HA ATI PROCT

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." which of the following responses should the nurse make?

"I am going to listen to your abdomen."

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1?

- Weak cry

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

A. Bt for bedtime B.SC for subcutaneously C. PC for after meals D.HS for half-strength C. PC for after meals

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

- "All of this equipment can be frightening"

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include?

- "With your palm facing down, move your wrist sideways toward your thumb."

A nurse is caring for a client who has a precription for acetaminophen 325 mg PO for an oral temperature above 38.4 C. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client?

- 101.1 Formula: F= (c x 9/5) + 32 F= (38.4 x 9/5) + 32

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicated that the nurse observed an indentation of which of the following depths after applying pressure?

- 2 mm

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

- Albumin

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?

- Areas with no public access

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse us next when assessing the client's abdomen?

- Auscultation

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

- Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

- Below the medial malleolus

A nurse is assessing a client who has fluid-volume excess. which of the following findings should the nurse expect?

- Crackles in the lung fields Rationale: manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain.

A nurse is monitoring the blood pressure of an older adult client. The nurse should understand that which of the following age-related changes can contribute to an increase in sytstolic blood pressure among older adults?

- Decreased elasticity of the blood vessels

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

- Dorsalis Pedis

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply)

- Dry, brittle hair -Edema -Poor wound healing

A nurse is assessing the lower extremities and ankles of a client who has peripheral arterial disease. which of the following findings should the nurse expect?

- Dry, pale skin with minimal body hair.

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take?

- Encourage the client to cough

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process?

- Make sure the device is functioning

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

- Measure the client's apical pulse rate

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

- Notify the provider of the client's decision

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

- Observe the rate, depth, and character of the client's respirations

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

- Osteoporosis

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

- Perform a blanch test Rationale: A blanch test is used to check capillary refill, which is an indication of peripheral circulation and tissue perfusion.

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?

- Physical examination

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following test?

- Romberg

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

- Second intercostal space to the right of the sternum

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

- cerebellum

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. which of the following actions should the nurse perform immediately following the transfer?

- check the client's vital signs

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select?

- choose a vein that is soft on palpation

A nurse is caring for a client who immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

- decreased cardiac output Rationale: During immobility, the client's heart rate increases to compensate for increased venous pooling. The reduction in circulating volume increases the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. which of the following actions should the nurse include in the plan of care to promote would healing?

- provide protein intake of 1.5 g/kg of body weight per day Rationale: A protein intake od 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities?

- scoliosis

A nurse is performing an abdominal assessment of a client. which of the following positions should the nurse tell the client to assume for this examination?

- supine

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions?

-papules

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority?

- "Can you tell me what the pain felt like and show me exactly where it was?"

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

- "It sounds like your pain is intermittent."

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. which of the following questions should the nurse ask to encourage discussion with the client?

- "What do you think caused the onset of your pain?"

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

- Inspect both breast simultaneously.

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

- Inspection

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

- Instruct the guard to ask the inmate

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

- Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is measuring a client's vital signs. the client's heart rate is 105/min. The nurse should document this finding as which of the following alterations?

- Tachycardia

A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?

- The client holds the hand with the palm up.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia?

- The client watches television in her bed during the day.

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

- Use the pain scale to determine the client's pain level

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

- Vesicular

A nurse is caring for a client with dehydration who has developed hypovolemic shock. which of the following laboratory values should the nurse expect for this client?

A. Bun 18 mg/dl B. Capillary refill 1.5 sec C.Hct 55% D. Urine specific gravity C. Hct 55% Rationale: an elevated hematocrit indicates hypovolemia. other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

A. Heart rate of 105/min B. soft nontender abdomen C. Temperature D. Overdue menses C. Temperature

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? select all that apply.

A. MS04 B. BID C. 30mL D. .2mg E. Q.D. B. BID C.30mL

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

A. calcium 9.5 mg/dL B. Sodium 150 mEq/L C.Potassium 4 mEq/L D.Magnesium 1.5 mEq/L B. Sodium 150 mEq/L Rationale: A sodium level of 150 mEq.L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider.

A nurse is performing a nutrional screening for a 12-year-old client who weight 41 kg (90lb) and has a height of 1.5m (60 in). which of the following values is the client's body mass index (BMI)?

- 18.2 - 1.5 x 1.5= 2.25 - 41kg/2.25 = 18.2

A nurse is conducting an admission interview with a client. which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

- A client's level of comfort and ability to participate in the interview.

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

- A. pain level -B. Hydration status -C. Airway -D. Urinary output C. Airway

A nurse is assessing an 18 month old infant who is postoperative. Which of the following pain scales should the nurse use?

-FLACC

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection?

A. WBC 15,000 mm^3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063 A. WBC 15,000 mm^3

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure?

- 116/70 mmHg Rationale: This BP is within the expected reference range, which is any vale <120 mmHg systolic and <80 mmHg diastolic

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?

- Bounding

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?

A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL A. Sodium 123 mEq/L Rationale: A sodium level of 123 mEq/L is below the expected reference range of 136 to 145 mEq/L. Low sodium levels can cause confusion and lead to seizures, coma, and death.

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

- Bounding pulse

A nurse is measuring a client's vital sings and notices an irregularity in the pulse. Which of the following actions should the nurse take?

- Count the apical pulse rate for 1 full min and describe the rhythm in the chart.

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?

- Faint pedal pulses Rationale: Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

- Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

- Grimacing

A nurse in a provider's office is assessing a client. The nurse determines the client's body mass index is 21.2. This finding is classified as which of the following?

- Healthy weight Rationale: A BMI from 18.5-24.9 is in a healthy range.

A nurse is caring for a client who is postoperative and has paralytic ileus. which of the following abdominal assessments should the nurse expect?

-Absent bowel sounds with distention.

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

-Lungs

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

-Palpation

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

-Romberg test

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulated extracellular fluid volume?

- sodium

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

- Evaluate pedal pulses

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following conditions?

- Leukopenia Rationale: Leukopenia occurs when there is a decrease in the production of WBC's, This alteration places the client at an increased risk of infection.

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. which of the following heart sounds should the nurse document?

- Pericardial friction rub

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). which of the following items should the nurse gather for the test?

- cotton wisps Rationale: the trigeminal nerve has both sensory and motor capabilities. to assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve V, the nurse should ask the client to clench the teeth.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

- cranial nerve XII

A nurse is caring for a client who has a dysrhythmia. which of the following techniques should the nurse use to assess for a pulse deficit?

- obtain the apical and radial rates

A nurse is assessing a clients peripheral pulses. which of the following descriptions should the nurse use to document the findings?

- peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?

- Irregular border

A nurse is beginning a therapeutic relationship with a client. which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?

- Assume an open position

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

- Gait