ATI Test B

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

O"We can talk about advance directives, and i can also give you some brochures about them."

Which of the following client statements indicates a understanding of the herbal supplement use?

" I can take echinacea to improve my immune system."

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

" I flushed what urinated at 7:00 am and have saved all urine since."

Client with crutches

" when descending stairs, I will first shift my weight to my right leg."

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurtturing and guiding young people."

the priority? A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the proirity?

Auscultate lung sounds.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should jave an occult blood test every year."

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 correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

-Inject 10 units of air into the bottle of NPH Insulin. -inject 5 units of air into the bottle of regular insulin. -withdraw the correct doe of regukar insulin from the bottle -withdral the correct dose of NPH Insulin from the bottle

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)

-Place the client in a room with negative-pressure airflow. - Wear gloves when assisting the client with oral care. -Use antimicrobial sanitizer for hand hygiene.

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

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?

Anurse asks a nurse from another unit to assist with documentation for a client.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.)

Check the cord routinely for frays or tearing. Consider purchasing a generator for power backup. Observe for signs of hypoxla.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points

A nurse is preparing to administer 0.5 ml of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

Romnerg test

Have the client stand with their arms at their sides and their feet together

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Hush the tube with 15 mof sterile water

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that within the RN scope of practice?

Initiate an internal feeding through a gastrostomy tube

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea over the past three days. What should the nurse expect to find?

Rapid heart rate

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the chent to keep the head of the bed elevated atieast 30

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

You should receive a pneumococcal vaccine when you are 65 years old

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

withhold the blood transfusion

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

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, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension.

A nurse is reviewing a clients medication prescription that reads, "digoxin .25 by mouth everyday." Which of the following components of the pick up prescription should the nurse verify with a provider?

Medication dose

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)

Narrowed arterial lumen

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

Skin blanching

A nurse in a surgical suite notes documentation on a client's medical record has latex allergy. In preparation for the client's which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr