ATI Exit Exam 2023

1. Set a specific time frame for meeting performance goals 2. Ask the nurse supervisor to review to plan 3. Include the performance standard that the AP should meet

A charge nurse in a LTC is developing a performance improvement plan for an AP. Which of the following actions should the nurse take when developing the plans? (SATA-3)

"I will instruct the client to sit when putting on a pair of pants"

A charge nurse in a long term facility is reinforcing teaching w a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?

A social worker who's assigned an involuntary committed school-age client

A charge nurse is discussing confidentiality requirements w a newly licensed nurse when sharing a client's medical info. Which of the following individuals should the charge nurse identify as appropriate with whom to share client info?

Suctions for 30 seconds

A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

"I will document in the medical record the support nurse who assists w planning care for my clients"

A charge nurse is reinforcing teaching w a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Soiled dressings should be places in a biohazard trash receptacle

A charge nurse is reinforcing teaching w a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Explain medical terminology using basic one-syllable words

A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take?

Grapes

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

The client's electrical wires are running under the carpet

A home health nurse is caring for an older adult client who has RA. Which of the following findings should the nurse identify as a safety risk?

Countertransference

A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. The action by the nurse is an example of which of the following?

Tells a client he will lose his phone privileges if he does not take his medication

A nurse charge on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?

Place a pillow under the child's head

A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Appears greenish-brown in color

A nurse in a clinic is caring for a client who is at 40 weeks gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?

Neisseria gonorrhoeae

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

Blurred vision

A nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately?

"I try not to look at the scales on my body"

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should report to the provider?

Somnolence

A nurse in a providers office is reinforcing teaching about cigarette smoking w a client. Which of the following adverse effects should the nurse include in the teaching?

Verify the client's identity using a photograph

A nurse in an acute care setting is preparing to administer meds to a client. Which of the following actions should the nurse verify the client's identity?

Defining responsibilities

A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship?

Hallucinations

A nurse in an urgent care clinic, recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?

Reduced fat in stools

A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effects of the treatment?

Move clients to a room above ground with a few windows

A nurse is an assisted living facility is reinforcing teaching w staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

Ensure the weights are hanging freely

A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the following actions should the nurse take?

Avoid range of motion in the right arm

A nurse is assisting in the care of a client who has an AV shunt in his right arm. Which of the following actions should the nurse take?

Assist the client to empty her bladder

A nurse is assisting in the care of a client who is 8 hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (SATA-1)

An older adult client who has heart failure and lives alone

A nurse is assisting w d/c planning for a group of clients. Which of the following clients should the nurse recommend a home health referral?

Administer liquid supplements

A nurse is assisting w the POC for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

"That must have been a difficult experience for you"

A nurse is assisting w the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light" Which of the following is an appropriate response by the nurse?

Initiate contact precautions for the child

A nurse is assisting w the admission of a school aged child. Which of the following actions should the nurse plan to take? (Exhibit)

Remind the client to press the button when she feels fetal movement

A nurse is assisting w the care of a client who is at 37 weeks gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

Distended neck veins

A nurse is assisting w the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess?

Inform the adolescent that he might experience a headache

A nurse is assisting w the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Contact precautions

A nurse is assisting with the admission of a client who has VRE of the urine. Which of the following types of precautions should the nurse implement for this client?

Airborne

A nurse is assisting with the admission of a client who has pulmonary tb. Which of the following types of isolation precautions should the nurse include?

Nuchal rigidity

A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?

Determine the client's ability to use the call light

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement?

Elevate HOB 30 degrees

A nurse is assisting with the care of a client who has ICP followed a closed head injury. Which of the following actions should the nurse take?

Apply support stockings

A nurse is assisting with the plan of care for a client who is in the 3rd trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Changes her personal login password at random times

A nurse is attending an educational workshop about client confidentiality. Which of the following actions by the nurse indicates an understanding of the teaching?

