ATI NurseLogic Testing and Remediation

A nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? A. Respiratory depression B. Hearing loss C. Hypertension D. Bradycardia

Hearing loss

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury? A. Lock knees B. Stand close to the client C. Keep feet close together D. Move client by twisting at the waist

Stand close to the client

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? A. "My child will need to be followed medically for at least 5 years" B. "My child can resume moderate activity after his fever subsides" C. "This illness will not recur because my child has now had it" D. "In a few weeks or months my child could experience sudden, involuntary movements"

"This illness will not recur because my child has now had it"

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? Select all that apply A. Drooling B. Stridor C. Difficulty swallowing D. Croupy cough E. High-grade fever

A B C E

A nurse in a long-term care facility is assisting with an education program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? Select all that apply A. Urinary tract B. Surgical wound C. Musculoskeletal system D. Respiratory tract E. Blood stream

A B D E

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider? A. A client who has diabetes mellitus with a fasting blood glucose of 150 mg/dL B. A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L C. A client who is prescribed oxygen therapy and albuterol (Proventil) with a PCO2 of 50 mm Hg D. A client who has urosepsis with a WBC count of 15,000 mm3

A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L

A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion? A. Dullness B. Hyper-resonance C. Resonance D. Tympany

Dullness

A nurse is preparing to auscultate a client's heart. Which of the following positions is the best for detecting a low-pitch diastolic murmur? A. Supine B. Left lateral C. Sitting D. Supine with knees bent

Left lateral (Side lying)

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? A. Wrap the cord in a towel saturated with 0.9% sodium chloride B. Apply oxygen via face mask C. Place client in knee-chest position D. Increase IV fluid rate

Place client in knee-chest position

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching? A. Lentils B. Soybeans C. Broccoli D. Oatmeal

Soybeans

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? A. Wrapping the cuff loosely around the arm B. Using a cuff that is too wide C. Leaving client's arm unsupported D. Taking client's blood pressure immediately after client sits down

Using a cuff that is too wide

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes.

Back of neck region

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? A. Partial thickness skin loss B. Visible subcutaneous fat C. Nonblanchable redness D. Exposed muscle

Partial thickness skin loss

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following critical findings should be immediately reported to the provider? A. Fine hand tremors B. Mild thirst C. Weight gain D. Slurred speech

Slurred speech

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective? A. "I am wide awake now." B. "My mouth is very dry." C. "I feel very relaxed." D. "My heart is racing."

"I feel very relaxed"

A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50mg/kg IM. The infant weighs 17.6 lb. Available is 500mg/mL. How many mL should the nurse administer?

0.8 mL

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.

1. Client stands, bearing weight on unaffected leg. 2. Client transfers body weight to the crutches 3. Client advances the unaffected leg between the crutches 4. Client shifts weight from crutches to the unaffected leg 5. Client aligns crutches on the stair

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief? A. Anger B. Acceptance C. Bargaining D. Denial

Bargaining

A nurse is caring for a client who is form a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care? A. Include the family in the client's care B. Identify one's own beliefs and values C. Determine the client's cultural beliefs D. Encourage the client to discuss the influence of illness on cultural practices

Identify one's own beliefs and values

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways? A. Vector B. Airborne C. Vehicle D. Bloodborne

Vector

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching? A. "I should eat frequently." B. "I should avoid eating 1 to 2 hours prior to my treatment." C. "I should eat foods served cold." D. "I should eat low carbohydrate foods."

"I should eat low carbohydrate foods"

A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? A. 1/2 inch B. 5/8 inch C. 1 inch D. 1 1/2 inch

1 1/2 inch

A nurse is reinforcing teaching to a client who was recently prescribed a 2000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? A. 1/2 cup of white rice B. 1 slice of wheat bread C. 1 cup of 2% milk D. 3/4 cup of canned tomato juice

3/4 cup of canned tomato juice

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (Select all that apply) A. Cooked oatmeal B. Grape juice C. Applesauce D. Ice cream E. Smooth peanut butter

Grape juice Ice cream

A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations? A. Hypertension and crackles B. Excessive thirst C. Shakiness and diaphoresis D. Twitching muscles

Shakiness and diaphoresis

A nurse is caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder? A. Grandiose sense of self importance B. Reckless disregard for safety of others C. Unstable interpersonal relationships D. Lack of empathy

Unstable interpersonal relationships

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning? A. Advocate B. Clinician C. Educator D. Manager

Advocate

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? A. Lithotomy B. Dorsal recumbent C. Prone D. Sims

Sims

A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?

2 tsp

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? A. Aspirin (Bayer) B. Acetaminophen (Tylenol) C. Guaifenesin (Robitussin) D. Diphenhydramine hydrochloride (Benadryl)

Aspirin (Bayer)

A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? A. Percussion B. Palpation C. Auscultation D. Inspection

Inspection

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following? A. Mood B. Immunity C. Memory D. Vitality

Mood

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak? A. Lethargy B. Neuralgia C. Bradycardia D. Oliguria

Oliguria

A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's Point.

RLQ or Right Lower Quadrant

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip (high pitched whistling sound heard on both inspiration and expiration). Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? A. Rhonchi B. Crackles C. Stridor D. Wheezes

Stridor

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider? A. Tachycardia B. Vomiting C. Hypotension D. Dilated pupils

Tachycardia