ATI Fundamentals 8

The nurse is reviewing the laboratory values of a client who has a positive Chvosteks sign which of the following laboratory findings should the nurse expect ?

A decrease in calcium As calcium is necessary for nerve conduction and muscle contraction when the client's total calcium level is below 8.4 tetany and muscle spasms may occur if the facial muscles twitch following a stimulation it is positive of Chvosteks sign and an indication of hypocalcemia

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 ?

Elevate the head of the clients bed to 45 degrees before the feeding to prevent aspiration

A nurse is admitting a client who will undergo a craniotomy during the planning phase of the nursing process which of the following actions should the nurse take ?

Establish client outcomes

A nurse is caring for a client who just received a diagnosis of cancer the client states I just don't know what I'm going to do now which of the following responses should the nurse make ?

Can you please explain the concerns you are having right now as this response is a therapeutic communication technique asking a relevant question which is open ended

A nurse is preparing to insert an Ng tube for a client which of the following actions will help facilitate the insertion of the tube ?

Coat the tip of the tube with a water soluble lubricant ask the client to swallow water while the tube enters her throat tell the client to tilt her head backwards as the insertion begins

A nurse is preparing to administer medications to a client who is unconscious the nurse should bring the medication administration record to the client's bedside and perform which of the following verification procedures ?

Compare the medical record number and the name on the MAR with the clients identification band as the use of two client identifiers must be used when administering medications

A nurse has received a prescription for dextrine to administer to a client the nurse should recognize that dextrin belongs in which of the following functional classifications ?

Dextran and albumin or plasma volume expanders that help correct hypovolemia in emergency situations such as after a hemorrhage or possible burn

A nurse is teaching a client about lifestyle changes to manage a chronic illness which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes ?

Help the client identify ways that these changes will result in positive personal outcomes as a client should first see how the changes directly affect their life thus enhancing the motivation to make the changes

A home health nurse is visiting an older adult client with severe dementia the client son who serves as her primary caregiver reports being exhausted from working part time and caring for his mother at home which of the following options should the nurse suggest to the caregiver ?

Respite care

A nurse is preparing to administer a unit of packed red blood cells to a client when she discovers that the Ivy line is no longer patent divy team informs her that someone can come to initiate a In 30 minutes which of the following actions should the nurse take ?

Return the blood back to the laboratory

A community health nurse is preparing a campaign about seasonal influenza which of the following plans should the nurse include as a form of secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is caring for an adult client who is grieving following the death of a loved one which of the following factors increases the clients risk of developing complicated grief ?

The death was sudden as complicated grief can occur when the death of a loved one is unexpected

A part of a neurological examination a nurse instructs a client to keep his eyes closed places an object in his hand and asks him to identify the object which of the following abilities is the nurse evaluating with this technique ?

The nurse is identifying stereognosis as the ability to identify an object size shape and texture via tactile sensations

A nurse is witnessing a client sign an informed consent form for surgery what is the nurse affirming by this action ?

The signature on the preoperative consent form is the clients as the nurse acts as a witness to confirm that the client signature is present

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 clients ability in which of the following intellectual functions ?

abstract reasoning As the exercise evaluates higher level thinking and ability to understand and interpret abstract thoughts

A nurse is caring for a group of clients in a long term care facility one of the clients is walking along the hallway and bumping into walls and does not respond to his name which of the following actions should the nurse take first ?

Accompany the client back to his room

A nurse is assessing a client for conductive hearing loss when using the renea tests 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 ear because this finding indicates conductive hearing loss of the left ear

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation for pain management the client asks the nurse how a 10s unit helps to relieve pain which of the following responses should the nurse make ?

It modulates the transmission of the pain impulse as it applies low voltage electrical stimulation directly over a location of pain at an acupressure point modulating the transmission of the pain impulse and causing a release of endorphins to assist with pain relief

A nurse in a providers office is collecting information from an older adult client who reports taking acetaminophen 500 milligrams a day for severe joint pain the nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects ?

Liver damage as large doses can be toxic to the liver daily intake should be limited to less than three to four grams and two to four grams for older adults

A nurse is cleaning a clients wound by swabbing from the area of least contamination to an area of greater contamination which of the following rationale should the nurse identify for using this technique?

So the nurse is keeping microorganisms from entering the the wound so by starting at the area of least contamination and working outward or toward the area of greater contamination it just prevents the spread of microorganisms

A nurse is caring for a client who has peripheral edema the nurse should identify that which of the following nutrients regulates extracellular fluid volume ?

Sodium regulates extracellular fluid balance as nerve impulse transmission acid base balance and various other cellular activities