ATI Foundations

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

hold the sterile drape above the waist and away from the body

a nurse is teaching the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. how many tablespoons of medication should the nurse instruct the parent to give to the child?

2

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2 a range of 0-4 for gastric secretions

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

2 mm

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following 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 caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical prinicple of veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

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 has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus.

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 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?

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 a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities

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 is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

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?

Evaluate the client.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

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

Have family members wear a gown and gloves when visting

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position

as a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further teaching is required?

If the client seems confused, i'll raise all 4 side rails so that he doesn't hurt himself.

A nurse is caring for a client who has fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial.

a nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include?

Protein serves as an energy source when other sources are inadequate

A nurse is reviewing protocol in preparation for suctioning secretions from 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 examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?

Sitting

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? Stat PRN Standing Single

Stat

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 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 is caring for a group of clients in a long term care facility. the nurse should understand that which of the following clients is eligible for hospice services at this time?

a client who has end-stage cirrhosis.

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions?

abstract reasoning

A nurse is assessing a client for conductive hearing loss. When using the rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

air conduction is less than bone conduction in the left air

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. which of the following instructions should the nurse include in the teaching?

bear weight on both of your legs

A nurse is caring for a client who requires a dressing change. which of the following actions should the nurse take?

clean the drain site from the center outward

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform?

cleanse the wound with 0.9% sodium chloride irrigation

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

depressed deep-tendon reflexes

A nurse is caring for a client who is producing large amounts of urine. the nurse should document this finding as which of the following?

diuresis

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse intiate?

droplet

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 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 in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium? gradual memory loss reduced level of consciousness difficulty with abstract thought verbalized feelings of hopelessness

reduced level of consciousness

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the inection?

side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs?

skin

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

loss

A nurse in a provider's clinic is taking a client's age, height, weight and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

assessment

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. the client states, "I have a document with me that names someone who can make health care decisions for me if a am not able." the nurse should identify that the client if referring to which of the following documents?

durable power of attorney document

a nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. which of the following actions should the nurse include in the plan of care? set the machine at 120 mmHg provide oral hygiene frequently measure the amount of drainage from the NG every shift secure the NG to the client's gown apply petroleum jelly to the client's nares

provide oral hygiene frequently measure the amount of drainage from the NG every shift secure the NG to the client's gown Single lumen NG tubes are used for intermittent suction with the machine being set at 80 to 100 mm Hg.

A nurse is evaluating the development of a group of clients. according to erikson, the developmental task of intimacy vs isolation occurs during which of the following stages of development?

Young adulthood

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation

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 is planning to insert a NG tube for a client after explaining the procedure. The client states, "you are not putting that hose down my throat" which of the following statements should the nurse make?

I can see that this is upsetting you

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 providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

Lentils

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 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