Administering an iron injection z-track method

A nurse is caring for 4 clients. Which of the following situations require a signed consent form?

Bleach

A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill?

Irrigate the bladder with 20-30 ml of 0.9% sodium chloride irrigation

A nurse is caring for a client who has a continuous bladder irrigation following a TURP . The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

The client has a decreased level of energy

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

Use an adhesive remover to remove tape before applying dressing

A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take?

Veracity

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medication. Which of the following ethical concepts is the nurse exhibiting?

BUN 18 mg/dL

A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

The psychiatric staff not the FBI. They're here to help you

A nurse is caring for a client who has paranoid schizo and believes that she is being followed by FBI agents who are pretending to be the psychiatric staff. Which of the following responses should the nurse make?

Talk with the nurse about the need to support the client's decision

A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt w the charge nurse. Which of the following actions should the charge nurse take?

Allow the client to choose treatment times

A nurse is caring for a client who has terminal cancer. Which of the following instructions should the nurse take to promote the client's autonomy?

Incident report

A nurse is caring for a client who is 2 days postop. The client has a prescription for acetaminophen 300 mg w codeine 30 mg. 1 tablet every 3-4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client in which of the following locations should the nurse document this error?

Measure the duration of the seizure

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Lorazepam

A nurse is caring for a client who is experiencing alcohol withdrawal. which of the following medications should anticipate administering to prevent complications of withdrawal?

Semi-fowler's

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

Advanced practice nurse

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the idt should the nurse make a referral?

1. Obtain an aPTT level

A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider?

"Let me show how to swaddle and cuddle him, then try."

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

The headaches should decrease as you get used to the medication

A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include?

Lower left

A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place a fetal heart monitor on which of the following sites to auscultate the fhr?

Elevate the client's HOB

A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first?

Secure the tubing w adhesive tape the lower abdomen

A nurse is caring for a female client who has an indwelling catheter w a urinary drainage bag system. Which of the following actions should the nurse take?

sublimination

A nurse is caring for an adolescent that states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

Observe the client during and after meals

A nurse is caring for an adolescent who has bulimia nervosa. Which of the following actions should the nurse take first?

Used a moisture barrier on the client's skin

A nurse is caring for an older adult client who is postop following a total hip arthroplasty. The client is incontinence of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

Administer the medication to the client

A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current bp is 114/55 mm Hg. Which of the following actions should the nurse take?

Provide information about moving to a shelter

A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client's arm's. The nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse's priority action?

Check for pain w passive movement of the affected extremity

A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale w a weak pedal pulse and the client reports foot numbness. Which of the following actions should the nurse take first?

Fruity breath odor

A nurse is collecting data from a client who has dka. Which of the following findings should the nurse report to the provider?

O2 sat 89%

A nurse is collecting data from a client who is 4 hr postop following a hemicolectomy. Which of the following findings is a nurse's priority, requiring immediate intervention?

Many women experience feelings of ambivalence during pregnancy

A nurse is collecting data from a client who is at 12 weeks gestation. The client states, "We've been trying to get pregnant for several months, but now I'm not sure I'm ready" Which of the following responses should the nurse make?

Dyspnea

A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergy reaction to this medication?

Boggy fundus 3 fingerbreadths above the umbilicus

A nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?

Lady with eyes closed with nodule on eyelid

A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasama?

Weight loss 10%

A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect?

I would rather be alone than with my fiance

A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority?

Encourage the client to take frequent walks during the day

A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?

A client who has a bmi of 32

A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interpersonal care conference w a dietitian?

Medication record

A nurse is completing chart reviews in a ltc facility in response to an increase in falls. Which of the following responses in the chart should the nurse use it to determine the potential causes of falls?

Remind the client of the day and time often

A nurse is contributing to the POC for a client experiencing delirium. Which of the following interventions should the nurse recommend?

