ATI Dynamic Quiz: Easy: My mistakes with rationale.

#143: During completion of a health history, a client reports having chest pain intermittently 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?" When using the urgent vs. non-urgent approach to client care, the nurse determines that the priority question for evaluating the client's pain is to quantify its characteristics, onset, duration, surrounding events, and location. This will help that nurse determine what actions to take next.

#50: A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates potential problem with achieving Erikson's developmental task of this age group?

"I go home on the weekends to be with my family because I don't have any good friends here on campus." According to Erikson, the stage of psychosocial development for young adults is intimacy vs. isolation. This statement indicates the student is having difficulty establishing relationship outside of the immediate family.

#63: A nurse is reinforcing teaching about heat therapy with a client who has low back pain. Which of the following statements by the client indicates an understanding of the teaching?

"I need to place a towel between the heating pad and my skin." The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns.

#116: A nurse is collecting data about a client's spiritual wellbeing. Which of the following questions should the nurse ask?

"What is your source of strength and hope?" This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope.

#44: A nurse is reinforcing teaching with a preschooler about how to use a metered-dose inhaler. Which of the following methods should the nurse use during this instructional session?

A simple demonstration of inhaler use. For preschoolers, simple explanations and demonstrations are developmentally appropriate. The nurse should explain how the inhaler works and demonstrate its use without the medication canister inside it. To make sure the client knows how to use the inhaler, the nurse should ask for a return demonstration.

#43: By asking a client to explain the statement, "A bird in the hand is worth 2 in the bush," the nurse is evaluating the client's ability in which of the following intellectual functions?

Abstract reasoning. This exercise evaluates higher-level thinking and ability to understand and interpret abstract thoughts.

#12: A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep?

Allow the client to maintain the same bedtime routine as at home. For many clients in an acute care facility, disrupting the usual sleep routine is the primary reason for a client's inability to sleep. Maintaining the client's home bedtime routine promotes sleep effectively. Those whose usual bedtime routines include warm milk, massage, or pharmacological sleep aids might need and appreciate those interventions in inpatient settings.

#106: A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac. The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

#61: A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked. The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are least invasive to the client, as long as those intervention do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduce into the body, decreasing the number of facility-acquired infections. Therefore, the nurse first should inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage may due to a kink in the tubing or the client lying on a part of it.

#90: 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?

Chronic hypoxemia. Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia as seen in COPD. It is a change in the angle between the nail and the nail base, often with enlargement of the fingertips.

#83: A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

Compare the medical record number and name on the MAR with the client's identification band. The Joint Commission requires the use of 2 client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band.

#110: A nurse is collecting data from a client who has fluid-volumed excess. Which of the following findings should the nurse expect?

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

#119: A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors places the client at risk of developing complicated grief?

The death was sudden. Complicated grief can occur when the death of a loved one is sudden and unexpected.

#122: A nurse is contributing to the plan of care for a client who had stroke and is scheduled to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend prior to initiating each feeding?

Elevate the head of the bed. Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently , the nurse should take actions to prevent aspirations such as elevating the head of the bed prior to initiating the feeding.

#95: A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music. The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.

#107: A nurse is collecting data from a client who requires hygiene care. Which of the following pieces of information is the nurse's priority to determine before preparing to bathe the client?

How much the client can assist with bathing. The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care. Therefore, the nurse's priority is to collect data about the client's muscle strength, flexibility, vision, cognition, and sensation and to adjust hygiene procedures accordingly to ensure safety.

#131: A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour. The nurse should monitor the client frequently as a means of reducing the client's fall risk. Other measures can include keeping the client's bed in a low position, creating elimination schedules, and using a gait belt when the client is ambulating.

#150: A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse perform when working with the interpreter?

Pace speech to allow time for the interpreter to convey the words. The nurse should speak distinctly and at a rate that allows time for the interpreter to convey the message and for the client to receive it.

#10: A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication. The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.

#34: A nurse is preparing to administer a medication to a client. Which of the following administration schedules indicates that the nurse should administer the medication once and as soon as possible?

Stat prescription. The should identify that a stat medication prescription is carried out immediately and one time only.

#37: A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

Talk with the AP about the technique used. The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves.