ATI exam 2

a nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?

250 mL/hr

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for intravenous pyelogram. Which of the following statement 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 clients needs further teaching?

"I watch television until I fall asleep at night."

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following clients statements indicates a need for further teaching?

"I will need to wipe my perineal area from back to front after urination."

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

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

a nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will wear synthetic clothing and 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 front to back"

a nurse is teaching client who is obese and 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 50 pounds, I might stop having so many apneic episode."

a nurse is providing teaching to a client who takes opioid pain medication and has new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of teaching?

"It might take up to 3 days for the medication to work."

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 preparing to administer heparin 3000 units by IV bolus. Available is heparin injection 5000 unit/mL. How many mL should the nurse administer?

0.6 mL

a nurse is preparing to administer clonidine 0.3 mg at bedtime to a client. The amount available is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose?

3 tablets

a nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

4 mL

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 placed. Which of the following readings should the nurse expect?

4.0

a nurse is preparing to administer lactated ringer's 400 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

44 gtt/min

A nurse in an emergency department is caring a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and 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 an indwelling urinary catheter. Which of the following actions should he nurse take to prevent infection.

Check the catheter tubing for kinks or twisting

a nurse is caring for a client who has newly inserted chest drainage system with a water seal. Which of the following actions 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 and 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 caring for client who has a prescription for a stool 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 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?

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

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 urinary tract infection (UTI). Which of following manifestation 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 note slow, steady bubbling in the suction control chamber. Which of the following actions 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 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 is reviewing the medical record of a client who has a urinary tract infection (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 and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe 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 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 constipations?

excessive laxative. 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 assistive personnel (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 who reports constipation. Which of the following instructions should the nurse include in the teaching?

increase dietary intake of raw vegetables

a nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestation as a complication and contact the provider immediately?

increased heart rate

a nurse is educating a client who is experiencing sleep disturbance and desire 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 the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

lower the height of the solution container

a nurse is caring for a client who has peripheral vascular disease and 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 be the nurse take first?

perform a bladder scan

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 in a PACU is assessing a client who has 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 unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

raise the head of the bed

a nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect?

report of feeling pressure. tenderness over the symphysis pubis. distended bladder. voiding 30 mL frequently.

a nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult wiht 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 has a new prescription for a meter dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

shake the inhaler for 3 to 5 seconds

a nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect?

sudden attacks of sleep. hallucinations at the onset of sleep.

a nurse in a long-term care facility is caring for an older adult client who has dementia an 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 intimate to manage this behavior?

take the client to the bathroom every 2 hr

a nurse removes an indwelling urinary catheter that an older adult client has had a 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 colostomy. Which of the following findings should the nurse report to the provider?

the stoma is pale in color

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

urinary tract infection