ATI FUNDAMENTALS 4

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound."

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"If I do this often I won't get pneumonia."

A client has 1 L of dextrose 5% in 0.45% sodium chloride in fusing IV at 125 mL per hour. How many hours will it take for the liter to infuse?

8

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night.

A nurse is preparing twin minister a TB skin test to a client. After performing hand hygiene, which of the following action should the nurse take?

Circle the injection area with a pen; circling the area with a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later.

A nurse is caring for a client who has a terminal illness. Which of the following findings indicate that the client death is imminent?

Cold extremities

A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking?

Collecting and trading game cards: collecting and trading game cards require seriation of the cards, involving what to collect, what to trade, and what has value. There is a characteristic of Piaget's concrete operational stage for ages 7 to 11 years.

A nurse on a medical surgical unit observed smoke billowing from a clients room. Which of the following action should the nurse take first?

Evacuate the client from the room

A client who has glaucoma of the right eye Self administer timolol eyedrops by looking at the ceiling, instilling a drop into 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 action should the nurse take?

Instruct the client to apply pressure to the inner corner of the eyes after installation; apply gentle pressure over the nasal lacrimal duct to prevent medication from flowing into the nasal passages where systemic absorption could result.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asked the nurse how the TENS unit helps relieve pain. Which of the following responses should the nurse make?

It modulate the transmission of the pain impulse; It can also cause a release of endorphins to assist with pain relief

A nurse is talking with the parent of a preschool aged child who tells the nurse, "my child has suddenly become this interested in certain foods." Which of the following statements should the nurse make?

Keep a diary of the foods your child eats each day

A nurse is admitting a client who has in hearing aid. Which of the following actions should the nurse take before beginning the interview process?

Make sure the device is functioning

A nurse in a provider's office is measuring a client and notes a lost in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

Osteoporosis

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following action should the nurse take?

Placed the bladder of the cuff over the posterior aspect of the thigh

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the clients urine is 1.035. Which of the following action should the nurse take?

Provide more water with feedings

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

A nurse is administering a IM injection to a five month old infant. which of the following injection sites would should the nurse use?

Vastus Lateralis

A nurse is screening a client who has an S shaped spinal column with unequal shoulder Heights. The nurse should identify these findings as manifestations of which of the following abnormalities?

scoliosis

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environment should the nurse manager identify as an acceptable place for discussing clients information?

Areas with no public access

A nurse is performing a focused assessment of a client peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus; The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle

A nurse is caring for a Miller middle aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with others; middle aged adults usually feel more comfortable with themselves and ceased to make comparison with others.

A nurse is caring for a client who has a stage III pressure ulcer on the hill. When preparing to irrigate the wound, which of the following action should the nurse take first?

Check the client's pain level

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?

Death is viewed as an interruption of what might have been

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decreased estrogen and testosterone production

A New resident Provider asked the charge nurse for an access code to review Clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?

Explain that it is against policy to share access codes and refer the resident to his supervisor.

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic test should the nurse recommend as part of this client routine health screening?

Eye examination every two years

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

Hold the breath for 5 sec after goal volume is reached

A nurse is teaching a client who is using a patient controlled analgesia PCA pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button

A nurse is teaching a group of older adults about expected age related changes. Which of the following statements by a group member indicates that the teaching has been effective?

I should expect my heart rate to take longer to return to normal after exercise as I get older

A nurse is caring for a client who is 48 hours post operative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this post operative complication?

Impaired peristalsis of the intestines