Health Assessment Proctored ATI

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

reporting laboratory findings to a member of the clients family

A nurse is preparing to administer an intramuscular (IM) injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

respiratory rate

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 caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

witness the clients signature on the consent form

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

wrap monitoring cords with stockinette and tape them in place

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 have a fecal occult blood test every year

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 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 caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?

auscultate breath sounds at least every 2 hours

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 priority?

auscultate lung sounds

A nurse is caring for a client. Complete the following sentence by using the lists of options.

bleeding, platelet count

A nurse in a medical-surgical unit is caring for six clients.Complete the following sentence by using the lists of options.

Client 3, Client 4

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 the stool for which of the following substances?

blood

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

breath sounds

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

check that the client lifts the walker and then places it down in front of her

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

check the patency of the clients airways

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

collect and organize client data

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

compare prescriptions with medications the client received while at the facility

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?

complete a neurological check

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

contact

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

current medications

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 television until I fall asleep at night"

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

"I'll apply ice to my ankle today and tomorrow"

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide?

"its my responsibility to remind you that we have to respect our clients privacy"

A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?

"respite care allows the primary caregiver time away from day to day care responsibilities"

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

"the client was lying on the floor next to his bed"

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"they improve your circulation to keep blood from pooling in your legs"

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

"what could I have done to deserve this illness"

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

-report of feeling pressure -tenderness over the symphysis pubis -distended bladder -voiding 30 ml frequently

A nurse is caring for a client who has a newly placed ileostomy. Complete the following sentence by using the lists of options.

-stoma color -skin around the stoma

A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

-temperature -WBC count -Prealbumin level -Pain level -Odor of wound

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 in the emergency department (ED) is caring for a client who reports abdominal pain. Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply.

-Assist the client to a left side-lying position with the right knee flexed -Administer a cleansing enema -Auscultate the client's bowel sounds -Perform a manual digital examination of the client's rectum

A nurse in the emergency department (ED) is caring for a client. Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again.

-Cachectic, with flaccid muscle tone -Skin dry and scaly with bruises on extremities -Pulse rate 118/min -Abdomen distended -BMI 17

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 hypoxia

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 is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

-Place the client on droplet isolation precautions -Apply oxygen at 2 L/min via nasal cannula -Request a prescription for an antipyretic medication -Remain 1 m (3 feet) from the client

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days.The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

-Request a prescription for an antibiotic medication is correct -Initiate droplet precautions is correct. -Wear a mask within 1 m (3 feet) of the client is correct. -Apply a mask on the client when they leave their room is correct.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.

-passive range of motion exercises to lower extremities performed once each day -plantar flexion contractures noted bilaterally -left heel with 1/3 cm x 1.3 cm area of nonblanchable erythema, skin intact

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.)

-protective mask -closed door -a puncture proof sharps container -hand hygiene

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?

208

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.)

1. inject 10 units of air into the bottle of NPH insulin 2. inject 5 units of air into the bottle of regular insulin 3. withdraw the correct dose of regular insulin from the bottle 4. withdraw the correct dose of NPH insulin from the bottle

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

740

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

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips

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?

N95 respirator

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of 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 I urinated at 7:00 am and have saved all urine since

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

discard the table and obtain another dose of medication

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 preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

reach around the pack and open the flap away from the body

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 caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse response affirmatively

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

a client who smokes one pack of cigarettes each day

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

a client who sustained a head injury and is having periods of confusion

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

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

albumin

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 is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

apply an ankle-foot orthotic device to the clients feet

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

assess the apical pulse for a full minute

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 of the following actions should the nurse take next?

evacuate the client

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?

flush the tube with 15 mL of sterile water

FLAG 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

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

gloves

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

have family members wear a gown and gloves when visiting

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

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

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

hold the container of solution 30 cm (12 in) above the anus

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

hold the ophthalmic solution 2 cm above the lower conjunctival sac

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

increased calcium excretion

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

initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?

instruct the family to refrain from pushing the button for the client while she is asleep

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

interpersonal

A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?

intimacy vs isolation

A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take?

report the discrepancy immediately

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

mask

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

medication dose

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

move the client to a room closer to the nurses station

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 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 the middle adulthood often find satisfaction in nurturing and guiding young people

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

practice sessions

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

prior to percussing the abdomen

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

provide an adaptive feeding device for the client

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

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 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 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 client to keep the head of the bed elevated at least 30 degrees

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 caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

test the pH of gastric aspirate

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

the caregiver insists on remaining in the room

A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver?

the client is not making any sounds

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

the clients hand is cool and pale

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

the nurse has already considered alternatives to restraints

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

the pain is like a dull ache in my stomach

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

this service began with the clients admission to the hospital

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

to 120

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

turn the client on his side before starting oral care

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

use a transfer device to life the client up in bed

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 orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene?

washes and rinses her hands for 10 seconds

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?

we can talk about advance directives, and i can also give you some brochures about them

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?

when asking if the client took his medications this morning

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

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