ATI Questions 2

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

clean the drain site from the center outward

A nurse is caring for a client who is receiving dextrose 5% water IV at 150mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8 hour volume intake

1560

A nurse is preparing to administer digoxin 0.125mg PO daily to a client who has heart failure. The amount available is digoxin 0.0625 mg/tablet. How many tablets should the nurse give?

2

A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task

"I think I have done a good job with my children since they are all independent now"

A nurse is instructing a client about collecting a 24 hour urine specimen for creatine clearance. Which statement indicates clients understanding?

"I will make sure to keep the collection bottle in the container of ice they gave me"

A nurse is preparing to collect data about the function of a clients trigeminal nerve or cranial nurse v. Which of the following items should the nurse gather for the test?

cotton wisps

A nurse is monitoring a client who is receiving lactaded ringers 500mL IV infused over 4 hours, the drop factor of the manual IV tubing is 15gtt/mL. The nurse should have the infusion pump deliver how many gtt/min

31

A nurse is caring for a semi-conscious client who had a small-bore NG tube placed yesterday for the administration of enteral feedings. Which of the following methods should the nurse use to verify correct placement? Select all that apply

Verify initial X Ray Measure the length of the exposed tube determine the pH of the aspirated fluid

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, what should the nurse increase?

Vitamin C and Zinc

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the OR. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision

A nurse in a providers office is measuring an adult client and notes a decrease 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 monitoring a clients lab results. Which of the following results should the nurse report to the provider?

Potassium 3.0mEq/L

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which action should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record

A nurse is planning a community presentation for young adults. What behavior should the nurse suggest incorporating into the presentation?

adjusting to living with a partner

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

apply pressure to the bridge of the nose after instillation of the medication

A nurse in a providers office is reinforcing teaching with a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? Select all that apply

black beans, whole grain bread

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward what?

ceasing to compare personal identity to others

A nurse is collecting data from a client who potassium level is 2.8mEq/L. Which of the following findings should the nurse expect?

decreased bowel sounds

A nurse is performing a mental-status examination for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?

discuss the meaning of a common proverb

A nurse is changing the dressings for a client recovering from an appendectomy followed by a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

halo of erythema on the surrounding skin

A nurse is reinforcing teaching about how to use an incentive spirometer with a client who is recovering from gallbladder surgery. What should the nurse include in the teaching?

hold a breath for 5 seconds after goal volume is reached

A nurse is caring for a client who has a stage 2 pressure ulcer. Which wound dressing should the nurse apply?

hydrocolloid

A nurse is collecting data from a client whose calcium level is 7.1 mg/dL. Which of the following findings should the nurse expect?

hyperactive reflexes

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can cause what?

hyperglycemia

A nurse is assisting a provider with performing thoracentesis to remove pleural fluid. How should the nurse position the client?

leaning forward over a pillow

A nurse is reviewing the lab results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as an indication of which of the following conditions?

leukopenia

A nurse is performing suctioning for a client who has a tracheostomy. Which action should the nurse take?

pull back suction catheter by 1 cm (0.5 in) if client starts coughing

A nurse is changing the dressings for a client who is 3 days post op. Nurse observes yellow, thick drainage. What type is this?

purulent

A nurse is caring for a client in a long-term care facility. Which finding should alert the nurse to identify a possibility of delirium

reduced level of consciousness

A nurse is caring for a client who has a history of dysrhythmias. The nurse discovers client is unresponsive to verbal/painful stimuli, has no respirations or pulses. What should the nurse do first?

start chest compressions

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates what outcome?

supports self-determination

A nurse is reinforcing teaching for a client about performing ROM exercises of the wrist. To have the client demonstrate adduction, which instruction should the nurse give?

with your palm facing down, move your wrist sideways toward your thumb

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the clients finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take?

wrap the client's finger in a warm washcloth

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following lab values can cause confusion?

sodium 123mEq/L