Measure the client's abdominal girth daily

A nurse is contributing to the POC for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

Tile the client's head forward during meals

A nurse is contributing to the POC for a client who has dysphagia. Which of the following interventions should the nurse include?

Lie in your left side with your top leg forward

A nurse is contributing to the POC for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the POC?

Decreased kidney function

A nurse is contributing to the POC for an older adult client. Which of the following physiological changes should the nurse consider when administering medication?

Place the client in high-fowler's position during feedings

A nurse is contributing to the POC of a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend?

Contact precautions

A nurse is contributing to the POC who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client?

A client who is attempting to hurt himself or others

A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the staff can medicate a client against his will, without a court hearing in which of the following situations?

I sometimes place a bottle containing team against the child's skin

A nurse is discussing health practices with a mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping?

Draw a horizontal line through the space and sign at the end of the line

A nurse is documenting client care in the nurses and notices that a space was left blank. Which of the following actions should the nurse take?

Check for residual urine after voiding

A nurse is implementing a bladder training program for client after she had a stroke. Which of the following interventions should the nurse take?

Complete post mortem care for a client who has died

A nurse is making client care assignments for an AP. Which of the following tasks should the nurse assign to the AP?

Observe the movements of the client's chest wall

A nurse is monitoring a client who is postop. Which of the following actions should the nurse take when collecting data about the client's respirations?

Remind the client about the specifics of the procedure

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary" Which of the following actions should the nurse take?

Identify data collection methods

A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?

Transparent film

A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel. Which of the following types of wound dressing should the nurse use?

Instruct the client to remain as still as possible during the recording

A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field?

A nurse is preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take?

This medication will decrease the risk of hemorrhage in your newborn

A nurse is preparing to administer Vitamin K to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make?

7.5 mL

A nurse is preparing to administer paroxetine 15 mg/PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/5mL. How many mL should the nurse administer (Round to nearest tenth)

1. Allows the nurse to touch him on the arm 2. Answers questions asked by the nurse 3. Makes eye contact with the nurse

A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (SATA-3)

Compress the container before replacing the drainage bag

A nurse is preparing to empty a postop client's closed-wound drainage system. Which of the following actions should the nurse plan to take?

Time of last pain medication

A nurse is preparing to give a change o shift report on a client who is 2 days postop following a total knee arthroplasty. Which of the following info about the client should the nurse include in the report?

A preschooler who has epiglottis and is drooling

A nurse is receiving areporton for clients. The nurse should plan to collect data from which of the following clients first?

A client who has a sodium level of 140 mEq/L after one episode of diarrhea

A nurse is recommending clients for d/c to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for d/c?

I will plan to avoid grapefruit juice while taking this medication

A nurse is reinforcing d/c teaching w a client who has bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching?

"You should have a sputum examination every 4 weeks"

A nurse is reinforcing dc teaching with a client who has a new diagnosis of tb. Which of the following instructions should the nurse include in the teaching?

16 lb

A nurse is reinforcing dietary teaching w clients whose pregnancy BMI was 30.5. the nurse should recognize that the client understands the teaching when she states that she should expect to gain how many lbs during her pregnancy?

Eat a small meal every 2-3 hr

A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching?

"You should avoid crossing your legs for 3 months"

A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate?

"Perform pulmonary hygiene 1 hr before meals"

A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?

Encourage client to be assertive

A nurse is reinforcing discharge teaching with a family of a client who has dependent personality disorder. What action should the nurse take?

"I should discuss this document with my family after I sign it"

A nurse is reinforcing teaching about advance directives w a client who has end stage renal heart failure. Which of the following statements by the client indicates an understanding of the teaching?

Feed newborn 8-12 times/day every 24 hr

A nurse is reinforcing teaching about breastfeeding w a client who gave birth 2 days ago. Which of the following info should the nurse include?

Glycoslated Hemoglobin

A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following lab tests is most accurate of blood glucose effective management?

