ATI practice B

a charge nurse is observing a newly liscensed nurse prepare a sterile field for a dressing change. wof actions by the new nurse requires intervention by the charge nurse? a. new nurse places cap of bottle of sterile solution on the sterile field b. new nurse places sterile objects 2.3 cm (1 in) within the border c. new nurse holds bottle of sterile saline outside the edge of the field when pouring d. sterile field is positioned at level of new nurse's waist

a

a nurse is caring for a client with TB. wof actions should the nurse take? (select all) a. place the client in a room with negative pressure airflow b. wear gloves when assisting with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing care e. use antimicrobial santizer

a, b, e

a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. wof instructions should the nurse provide to the client and his family? (select all) a. check the cord routinely for frays or tearing b. keep the unit at least 1.2 m (4 ft) away from a gas stove c. consider purchasing a generator for power backup d. observe signs of hypoxia e. select synthetic clothing and bedding

a, c, d

a nurse is admitting a client who has rubella, wof transmission based precautions should the nurse initiate a. droplet b. airborne c. contact d. protective

a. droplet

a nurse is assessing an adult client who has been immobile for the past 3 weeks. for wof findings should the nurse intervene? a. erythema in pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3000 ml per day d. one bowel movement every other day

a. erythema in pressure points

A nurse is preparing to administer 0.5ml of oral single dose of liquid med to a client. wof actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the med to a med cup c. place the client to a semi-fowlers position prior to medication administration d. verify the dosage by measuring the liquid before administering it

a. gently shake the container of medication prior to administration

who is the highest risk for hypertension a. a client who is 52 b. a client who smokes a pack a day c. walks 30 mins a day d. pt who drinks a glass of wine 3 times a week

b

a nurse is caring for a client who is reporting pain. when documenting the quality of the clients pain on an initial pain assessment. the nurse should record wof statements? a. " im having mild pain" b. " the pain is like a dull ache in my stomach" c" i notice the pain gets worse after i eat" d. the pain makes me feel nauseous

b. the pain is like a dull ache inmy stomaach

a nurse is reviewing practice guidelines with a group of newly licensed nurses, wof interventions should the nurse include that is within the Rn scope of practice? a. insert an implanter port b. close a laceration with sutures c. place an endotracheal tube d. initiate an enternal feeding through a gastrostomy tube

d

a nurse is administering IV fluids to a client. when monitoring for adverse effects, wof assessments should the nurse identify as a priority a. auscultate lung sounds b. measure urine output c. moniter bp readings d, monitor electrolyte levels

a

a nurse is admitting a client who has been having frequent tonic-clonic seizures. wof actions should the nurse add to the client's plan of care? a. wrap blankets around all four sides of bed b. apply restraints during seizure activity c. place the client in supine during seizure d. have a tongue depressor at the client's bedside

a

a nurse is caring for a client who has terminal diagnosis and whose health is declining. the client requests info about advance directives. wof responses should the nurse take a. we can talk about advance directives, and i can also give you some brochures b. you should set up a time to talk to your provider about that c. lets discuss how you are feeling today, and we'll save the planning for when you are feeling a little better d. why do you want to discuss this without your partner here to plan this with you

a

a nurse is teaching a client whos left leg is in a cast about using crunches. wof statements should the nurse identify as an indication that the client understands the teaching? a. when descending stairs, I will first shift my weight to my right leg b. i should place my crutches 12 inches in front and to the side of each foot c. as I sit down, I will hold one crutch in each hand d. i will make sure the shoulder rests are snug against my armpits

a

a nurse has just inserted an ng tube for a client. wof findings should the nurse expect to confirm current tube placement a. tube aspirate has pH of 7 b. x ray shows tube end above pylorus c. bowel sounds are present on ausculation d. client report relief of nausea

b

a nurse is reviewing protocol in prep for suctioning secretions from a client who has had a new tracheostomy. wof actions should the nurse plan to take? a. use a resuscitation bag with 80% O2 prior to the procedure b. select a suction cath that is half the size of the lumen c. place the end of the suction cath in water-soluble lubricant d. adjust the wall suction apparatus to a pressure of 170 mm Hg

b

a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the clients partner wants the client to have the blood transfusion. wof actions should the nurse take? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the clients family to intervene

b. withhold the blood transfusion

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. wof findings should the nurse expect a. neck vein distension b. urine specific gravity 1.010 c. rapid heart rate d. bp 144/82

c

a nurse is in an acute care facility is preparing a discharge summary for a client who is transferring to a long term care facility. wof documentation should the nurse take? a. client flow sheet b. acuity rating c. current medication d. incident report

