ATI Kaylee

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping . Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties ? "

. " often have a cup of coffee with my dessert before going to bed .

nurse is assessing a client who has fluid - volume excess . Which of the following findings should the nurse expect ?

A Crackles in the lung fields

nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission - based precautions . Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions ?

Assigning another client with the same infection to share the room with the client

A nurse is admitting a client who is experiencing an exacerbation of heart failure . At which of the following times should the nurse initiate discharge planning

During the admission process

A nurse is caring for a client who has cancer and is experiencing pain . The nurse should implement which of the following interventions to assist the client with pain relief ?

Encourage the client to listen to soft music

A nurse is caring for a client who has the head of his bed elevated to a 45 " angle with his knees slightly flexed . Which of the following positions should the nurse document for the client ?

Fowler's

catheter bag . The nurse recognizes these manifestations as which of the following types of transfusion reactions ? A nurse is caring for a client who is receiving a blood transfusion . The client reports flank pain , and the nurse notes reddish - brown urine in the client's urinary

Hemolytic

A nurse is caring for a client who has a stage il pressure ulcer . Which of the following wound dressings should the nurse apply to the ulcer ?

Hydrocolloid

nurse take to assess the client's skin turgor ? A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days . Which of the following actions should the

VB . Grasp a skin fold on the chest under the clavicle , release it , and note whether it springs back

A nurse is planning care for an adult client who has fluid volume excess . Which of the following interventions should the nurse plan to include to monitor the client's weight

Weigh the client on arising

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery . The nurse should identify that the surgical wound should be cleansed in which of the following directions ?

From the wound toward the surrounding skin

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection . The client reports gas pains in the periumbilical area . The nurse should plan care based on which of the following factors contributing to this postoperative complication ?

Impaired peristalsis of the intestines

A nurse is caring for a toddler at a well - child visit when the mother calls , " Help ! My baby is choking on his food . " Which of the following findings indicates the toddler has an airway obstruction

Inability to cry or speak

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema . Which of the following is the underlying cause of this finding ?

Chronic hypoxemia

A nurse is providing teaching about proper care to a client who has a new colostomy . Which of the following pieces of information should the nurse include in the teaching

Cleanse the skin around the stoma with warm water

A nurse is teaching a middle - aged adult client about health promotion and disease prevention . The nurse should inform the client that which of the following changes could occur ?

could occur Decreased estrogen and testosterone production

A nurse is caring for a client who was admitted to a long - term care facility for rehabilitation after a total hip arthroplasty . At which of the following times should the nurse begin discharge planning ?

discharge Upon the client's admission to the care facility

A nurse is teaching a client who is postoperative about the importance of turning , coughing , and breathing deeply . Which of the following statements should the nurse identify as an indication that the client understands the instructions ?

do this often , I won't get pneumonia

A nurse is teaching a group of older adults about expected age - related changes . Which of the following statements by a group member indicates that the teaching has been effective ?

should expect my heart rate to take longer to retum to normal after exercise as I get older . "

A nurse is explaining the use of written consent forms to a newly licensed nurse . The nurse should ensure that a written consent form has been signed by which of the following clients ?

Aclient who has a prescription for a transfusion of packed red blood cells

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg / day for severe joint pain . The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects ?

D. Liver damage

as promised . Which of the following ethical principles is the nurse demonstrating ? A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis . The nurse returns to the client promptly

Fidelity

A nurse is preparing to administer medication to a client who has gout . The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol . Which of the following interventions is the nurse's priority ?

Measure the client's apical pulse

A nurse is collecting health history data from a client who is deaf and uses American Sign Language ( ASL ) to communicate . The nurse will be working with an ASL interpreter . Which of the following actions should e nurse take when working with the interpreter ?

Pace speech to allow time for the interpreter to convey the words .

A nurse is performing a physical assessment of a client . Which of the following actions should the nurse take to assess the client's tissue perfusion ?

Perform a blanch test

A nurse is preparing to administer a cleansing enema to a client . Which of the following actions should the nurse plan to take ?

Position the client on his left side

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 ?

Remove the IV catheter

members are present and answer the nurse's questions about the client's medical history . The nurse document information which of the A nurse is assessing a client who is unconscious . Family following types of data ?

Secondary source data

nurse is caring for a client who has peripheral edema . The nurse should identify that which of the following nutrients regulates extracellular fluid volume

Sodium

An assistive personnel ( AP ) is helping a nurse care for a female client who has an indwelling urinary catheter . Which of the following actions by the AP indicates a need for further teaching ?

The AP hangs the collection bag at the level of the bladder .

A murse is developing a plan of care for a client . Which of the following pieces of information should the nurse consider when planning care that is culturally congruent ?

The meaning of disease can vary widely across cultures

A nurse is reviewing measures to prevent back injuries with assistive personnel ( AP ) . Which of the following instructions should the nurse include

When lifting an object , spread your feet apart to provide a wide base of support .

A nurse is planning an in - service training session about various dietary practices . Which of the following pieces of information should the nurse include in the teaching

Kosher diets have restrictions regarding how the food must be prepared .

A nurse is caring for a client who is postoperative and has paralytic ileus . Which of the following abdominal assessments should the nurse expect

B. Absent bowel sounds with distention

After assessing a client's radial pulses , the nurse documents radial pulses bilaterally The nurse should document this finding when a client's pulses have which of the following qualities ?

Bounding

A nurse is measuring a client's vital signs and notices an irregularity in the pulse . Which of the following actions should the nurse take ?

C.Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who is well - hydrated and has no visible evidence of nutritional deficiencies . A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis ?.

Albumin