Ati practice A

A nurse in a long term care facility is caring for a client who dies during the night shift.Indentify the sequence in which the nurse should perform the following steps.

1)Obtain the pronouncement of death from the provider 2)Remove the tubes and indwelling lines 3)wash the clients body 4)Ask the clients family members if they would like to view the body 5)Place a name tag on the body

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A) press gently on tragus of the clients ear B) Pack a small piece of cotton deep into the clients ear canal C)Move the clients auricle down and back inward and back toward her head

A) press gently on tragus of the clients ear C is incorrect bc auricle is move upward and backward

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to the AP? Select all that apply A)Assist the client with a partial bed bath B)Measure the clients BP after the nurse administers an antihypertensive medication C)Use a communitive board to ask what the client wants for lunch D) Test the clients swallowing ability by providing thickened liquids E)Irrigate the Clients indwelling urinary catheter

A)Assist the client with a partial bed bath B)Measure the clients BP after the nurse administers an antihypertensive medication C)Use a communitive board to ask what the client wants for lunch D and E the nurse performs those task

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? A)Examine personal values about the issue B)Tell the parents that this is a neccesary procedure C)Inform the parents that the staff does not require consent D)Contact a spiritual suppourt person to explain the importance of the procedure

A)Examine personal values about the issue

A nurse is planning to insert a peripheral IV catheter for an adult client.Which of the following actions should the nurse plan to take? A)Insert the catheter at 45' angle B)Place the clients arm in dependent position C)shave excess hair from the insertions site D)Intiate IV therapy in the veins of the hand

B)Place the clients arm in dependent position

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I have difficulty breathing?" Which of the following responses should the nurse make? A. )"We would consult the person appointed by your health care proxy to make decisions." B.)"We would give you oxygen through a tube in your nose." C) " You would be unable to change your previous wishes about your care" D)"We would insert a breathing tube while we evaluate your condition"

B.)"We would give you oxygen through a tube in your nose." Bc Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula

A nurse is providing discharge teaching to a client about self administering heparin.WHich of the following instructions should the nurse include in the teaching? A)Insert the needle at 15' angle B) Aspirate for blood return prior to administration C) Administer the medication into the abdomen D) Massage the site following the infection

C) Administer the medication into the abdomen - it is not A) bc is SM

A nurse admitting a new client.which of the following actions should the nurse take while performing medication reconciliation? A)Verify the clients name on their identification bracelet with the medication administration record B) call the pharamacy to determine wheter the clients medications are avaliable C)Compare the clients home meds with the providers prescription

C)Compare the clients home meds with the providers prescription

A nurse is administering 1 L of 0.9% Sodium Chloride to client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A)Increase hematocrit B) increase in respiratory rate C)Decrease in heart rate D)Decrease in capillary refill time

C)Decrease in heart rate ABD are causes of fluid volume deficit A)Increase hematocrit B) increase in respiratory rate D)Decrease in capillary refill time

A Nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? A) "is your pain constant or intermittent" B) "what would you rate your pain on scale 0 to 10" C) "Does the pain radiate" D) "Is your pain sharp or dull"

D) "Is your pain sharp or dull" Rationale: determines quality A) "is your pain constant or intermittent" -determines the onset, duartion, and pattern of pain B) "what would you rate your pain on scale 0 to 10" -determines intensity of pain C) "Does the pain radiate"- determines the pain location

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse intiate ? A) Protective environment B) Airborne Precautions... C) Droplet Precautions D) Contact precautions

D) Contact Precaution

A nurse is caring for a client who has a sodium level of 125 mlg/L.Which of the following findings should the nurse expect? A)Numbness of the extremities B) Bradycardia C)Positive chvostek sign D)Abdominal cramping

D)Abdominal cramping A)Numbness of the extremities hyperkalemia B) Bradycardia-hypovolemia C)Positive chvostek sign-hypocalcemia

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is contraindication for which of the following? A)biofeedback B)Aloe C)Feverfew D)Acupuncture

D)Acupuncture -can furter cause skin infection bc open wound A)biofeedback-stroke recovery,smoke cessestion B)Aloe- help improve disorders and can have wound healing effects C)Feverfew-promote wound healing

a nurse receives report about a client who has a 0.9 sodium chloride infusing IV at 125 mL/hr. when the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. which of the following actions should the nurse take first? A) Reposition the client B)Document the clients IV intake in the medical record C)Request a new Iv fluid prescription D)Check the Iv Tubing for obstruction

D)Check the Iv Tubing for obstruction Bc first action should be assess the client

A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? A)Alginate B)Gauze C)Transparent D)Hydrocolloid

D)Hydrocolloid by creating a moist wound bed A)Alginate is stage 3 and 4 to absorb drainage B)Gauze is stage 4 by causing debridement and allowing granulation of the wound bed C)Transparent stage 1 by preventing further friction and shearing

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and to report back in 1 hr. which of the following actions should the nurse take next? A)Document the providers statement in the medical record B)Complete an incident report C)Consult the facility risk manager D)Notify the nursing manager

D)Notify the nursing manager

A nurse is caring for a client who has diarrhea due to shigella . which of the following precautions should the nurse implement for this client? A)Have the client wear mask when receiving visitors B) Limit the clients time with visitors to no more than 30 mins per day C)Assign the client to a room with negative pressure airflow exchange D)Wear a gown when caring for the client

D)Wear a gown when caring for the client - prevent transmission of the bacteria

A nurse is caring for a client who has pharyngeal diphtheria . Which of the following types of transmission precautions should the nurse initiate ? Contact Droplet Airborne Protective

Droplet

A nurse is caring for a client who requires a NG tube for stomach Decompression. Which of the following actions should the nurse Take when Inserting the Ng tube?

Have the client sip water to promote insertion of NG tube into the esophagus

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs ? pupil clarity visual fields visual acuity Lacrimal Apparatus Appearance of bulbar conjunctiva

pupil clarity - cloudy pupils mean cataracts visual fields - check peripheral vision visual acuity-us Snellen chart