c. current medication

A nurse is reviewing a client medication prescption that reads "digoxin 0.25 by mouth everyday" wof components should the nurse verify with the provider? a. medication name b. route of administration c. medication dose d. frequency of medication

c. medication dose

a nurse is assessing a client who received IV fluid bolus for dehydration. wof findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins

d

A nurse is planning teaching for a group of teens who each recently had surgical placement of an ostomy. of methods should the nurse use as a psychomotor approach to learning? a. role-play b. group discussions c. q&a meetings d. practice sessions

d. practice sessions

a nurse is caring for a group of med-surg unit clients. wof does the nurse demonstrate veracity? a. client who is unaware of recent cancer dx asks the nurse if she has cancer, nurse responds affirmatively b. client who has a prescription for a nasogastic tube refuses it, and the nurse complies with client's wishes c. a client who is DNR order has a cardiac arrest, and the nurse does not perform CPR despite requests from the clients d. a client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer

a

a nurse is discussing the use of herbal supplements for health promotion with a client. wof clients statements indicate an understanding if herbal supplement use? a. i can take echinacea to improve my immune system b. i can take feverfew to reduce my level of anxiety c. i can take ginger to improve my memory i can take ginkgo biloba to relieve nausea

a

a nurse is preparing to delegate client care tasks to AP. wof task should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary cath for a client c. demonstrating the use of an incentive spriometer to a client d. confirming that a client's pain has decreased after receiving an analgesic

a

a nurse is teachign an older adult clinet who is at risk for osteoporosis about beginning a program if regular physcial activity. wof types of activity should the nurse recommend? a. walking briskly b. riding a bike c. performing isometric exercises d. engaging in high impact aerobics

a

a nurse in a surgical notes documentation on a clients medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? a ensure sterilization of nondisposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place c. cleanse latex ports on IV tubing with chlorhexidine before injecting meds d. wear hypoallergenic latex gloves that contain powder

b

a nurse is caring for a client who reports difficulty falling asleep. wof rec should the nurse make? a. drink a cup of hot cocoa before bedtime b. maintain a consistent time to wake up each day c. exercise 1 hour before going to bed d. watch a television program in bed before going to sleep

b

a nurse is caring for a client who is receiving pain meds through PCA pump. wof actions should the nurse take? a. instruct family to not push the button when the client is sleeping b. inform the client that b/c on PCA vital signs will be taken every 8 hr c. teach client to avoid pushing button until pain is above a 7 on the scale d. increase basal rate and shorten lock-out interval time if pain is too high

a

a nurse is caring for a client with terminal liver cancer. wof should the nurse identify as an indication that the client is experiencing spiritual distress? a. what could i have done to deserve this illness b. i blame medical science for not curing me c. where is my daughter at a time like this d. will i every begin to feel in charge of my life again

a

a nurse is performing a romgerg test in the physical assessment of a client. wof techniques should the nurse use a. touch face with cotton ball b. apply a viberating tuning fork to the clients forehead c. have the client stand w/ their arms to their sides and their feet together d. perform direct percussion over the area

c

a nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment, wof actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is farthest from the chair c. assess the client for orthostatic hypotension d. apply a gait belt to the client

c

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the order of steps a. inject 5 units of air into the bottle for regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

c, a, d, b

a nurse is caring for a client who has an indwelling urinary cath. wof findings indicates that the cath requires irrigation? a. unusual odor b. specific gravity is 1.035 c. bladder scan shows 525 ml of urine d. positive for ketones

c.

a nurse has accepted a verbal prescription "for three tenths of a milligram" what is that

0.3 mg

A nurse is preparing a heparin infusion for a client who was admitted w/ dvt/ the perscription reads: 25,000 units of heparin in 0.9% sodium chloride 250 ml to infuse at 800 units per hour. at what rate should the nurse set the infusion pump?

