ATI Practice A

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?

Check the client for injuries

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. -To ensure the medication is mixed

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?

I can concentrate best in the morning -This statement indicates a readiness to learn since he is verbalizing the best time for him to learn

A nurse is caring for a client who require a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse if performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen -Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries

A nurse is assessing an older adult 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.)

Pupil clarity, Visual fields, Visual acuity --Cloudy pupils mean that the pt has cataracts, which can increase his risk for falls --Visual fields are tested by the use of a finger test by moving it out of range and then back into his visual field to determine when he sees the finger --Visual acuity should be assessed using a Snellen chart

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting the object?

Stand close to the cabinet when lifting -This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output -For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter

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?

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

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 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. -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 nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid -The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further medical incidents

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward -The nurse should clean the wound from the center outward to prevent introduction of microorganisms from the outer skin surface

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 -By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

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.

Inject 10 units of air into the bottle of NPH insulin.Inject 5 units of air into the bottle of regular insulin.Withdraw the correct dose of regular insulin from the bottle.Withdraw the correct dose of NPH insulin from the bottle.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Kkin blanching -Skin blanching, edema, and coolness and the IV site indicate infiltration.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position -The nurse should place the pt's arm in a dependent position because the veins will dilate due to gravity

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate -Tachycardia indicated fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees -All of the actions are appropriate; HOWEVER, the first action the nurse should take when using the ABC approach to pt care is to prevent aspiration of the enteral formula. This is done to prevent reflux of the formula backward into the esophagus

A nurse in a clinic is caring for a middle aged adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a 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. -Colorectal cancer screening for clients at average risk begins at age 50.