Nursing Theory: ATI Final Quiz

What is the typical WBC range?

4000-11000

What is the typical reference range for calcium?

9-10.5 mg/dL

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? a. airborne b. droplet c. contact d. protective environment

a. airborne

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? a. don clean gloves to remove the old dressing b. loosen the dressing by pulling the tape away from the wound c. remove the entire old dressing at once d. open sterile supplies after donning sterile gloves

a. don clean gloves to remove the old dressing

A nurse is admitting a client who experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? a. during the admission process b. as soon as the client's condition is stable c. during the initial team conference d. on the day prior to discharge

a. during the admission process

A nurse is caring for a client with a stage 2 pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? a. hydrocolloid b. collagen c. calcium alginate d. proteolytic enzyme

a. hydrocolloid

A nurse is collecting data from a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? a. increased blood pressure b. decreased blood sugar level c. decreased oxygen use d. increased GI motility

a. increased blood pressure

A nurse is caring for a patient who has chronic kidney disease. The kidneys regulate body fluids and assist with which of the following functions? a. regulation of acid-base balance b. reabsorption of nutrients for cell growth c. regulation of body temperature d. secretion of hormones needed for growth

a. regulation of acid-base balance

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document the client's reflex? a. diminished b. average c. brisk d. hyperactive

b. average

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark has moved since the last feeding. Which of the following actions should the nurse plan to take? a. auscultate over client's stomach while injecting air b. request an X-ray of the client's abdomen c. place the head of the client's bed in a flat position d. administer the feeding if the pH of the aspirated contents is greater than 6

b. request an X-ray of the client's abdomen

A nurse is reenforcing teaching about using crutches with a client who has a fractured left ankle. Which of the following statements indicates an understanding of the instruction? a. I'll place my weight on the crutch pads at my armpits b. I'll wear my leather sole shoes when I am using my crutches c. I'll bend my elbows 20-25 degrees when I walk with my crutches d. When I go downstairs, I will put my crutches and my right leg on the lower step first

c. I'll bend my elbows 20-25 degrees when I walk with my crutches

A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions should the nurse take? a. assist the client into a semi-sitting position b. have the client lean slightly backward c. advise the client to tuck his chin downward d. instruct the client to tilt his head slightly

c. advise the client to tuck his chin downward

A nurse is reenforcing teaching who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include? a. do not use any electrical devices when receiving oxygen b. keep the oxygen tank lying on the floor c. do not use any materials containing oil or alcohol when using oxygen d. use synthetic blankets and clothing when using oxygen

c. do not use any materials containing oil or alcohol when using oxygen

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? a. auscultate for bowel sounds after each feeding b. ensure the formula is cold before administering c. elevate the client's head of bed 45 degrees before the feeding d. flush the tubing with 15 mL of water after the enteral feeding

c. elevate the client's head of bed 45 degrees before the feeding

A nurse is reenforcing teaching with a client who needs to have a bladder scan to check for urinary retention. Which of the following information should the nurse provide about the procedure? a. the bladder scan will take place in the endoscopy unit b. deep pressure will be applied to the bladder area during scan c. the bladder scan will be performed after urination d. pelvic muscle exercises will need to be performed during the bladder scan

c. the bladder scan will be performed after urination

A nurse is administering an IM injection to a 5 month old infant. Which of the following injection sites should the nurse use? a. deltoid b. ventrogluteal c. vastus lateralis d. dorsogluteal

c. vastus lateralis

A nurse should apply __________ to a stage 4 pressure ulcer. This type of dressing is used for wounds with significant exudate and must be covered with a secondary dressing

calcium alginate

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual. Which of the following actions should the nurse take? a. have the client urinate 20 minutes before the scan b. assist the client into a Semi-Fowlers position c. position the head at the pubic symphysis d. apply light pressure to the scanner head once it is in position

d. apply light pressure to the scanner head once it is in position

A nurse documents clubbing of the fingernails for a client who has emphysema. The nurse should identify that which of the following is the underlying cause of this finding? a. trauma b. severe infection c. iron-deficiency anemia d. chronic hypoxemia

d. chronic hypoxemia

A nurse is preparing to administer a tuberculin test to a client. After performing hand hygiene, which of the following actions should the nurse take? a. select a 23 gauge needle b. insert the needle into the skin at a 25 angle c. massage the injection area following removal of the needle d. circle the area of the injection with a pen

d. circle the area of the injection with a pen

A nurse is preparing to measure a client's blood pressure with a sphygmomanometer and a stethoscope. Which of the following actions should the nurse take? a. wrap the cuff loosely around the upper arm b. use a cuff with a bladder than encircles 60% of the client's upper arm c. place a cuff so it's lower edge is 0.5 inches above the antecubital space d. have the client place both feet flat on the floor

d. have the client place both feet flat on the floor

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a. auscultate for the blood pressure at the dorsalis pedis artery b. measure the blood pressure with the patient sitting on side of bed c. place the cuff 3 inches above the popliteal artery d. place the bladder of the cuff over the posterior aspect of the thigh

d. place the bladder of the cuff over the posterior aspect of the thigh

A nurse is caring for a patient who is dehydrated. An insensible loss of fluid of approximately 500 to 600 mL each day occurs through which of the following organs? a. kidneys b. lungs c. GI tract d. skin

d. skin

A nurse should apply a ________ ________ to an unstageable pressure ulcer. This type of dressing is applied to facilitate debridement and to soften eschar.

proteolytic enzyme