Gently stroke her abdomen during contractions

A nurse is reinforcing teaching to the support person of the client who has early stage labor. Which of the following instructions should the nurse include regarding effleurage?

Yogurt

A nurse is reinforcing teaching w a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea?

I will mix the medication w water

A nurse is reinforcing teaching w a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?

Engage in low-impact aerobic exercises

A nurse is reinforcing teaching w a client who has arthritis. Which of the following instructions should the nurse include in the teaching?

You should increase fluid intake to relieve dysuria

A nurse is reinforcing teaching w a client who has genital herpes. Which of the following info should the nurse include in the teaching?

I should check heart rate while taking this medication

A nurse is reinforcing teaching w a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching?

You can sign the informed consent form after the provider explains the pros and cons of the procedure

A nurse is reinforcing teaching w a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?

Persistent headache

A nurse is reinforcing teaching w a client who is at 18 weeks gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider?

I am having this test because my baby was not reactive during a nonstress test

A nurse is reinforcing teaching w a client who is at 38 week's gestation and it to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching?

Skin rash w fever

A nurse is reinforcing teaching w a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

You might experience swollen gums while taking this medication

A nurse is reinforcing teaching w a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching?

"You should not palpate your child's abdomen prior to surgery"

A nurse is reinforcing teaching w the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching?

Administer the medication to the toddler each evening

A nurse is reinforcing teaching w the parents of a toddler who has a new diagnosis of asthma and a prescription of Montelukast. Which of the following instructions should the nurse include in the teaching?

"The harness can promote hip joint development"

A nurse is reinforcing teaching w the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?

"You will need to urinate before the procedure"

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following info should the nurse include in the teaching?

"I should take this medication in the morning and at night"

A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates and understanding of the teaching?

"Monitor for muscle weakness while taking the medication"

A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching?

You should expect your urine to turn brown

A nurse is reinforcing teaching with a client who has trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching?

Avoid exposing the neck to the cold

A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?

"Advances directives include a living will"

A nurse is reviewing info about advanced directives w a newly admitted client. Which of the following statements by the client indicates an understanding of the info?

Creatinine 15 mg/dL

A nurse is reviewing lab findings for 4 clients. Which of the following lab values is an expected findings for a client who has end stage renal disease?

Urine protein plus

A nurse is reviewing lab values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?

Hypotension

A nurse is reviewing the MAR of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client?

Naproxen

A nurse is reviewing the home medications with a client who recently had a transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following otc meds interact adversely w clopidogrel?

Peripheral Vascular Disease

A nurse is reviewing the med record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings?

Oral suction equipment

A nurse is supervising an AP obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

"Tell me what I can do for you at this time"

A nurse is talking with the partner of a client who recently died. Which of the following statements should the nurse take?

Keep the finger in dependent position

A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

I am thankful I am done having children

A nurse is verifying informed consent for a client who is postop from a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A client who has schizo and is having command hallucinations

A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first?

Ask the AP to discuss the issue in a private area

An AP tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?

tell the aps to stop the conversation

a charge nurse working in a ltc facility overhears 2 aps in the nurses stations discussing a client who was just admitted. which of the following actions should the nurse take?

a client who has had a radial mastectomy 36 hr ago and has a surgical drain

a nurse in a med surg unit is preparing to assist w the admission of clients who were injured in a tornado. which of the following clients should the nurse recommend for d/c to make room for the new admissions?

holding eye contact for brief instances

a nurse in an inpatient psychiatric unit is caring for a client who was raised in an asian culture. which of the following communication techniques by the nurse demonstrates cultural sensitivity?

Chadwick's sign

a nurse is assisting w a prenatal exam of a client who is at 8 weeks gestation. the nurse notes that the client's vagina and vulva are a purplish color. the nurse should document this finding as which of the following?

