ATI NCLEX questions

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 cleaned in which of the following directions?

from the wound toward the surrounding skin

A nurse enters a clients 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?

Check the client for injuries

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the clients ability to think abstractly?

Discuss the meaning of a common proverb

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 identify as an indication that the client understands the instructions?

If i do this often, i wont get pneumonia

A nurse is providing teaching about nutritious diets to a group of adult woman. Which of the following statements should the nurse include?

Include 2.5 cups of vegetables in your daily diet

A nurse is explaining piaget's theory of cognitive development to a group of daycare providers for employees children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking?

collecting and trading game cards

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. WHich of the following actions should the nurse plan to take?

hold the dropper 1 cm above the ear canal during administration

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take?

obtain a new catheter and reattempt insertion

A nurse is caring for a client who has zeros to Mia with lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

starch

A nurse is assessing a clients respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

vesicular

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will clip each suture close to the skin and pull it through from the other side."

A nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2

A nurse is caring for client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many mL of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift?

90 mL

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

Lactose

A nurse is caring for a client who has terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube?(select all that apply)

Coat the tip of the tube with a water-soluble lubricant Ask the client to swallow water while the tube enters her throat Tell the client to tilt her head backward as insertion begins

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

Granulation tissue fills the wound during healing

A nurse is preparing a sterile field for a procedure the provider will perform at the clients bedside. Which of the following actions should the nurse take?

Hold the sterile drape about waist and away from the body

A nurse is caring fora client who has stage 2 pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infections should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure

A nurse on a ,epically-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information

A nurse is performing a physical assessment for a client. Which of the following actions should the nurse take to access the clients tissue perfusion?

Perform a blanch test

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the stethoscope positioned at the left eternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is caring for client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

bear down

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