ATI Fundamentals with reasoning

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? A. Allow extra time for the client to respond to questions B. Expect the client to have difficulty understanding the information C. Avoid references to the client's past experiences D. Keep the learning session private and one-on-one

A. Allow extra time for the client to respond to questions Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information

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? A. Gently shake the container of medication prior to administration B. Transfer the medication to a medicine cup C. Place the client in a semi-Fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administering it

A. Gently shake the container of medication prior to administration The nurse should gently shake the liquid mediation to ensure the medication is mixed

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. A. Withdraw the correct dose of regular insulin from the bottle B. Inject 10 units of air into the bottle of NPH insulin C. Withdraw the correct dose of NPH insulin from the bottle D. Inject 5 units of air into the bottle of regular insulin

B. Inject 10 units of air into the bottle of NPH insulin D. Inject 5 units of air into the bottle of regular insulin A. Withdraw the correct dose of regular insulin from the bottle C. Withdraw the correct dose of NPH insulin from the bottle Just remember cloudy (NPH) to clear (regular) then clear (regular) to cloudy (NPH)!

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity

B. Pupil clarity D. Visual fields E. Visual acuity Impairment of the ability to produce tears and the condition of the conjunctivae should not impede client safety

A nurse is caring for a client who requires 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. I had a bowel movement but was unable to save the urine B. I have a specimen in the bathroom from about 30 minutes ago C. I flushed what I urinated at 7am. I have saved all urine since D. I drink a lot, so I will fill up the bottle and complete the test quickly

C. I flushed what I urinated at 7am. I have saved all urine since For a 24 hour urine collection, the client should discard the first voiding and save all subsequent voidings

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A. Apply the stockings so the creases are on the front side of the leg B. Apply the stockings while the client's legs are in a dependent position C. Remove the stockings at least once per shift D. Remove the stockings while the client is sitting in a reclining chair

C. Remove the stockings at least once per shift The nurse should remove the stockings at least once per shift to check the client's circulation and skin integrity

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? A. Drink a cu of hot cocoa before bedtime B. Exercise 1 hour before going to bed C. Use progressive relaxation techniques at bedtime D. Reflect on the day's activities before going to bed

C. Use progressive relaxation techniques at bedtime Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension

A charge nurse is discussing the responsibility of nurses caring for clients who have C.diff infection. Which of the following information should the nurse include in the teaching? A. Assign the client to a room with a negative-airflow system B. Use alcohol-based hand sanitizer when leaving the client's room C. Clean contaminated surfaces in the client's room with a phenol solution D. Have family members wear a gown and gloves when visiting

D. Have family members wear a gown and gloves when visiting Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of C.diff spores. Caregivers must also wear gowns and gloves

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer B. Focus teaching on what the client will need to do in the future to manage his illness C. Provide the client with written information about the phases of loss and grief D. Reassure the client that this is an expected response to grief

D. Reassure the client that this is an expected response to grief During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A. Auscultate lung sounds B. Measure urine output C. Monitor blood pressure readings D. Monitor serum electrolyte levels

A. Auscultate lung sounds The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid-volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries B. Move hazardous objects away from the client C. Notify the provider D. Ask the client to describe how she felt before the fall

A. Check the client for injuries The first action the nurse should take when using the nursing process is to assess the client for injuries

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A. Erythema on pressure points B. Lower-extremity pulse strength of 2+ C. Fluid intake of 3,000 mL per day D. A bowel movement every other day

A. Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics

A. Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventative and therapeutic strategy

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A. Insert an implanted port B. Close a laceration with sutures C. Place an endotracheal tube D. Initiate an enteral feeding through a gastrostomy tube

D. Initiate an enteral feeding through a gastrostomy tube It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse B. A nurse asks a nurse from another unit to assist with her documentation C. A nurse who is caring for a client returns a call to the client's durable power of attorney for healthcare designee to discuss the client's care D. A nurse discusses the client's status with the physical therapist that is caring for the client at the client's bedside

B. A nurse asks a nurse from another unit to assist with her documentation Only healthcare professionals directly caring for a client may access medical information; therefore, this is a violation of HIPAA guidelines

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? A. Ensure sterilization of non-disposable items with ethylene oxide B. Wrap monitoring cords with stockinette and tape them in place C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication D. Wear hypoallergenic latex gloves that contain powder

B. Wrap monitoring cords with stockinette and tape them in place Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a non-latex barrier material, such as stockinette, and using non-latex tape to secure them

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? A. I'll get a blood sample from you and send it for a screening test B. Beginning at age 60, you should have a colonoscopy C. You should have a fecal occult blood test every year D. The recommendation is to have a sigmoidoscopy every 10 years

C. You should have a fecal occult blood test every year Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube B. Remove the NG tube if the client begins to gag or choke C. Apply suction to the NG tube prior to insertion D. Have the client take sips of water to promote insertion of the NG tube into the esophagus

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. I can concentrate best in the morning B. It is difficult to read the instructions because my glasses are at home C. I'm wondering why I need to learn this D. You will have to talk to my wife about this

A. I can concentrate best in the morning The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply) A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2-hour increments D. Wear a surgical mass when providing client care E. Use antimicrobial sanitizer for hand hygiene

A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care E. Use antimicrobial sanitizer for hand hygiene The nurse does not need to limit the client's visitors, but should limit the amount of time the client is outside of their room The nurse should wear an N95 respirator during client care

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. Use the complete name of the medication magnesium sulfate B. Delete the space between the numerical dose and the unit of measure C. Write the letter U when noting the dosage of insulin D. Use the abbreviation SC when indicating an injection

A. Use the complete name of the medication magnesium sulfate The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medication in order to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C. Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? A. Touch the face with a cotton ball B. Apply a vibrating tuning fork to the client's forehead C. Have the client stand with her arms at her side and her feet together D. Perform direct percussion over the area of the kidneys

C. Have the client stand with her arms at her side and her feet together Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her side and her feet together to observe her for swaying and loss of balance