ATI PRACTICE A

A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching

"I must stop smoking" "I need to monitor my weight" "I am limiting my intake of fast foods"

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the clients partner should indicate to the nurse that the teaching was effective?

"My partner should tilt their head forward when swallowing"

A nurse is providing teaching to a client who is taking warfarin about monitoring its therapeutic effects. Which of the following explanations should the nurse provide about the international normalized ratio(INR) test?

"the INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times"

A nurse is collecting data on a client who has a new prescription for ampicillin. The nurse should recognize which of the following findings is priority.

(Wheezing)***** When using the airway, breathing circulation approach to client care, the nurse should determine the priority finding is wheezing. Wheezing is a manifestation of an anaphylactic allergic reaction due to bronchospasm and edema in the airway. wheezing indicates a constriction of the airway and requires immediate intervention to support respiratory function. The nurse should advice the client to wear identification to indicate and allergy to this medication.

Steps to remove PPE

1.Remove the gloves 2.Remove the protective eye wear 3.Remove the gown 4.Remove the mask

A nurse is caring for client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints

Assist the client with toileting at frequent intervals Use an electronic position-sensitive device Provide diversionary activities for the client Involve the family in the clients care

A nurse is caring for a client who is admitted with community acquired pneumonia and has been receiving oxygen therapy for several days which of the following findings indicate an adverse effect of oxygen therapy.

Cracks in the oral mucosa

A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. during which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange

Diagnosis

A nurse is caring for a client who has an infection and a prescription for gentamicin intermittent Iv bolus every 8hr. A peak and trough is required with the next dose. Which of the following actions should the nurse take to obtain an gentamicin serum level?

Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose

Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia.When assessing this client a nurse should expect which of the following findings?

Elevated blood pressure

A nurse is caring for a client who frequently attempts to remove his iv catheter. A family member requests that the nurse apply restraints.Which of the following responses should the nurse make

I will cover the catheter so he cannot see it

A nurse is caring for a client who is scheduled for surgery.The nurses role in regard to informed consent is which of the following

In the role of clients advocate, the nurse is responsible for ensuring the client understands the information provided by the surgeon and must notify the surgeon if the client has answers.

A nurse is caring for a client whose informed consent form has been signed in preparation for a procedure. The client states, "I have decided not to have the procedure." Which of the following actions should the nurse take

Inform the provider that the client is withdrawing consent

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which of the following adverse reaction to this medication

Jaundice

Administering oxygen therapy with a non breather mask has which of the following advantages?

Offers the highest oxygen concentration of the low flow systems

A nurse should recognize that which of the following findings is an indication for oxygen therapy

Oxygen saturation (SaO2) 90%

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory valves should the nurse monitor for therapeutic effect of warfarin?

Prothrombin time (PT)

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following non modifiable risk factors should the nurse include in the teaching?

Race (race is a nonmodifiable risk faactor which the client is unable to control)

A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must

Reposition the elastic band frequently

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Respiratory rate (When using the airway, breathing circulation approach to client care, the nurse should determine the priority assessment is respiratory rate. Morphine can cause respiratory depression. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12/min)

A nurse is caring for a client who has been receiving oxygen via nasal cannula for four hours. Which of the following assessment findings helps indicate the oxygen therapy has been effective.

Respiratory rate 14/minute

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching

Take the medication with food

A newly licensed nurse is applying prescribed wrist restraints on a client.Which of the following actions should the nurse take?

The nurse should secure the restraints using a quick release tie for easy removal in an emergency

A nurse is caring for a client who has methicillin resistant staphylococcus aureus(MRSA) in an abdominal wound. The nurse enters the room to check the pulse. Which of the following actions should the nurse take?

The nurse should wear clean gloves to prevent the transmission of MRSA

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect.

The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere

A nurse is caring for a critically ill client who has COPD and Requires delivery of a precise concentration of oxygen which of the following types of oxygen delivery devices as indicated for this client

Venturi mask

A nurse is providing teaching for a client who is postoperative below the knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for wound healing?

Vitamin C

A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include?

Who is the oxygen tank and a clutter free environment

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

Witness the clients signature

A nurse is preparing a client who is postoperative following a below the knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?

Wrap the stump helps with an elastic bandage in a figure eight configuration

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?

You should avoid grapefruit juice

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci(VRE). Which of the following types of precautions should the nurse plan to initiate?

contact precautions are a type of transmission based precaution for clients who have an infection, such as VRE, Which spreads either by direct or indirect contact