I have decided to tell my husband I'm leaving him

a nurse is assisting w a support group for client who have experienced intimate partner violence. the nurse should identify which of the following client statements as indicating the greatest risk for violence?

initiate contact precautions for the client

a nurse is assisting w the admission of a client who has varicella zoster. which of the following interventions should the nurse plan to implement?

disorientation

a nurse is assisting w the care of a client following ect therapy for the treatment of depressive disorder. which of the following findings should the nurse expect 15 mins following this procedure?

occupational therapist

a nurse is assisting w the d/c plan for a client who has burns on his arms and hands. which of the following referrals should the nurse recommend to improve the client's ADLs?

verify the status of the client's advanced directive

a nurse is assisting w the poc of a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. which of the following actions should the nurse take?

believes his bad behavior is causing his brother's death

a nurse is caring for a child who has terminated cancer. which of the following responses by the child's school-age brother should the nurse expect?

i am afraid to discuss my own concerns w my husband

a nurse is caring for a client who has a new mastectomy. which of the following statements by the client should indicate to the nurse that the client is beginning to cope w the changes in her body image?

submissive

a nurse is caring for a client who has dependent personality disorder. which of the following manifestations should the nurse expect?

identifying the client's perception of the changes of her physical appearance

a nurse is caring for a client who is 2 days postop following a total bilateral mastectomy. the client is tearful and looks away when her surgical dressings are removed. the nurse should place the priority action on which of the following actions?

1. move the client to a safe location 2. pull the nearest fire alarm 3. shut all the doors and windows 4. attempt to extinguish

a nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room (move steps in order)

urinary retention

a nurse is caring for a client who's receiving morphine for pain. which of the following findings indicate that the client is experiencing an adverse effect of the medication?

establish daily exercise routine

a nurse is caring for an older adult client who reports having trouble getting sleep at night. which of the following recommendations should the nurse make?

hypotension

a nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. which of the following findings should the nurse expect?

encourage the client to use positive self talk

a nurse is contributing to the poc of a client who has major depressive disorder. which of the following recommendations should the nurse include in the poc?

i will place the patch on a hairless area of skin

a nurse is nurse is reinforcing teaching with a client who has a prescription for a transdermal nitroglycerin patch. which of the following statements by the client indicates an understanding of this medication?

allow separate meds to flow through the tube by gravity

a nurse is planning to administer 4 different meds to a client via gtube. which of the following actions should the nurse take?

1.5 mL

a nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. how many mL should the nurse administer?

surgical mask

a nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. which of the following supplies should the nurse use while caring for this client?

i have unsalted pretzels for a snack

a nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. which of the following statements by the client indicates an understanding of the teaching?

I will be sure to cook chicken to 180 degree fahrenheit

a nurse is reinforcing teaching about safe food handling w a client who is recovering from food poisoning. which of the following statements by the client indicates an understanding of the teaching?

orthostatic hypotension

a nurse is reinforcing teaching w a client who has a prescription for amytriptyline. which of the following findings should the nurse include in the teaching as an adverse effect of this med?

walk 30 mins 5 days per week

a nurse is reinforcing teaching w a client who is at risk for hypertension. which of the following risk reduction strategies should the nurse include in the teaching?

i will feel a warming sensation after the injection of the dye

a nurse is reinforcing teaching w a client who is scheduled for an intravenous pyelogram. which of the following statements made by the client indicates an understanding of the teaching?

i will have an identification band that matches the one that my baby wears

a nurse is reinforcing teaching w a new mother facility safety measures. which of the following statements by the mother indicates an understanding of the teaching?

pH 7.30 PaCO2 50 mm Hg

a nurse is reviewing lab values for a client who is experiencing respiratory acidosis. which of the following ABG values should the nurse expect?

a nurse tells the chaplain that her assigned client has a new diagnosis of cancer

a nurse should recognize that a client's right of confidentiality has been breached when which of the following occur?

skim milk

the nurse is reinforcing dietary teaching w a client who has cholecystitis. which of the following food choices should indicate that the client understands the teaching?