs -tell the client that she will be all right after receiving medical care -informt the client that she must stop smoking or the provider wil not be able to care for her -advocate for the client by supporting her statement about not quitting
assist the client in finding local smoking-cessation assistance programs
a nurse in a provider's office is assessing a client who has GERD. when documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? -stair-climbing -bending over -sitting -walking2
bending over
a nurse in the emergency department is caring for a client who has a fruity breath odor, a dry mouth, and extreme thirst. which of the following assessments should the nurse make? -blood glucose level -pupillary reaction to light -deep tendon reflexes -liver function tests
blood glucose level
a nurse is caring for a client who has chronic glomerulonephritis with oliguria. for which of the following electrolyte imbalances should the nurse monitor? -hypercalcemia -hyperkalemia -hypomagnesemia -hypophosphatemia
hyperkalemia
a nurse is assessing an infant who has acute gastroenteritis. which of the following findings should the nurse identify as the priority? -decreased skin turgor -capillary refill 5 seconds -heart rate 150/min -dry mucuos membranes
capillary refill 5 seconds
a nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. the client states she slipped while getting out of bed. which of the following actions should the nurse take first? -complete an incident report -check the client for injuries -make sure the client has skid-free footwear -remind the client to ask for help when getting out of bed
check the client for injuries
after entering a client's room, a nurse notices the client has fallen on the bathroom floor. which of the following actions should the nurse perform first? -obtain support from another nurse -check the client for injuries -file an incident report -notify the client's provider
check the client for injuries
a nurse is caring for a 3-year-old child on a pediatric unit. the nurse should identify which of the following as an appropriate toy for the child? -jump rope -coloring book and crayons -checkers game -jack-in-the-box
coloring book and crayons
a nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. which of the following findings of PVD is a risk factor for ulceration of the extremities? -insufficient skin care -dehydration -immobility -impaired circulation
impaired circulation
a nurse is teaching a school-age child and his parents how to self-administer insulin. which of the following actions should the nurse take first? -allow a parent to administer an injection to the nurse -have the child teach the injection technique to the parents -have a parent administer the insulin injection to the child -demonstrate the injection technique on an orange
demonstrate the injection technique on an orange
a nurse is teaching a class of new parents about otitis media. which of the following manifestations should the nurse include in the teaching? -high-pitched sound heard in the ear -intermittent rapid eye movement -itching of the external canal -feeling of fullness in the ear
feeling of fullness in the ear
a nurse is caring for a client who is postoperative following a rhinoplasty. which of the following findings should the nurse report to the surgeon? -nasal edema -mouth breathing -periorbital ecchymosis -frequent swallowing
frequent swallowing
a nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? -urinary output -blood pressure -fundal consistency -pulse rate
fundal consistency
a nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. the infant is in the 90th percentile for height. which of the following findings should the nurse report to the provider? -heart rate 175/min -respiratory rate 26/min -blood pressure 88/40 mmHg -temperatyre 37.6 degrees Celsius (99.7 degrees Faherenheit)
heart rate 175/min
a nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. the newborn's 1-minute Apgar score was 9. the newborn's heart rate is 120/min, and his respiratory rate is 70/min. there are no indications of retractions, grunting, or nasal flaring. which of the following actions should the nurse take? -request a prescription for continuous positive airway pressure (CPAP) -initiate close observations of the newborn for indications of respiratory distress 0 -consult a respiratory therapist for chest physiotherapy -request an order for nitric oxide therapy
initiate close observation of the newborn for indications of respiratory distress
a nurse is assessing a newborn. for which of the following findings should the nurse notify the provider? -heart rate 136/min -acrocyanosis -mottling -respiratory rate 60/min
mottling
a nurse is caring for a client at 36 weeks gestation who has pre-eclampsia. which of the following findings should the nurse identify as the priority? -1+ proteinuria -blood pressure 140/98 mmHg -nonreactive nonstress test -fundal height 33 cm
nonreactive nonstress test
a nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. using this scale, which of the following parameters should the nurse evaluate? -incontinence -mental state -nutrition -general physical condition
nutrition
a nurse is preparing to give a change-of-shift report to the oncoming nurse. which of the following pieces of information should the nurse include? -routine care procedures for the client -biographical information -assumptions regarding relationships among the client's family members -objective measurements about the client's condition
objective measurements about the client's condition
a nurse is caring for a male client who reports a thick urethral discharge. which of the following actions should the nurse take? -contact the client's sexual partners -obtain a urethral specimen for culture -prepare to administer penicillin to the client -obtain blood for a rapid plasma reagin test
obtain a urethral specimen for culture
a nurse is caring for a client who has obsessive-compulsive disorder. which of the following actions should the nurse take when dealing with the client's ritualistic behaviors? -plan the client's schedule to allow time to perform rituals -verbalize disapproval of ritualistic behavior -place the client in protective isolation -increase stimuli in the client's immediate surroundings
plan the client's schedule to allow time to perform rituals
A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. which of the following interventions is the priority when planning care for this client? -promoting and maintaining client safety -discussing reasons for the client's behavior -helping the client recognize feelings -teaching the client alternative coping strategies
promoting and maintaining client safety
a nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. the nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. which of the following actions should the nurse take? -change the infusion tubing -flush the IV catheter -remove the IV catheter -apply a cool compress to the site
remove the IV catheter
a nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. which of the following findings should the nurse report to the provider immediately? -slurred speech -hemoglovin level of 9 g/dL -hematuria -pain level of 7 on FACES scale
slurred speech
a nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. which of the following findings should the nurse expect? -telemtry monitoring showing QRS complexes occuring at a rate of 74/min with no pacing spikes -premature ventricular complexes at 12/min -telemtry monitoring showing pacing spikes with no QRS complexes -hiccups
telemtry monitoring showing QRS complexes occuring at a rate of 74/min with no pacing spikes