8ml/hr

a nurse is caring for a client who is receiving fluid through a peripheral IV cath. wof findings at the IV site should the nurse identify as indicating infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding

c

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. wof actions nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep head of bed elevated at least 30 deg c. make sure the enteral formula is at room temp d. wipe the top of the formula can with alcohol

b

a nurse is caring for a client who requires an informed consent for a surgical procedure. wof actions is the nurses responsibility? a. describe the procedure to the client b. witness the client's sig on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure

b

a nurse is giving a change of shift about a client they admitted earlier that day that has pneumonia, wof pieces of info is the prioriy for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temp d diagnostic test results

b

a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap

b

a nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with a nurse b. a nurse asks a nurse from another unit to assist with documentation for a client c. a nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care d. a nurse discusses a client's status with the PT who is caring for the client d.

b

The nurse is caring for a client who is receiving 24-hour urine collection. wof statements by the client indicate an understanding of the teaching a. i had a bowel movement but I was able to save the urine b. i have a specimen from the bathroom from about 30 min ago c. i flushed what I urinated at 7 am and have saved all since d. i drink a lot so I will complete the test quickly

c

a client who is nonambulatory notifies the nurse that his trash can is on fire. after the nurse confirms the presence of the fire which action should the nurse take next a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fire

c

a nurse enters a clients room and finds her on the floor, the clients roomate reports that the client was trying to get out of bed and fell pver the side rail on to the floor. wof should the nurse document about this incident? a. incident report completed b. client climbed over the side rails c. client found lying on the floor d. client was trying to get out of bed

c

a nurse in a clinic is caring for a middle adult client who states, "the dr says that since i am at an average risk for colon cancer, i should have a routine screening. what does that involve?" wof response should nurse make? a. ill get a blood sample from you and send it for a screening b. beginning at age 60, you should have colonoscopy c. you should have a fecal occult blood test every year d. the recommendation is to have a sigmoidoscopy every 10 years

c

a nurse is calculating client's fluid intake over the past 8 hr. wof items should the nurse plan to document on the client's intake and output record as 120 mL fluid. a. 2 cups of soup b. 1 quarts of water c. 8 oz of ice chips d. 6 oz tea

c

a nurse is caring for a client who has a prescription for wound irrigation. wof should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 105 F c. cleans the wound from the center outward d. use a 20 mL syringe to irrigate the wound

c

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting

d

a home healthcare nurse is completing admission assessment of an older adult who has caregiver present. wof findings should the nurse identify as potential indication of elder abuse? a. caregiver is client's financial power of attorney b. client in wheelchair with wheels locked c. client reports receiving full bath 2x/week d. caregiver insists on remaining in room

d

a middle adult client tells the nurse, "i feel so useless now that my children don't need me anymore." wof responses should the nurse make? a. most people are happy when children grow up and leave b. you should be proud that your children are becoming independent c. maybe you should consider why you are feeling useless d. people in middle adulthood often find satisfaction in nurturing and guiding young people

d

a nurse is caring for a client who has decreased mobility. wof actions shoudl the nurse take to decrease the client's risk of developing plantar flexion contractures? a. pillow under client's knees b. position a trochanter roll under each of client's hips c. advise the client to wear rubber soled slippers d. apply an ankle foot orthotic device to client's feet

d

a nurse is caring for a client who has limited mobility in his lower extremities. wof actions should the nurse take to prevent skin breakdown? a. place the client in high-fowlers position b. increase the client's intake of carbohydrates c. massaged reddened areas with unscented lotion d. have the client use a trapeze bar when changing position

d

a nurse is caring for a client who has recently started using a behind-the ear hearing aid. wof statements should the nurse identify as an indication that the client understands the device? a. this type of hearing aid does not allow for fine tuning of volume b. i shouldn't have trouble keeping the hearing aid in place during exercise c. i expect to hear a whistling sound when i first insert the hearing aid d. i will be sure to remove my hearing aid before taking a shower

d

a nurse is planning an education program for a group of older adults at a senior living center, wof recommendations should the nurse include a. you should have an eye exam every 2 years b. tentanus booster every 5 years c. shingles vaccine when your 70 d. pneumoccocal vaccine when your 65 years

d

a nurse is planning care for a pt who has vision loss, wof should the nurse include in a plan of care to assist the client with feeding a. assign a staff member to feed the client b. provide small-handled utensils for the pt c. thicken liquids d. arrange food in a consistent patteren on the client plate

d

a nurse is preparing to administer multiple meds to a client who has an enteral feeding tube, wof actions should the nurse plan to take a. dissolve each med in 5ml of sterile water b. draw up med together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15 ml of sterile water

d

A nurse on a medical unit is preparing for discharge a client to home. wof actions should the nurse take as part of the medication reconciliation process? A. seal unused meds from the facility in a plastic bag b. evaluate the client's ability to self-administer meds c. report an identified discrepancies to the joint commission d. Compare prescriptions with meds the client received during hospitalization

d. Compare prescriptions with meds the client received during hospitalization

A nurse is teaching a group of staff nurses about the use of essential oils for aroma therapy, the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. history of physical abuse b. pacemaker c. ulcerative colitis d. asthma

d. asthma