ATI unit exam 2 - practice

a nurse is caring for a client & observes that the client's urine is dark amber, cloudy, & has an unpleasant odor. the nurse should recognize that these findings are associated with which of the following

UTI

a nurse is caring for a client who has an NG tube. the nurse tests the pH of the secretions to determine if the tube is correctly places. which reading should the nurse expect?

4.0

a nurse is caring for a female client who has recurrent kidney stones & is scheduled for an intravenous pyelogram, which of the following statements by the client should the nurse report to the provider?

"i don't eat shellfish because it gives me hives."

a nurse is instructing a young adult client about healthful sleep habits. which of the following statements should the nurse identify as an indication that the client needs further teaching?

"i watch tv until i fall asleep at night."

a nurse is providing teaching to a client about measures to prevent UTIs. which of the following client statements indicates a need for further teaching?

"i will need to wipe my peri area from back to front after urination"

a nurse is teaching a client who reports insomnia about promoting rest & sleep. which of the following statements should the nurse identify as an indication that the client understands the instructions?

"i will no longer have a glass of wine before bedtime."

a nurse in an emergency department is caring for a pt who has a sucking chest wound resulting from a gunshot. the client has a BP of 100/60 mm Hg, a weak pulse rate of 118/min, & a respiratory rate of 40/min. which of the following actions should the nurse take?

administer oxygen via nasal cannula

a nurse is caring for a client who has a prescription for a stool test for guaiac. the nurse understands the purpose of the test is to check for the stool for which of the following substances?

blood

a nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. which of the following should the nurse include in the teaching? (SATA)

check the cannula position on a regular basis check the tops of the ears for skin breakdown post "no smoking" signs in the home

a nurse is caring for a client who has an indwelling catheter. which of the following actions should the nurse take to prevent infection?

check the catheter tubing for kinks or twisting

a nurse is assessing a client who has chronic respiratory insufficiency. which of the following findings should the nurse expect as result of the long-term inadequate oxygenation?

clubbing of the fingers

a nurse is monitoring an older adult client immediately following a bronchoscopy. the nurse's priority is to monitor the client for which of the following?

confirming the gag reflex

a nurse is caring for an older adult client who has a UTI. which of the following manifestations should the nurse identify as a finding specifically associated with this client?

confusion

a nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. the nurse notes slow, steady bubbling in the suction control chamber, which action should the nurse take?

continue to monitor the client's respiratory status

a nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. the nurse explains to the client that this method of oxygen delivery does which of the following?

delivers a low concentration of oxygen

a nurse in a PACU is assessing a client who has a newly created colostomy. which of the following findings should the nurse report to the provider?

purplish-colored stoma

a nurse is caring for a client who has returned to the unit following a surgical procedure. the client's oxygen saturation is 85%. which action should the nurse take first?

raise HOB

a nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. after the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

take the client to the bathroom every 2 hours

a nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

temporary urinary retention

a nurse is assessing a client who has a colostomy. which finding should the nurse report to the provider?

the stoma is pale in color

a nurse is teaching a client who has a new prescription for docusate. which of the following information should the nurse include in the teaching?

"take the medication with a full glass of water."

A nurse is providing teaching to a client who has a new colostomy. which of the following information should the nurse include in the teaching?

"you may experience a small amount of bleeding around the stoma."

a nurse is providing a teaching to a client who takes opioid pain meds and has a new prescriptions for docusate sodium. which statement indicates an understanding of the teaching?

"it might take up to 3 days for the meds to work"

a nurse is preparing to discontinue a client's indwelling urinary catheter. which of the following actions should the nurse take first?

position the client supine

a nurse is assessing a client who is experiencing prostatic hypertrophy, which finding associated with urinary retention should the nurse expect? (SATA)

report of felling pressure tenderness over symphysis pubis distended bladder voiding 30mL frequently

a nurse is planning the discharge of a client who has sleep apnea & requires bi-level positive airway pressure (BiPAP) at night. the nurse should plan to consult with which of the following health care team members to help educate the client?

respiratory therapist

a nurse is caring for a client who needs a stool specimen collected, which of the following actions should the nurse take when obtaining the specimen?

send specimen container immediately to the lab

a nurse is providing discharge teaching to a client with a new prescription for a MDI. which instruction should the nurse include?

shake inhaler for 3-5 seconds

a nurse is assessing a client who has narcolepsy, which of the following findings should the nurse expect? (SATA)

sudden attacks of sleep hallucinations at the onset of sleep

a nurse is providing discharge teaching for a client who requires home oxygen therapy, which statement should the nurse identify as an indication that the client needs further teaching?

"i will wear synthetic clothing & woolen socks when using my oxygen."

a nurse instructs a female client about collecting a midstream urine sample. which of the following client statements indicates an understanding of the procedure

"i'll use the cleansing wipe from front to back."

a nurse is teaching a client who is obese & has obstructive sleep apnea how to decrease the number of nightly apneic episodes. which of the following client statements indicates an understanding of the teaching?

"if i could lose about 50lbs, i might stop having so many apneic episodes."

a nurse is reviewing the medical record of a client who has a UTI. which of the following findings should the nurse recognize as a risk factor?

diabetes mellitus

a nurse is preparing to measure a client's level of oxygen saturation & observes edema of both hands & thickened toe nails. the nurse should apply the pulse oximeter to which of the following locations?

earlobe

a nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. which of the following information should the nurse include?

empty the pouch when it is 1/2 full

a nurse is teaching a client who has constipation. which of the following should the nurse discuss as causes of constipation? (SATA)

excessive laxative use ignoring the urge to defecate inadequate fluid intake

a nurse is caring for a client who reports difficulty sleeping while in the hospital. which of the following actions taken by the AP while the client is sleeping should prompt the nurse to intervene?

flushes the client's toilet after emptying the urinary catheter's drainage bag

a nurse is teaching an older adult client who reports constipation, which instruction should the nurse teach

increase dietary intake of raw veggies

a nurse is monitoring a client following a thoracentesis. the nurse should identify which of the following manifestations as a complication & contact the provider immediately?

increased heart rate

a nurse is caring for a pt who has a newly inserted chest drainage system with a water seal, which action should the nurse take?

keep the collection device below the level of the client's chest

a nurse is caring for a client who has a chest tube connected to a closed drainage system & needs to be transported to the x-ray department. which of the following actions should the nurse take

keep the drainage system below the level of the client's. chest at all times

a nurse is educating a client who is experiencing sleep disturbances & desires to decrease caffeine intake, which of the following beverages should the nurse recommend?

lemon-lime soda

a nurse is administering a tap water enema to a client who is constipated. during administration the client states he is having abdominal cramps. what should the nurse do the relieve the client's discomfort?

lower the height of the solution container

a nurse is caring for a client who has peripheral vascular disease & reports difficulty sleeping because of cold feet. which of the following nursing actions should the nurse take to promote the client's comfort?

obtain a pair of slipper-socks for the client

a nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. which of the following actions should the nurse take first?

perform a bladder scan