NCLEX- ATI study prep

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? a. isopropyl alcohol b. chlorheixdine gluconate c. chlorine d. iodophor

C

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? a. determining the clients responsibility. rate b. measuring the clients chest diameter c. obtaining the clients level of oxygen saturation d. checking the clients depth of respiration's

C- oxygen saturations measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues

A nurse is assigned to care for four clients. the client with which of the following drainage tubes is at an increase risk for hypokalemia? a. nephrostomy tube to drainage bag b. indwelling catheter to gravity c. chest tube to water seal d. NG tube to suction

D

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis? a. tuberculin test b. chest x-ray c. enzyme linked immunoassay (ELISA) test d. sputum culture for acid - fast bacillus

D- this is the only method to confirm active TB

A nurse is caring for a client following a right below the knee amputation. Which of the following should the nurse include in the plan of care to prevent infection? a. position the affected limb elevated on a pillow b. encourage the client to lie prone for 20-30 mins several times a day c. encourage the client to lie spin 20-30 mins several times a day d. position the affected limb in a dependent position

D- this will promote blood flow and oxygenation which will decrease the risk of infection

What is caused by a reduced oxygen level in the tissues because of an increase in circulating deoxygenated hemoglobin?

cyanosis- blue

what is caused by increased amounts of bilirubin being deposited in the tissues?

jaundice- yellow orange color

A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? a. change tracheostomy ties when soiled b. clean disposable inner cannula with hydrogen peroxide c. suction the tracheostomy before beginning care d. remove soiled dressing with sterile gloves

A

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the clients code status to DNR? a. a written prescription from the provider b. signed documentation from the client c. family support of the decision d. admission to hospice for palliative care

A

A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water deal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate? a. assist the client to a side lying position b. remove 10 mL of water from the suction control chamber c. apply a padded clamp on the tubing for 1-2 min d. move the drainage system above the level of the clients heart

A

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform electronic blood pressure measurement? a. a client who is recovering from a cardiac cath b. a client who is in stage 4 Parkinson's disease c. a client who has anorexia and hypotension d. a client who has a temp. to 102.4 F and is shivering

A

A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? a. twisting at the waist and shoulders b. standing with feet in a wide stance c. positioning self close to the client d. using arms and legs to lift

A

a nurse in a providers office is orienting a newly licensed nurse on how to position a client for vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? a. lithotomy b. dorsal recumbent c. prone d. lateral recumbent

A

a nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? a. states that pain is an 8 on a scale of 0-10 b. states the her partner should be given the information c. expresses concern about the exercises causing pain when performed after surgery d. expresses uncertainty about the benefits of the exercises

A

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? a. toast with peanut butter b. apple juice c. yogurt with fresh fruit d. beef broth

A- dumping syndrome results from rapid emptying of the stomach into the small intestine after eating and manifests as a group of vasomotor symptoms; vertigo, tachycardia, syncope, sweating, pallor, palpitations

A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing adverse effect of the medication? a. urinary retention b. rapid respirations c. dilated pupils d. diarrhea

A- it increases bladder sphincter and detrusor muscle tones and reduces awareness of bladder stimuli

a nurse is caring for a client who is receiving parental nutrition through a non tunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? a. notify the provider b. obtain a chest x-ray c. flush the catheter d. stop the infusion

A- this should be done after flushing B- this should be done after notifying the provider C- this should be done after stopping the infusion D- this is the answer

A client with pneumonia has an oxygen saturation of 85%, HR of 88, RR of 22, and BP of 132/88. Which of the following is the priority nursing intervention? a. immediately notify provider b. reassess pulse ox c. administer albuterol inhaler d. place the client on 2 L of oxygen

B

A nurse administrator is reviewing policies of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information? a. requiring client information be sent to providers using resaved numbers on speed dial of the fax machine b. assigning staff members on each shift the same password for accessing medical records c. allowing nurses to complete electronic documentation on a client while at the clients bedside d. discussing a clients financial hardship at an interdisciplinary team meeting

B

A nurse is assisting with preparation of a teaching program about health nutrition for a group of clients who are tactile learners. Which of the following actives should be included as a learning strategy in the program? a. watch a video discussing health meal prepartion b. prepare a health meal to serve at the end of class c. read pamphlets about preparing a healthy meal d. discuss health meal preparation as a class

B

A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluids over 2 hours. Which intervention is the priority? a. monitor urine output b. fill out an incident report c. report the defective equipment d. document the amount of fluid infused

B

A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone. Which of the following indicates the client is experiencing an adverse effect of this medication? a. hypomagnesemia b. hyperglycemia c. hyponatremia d. hyperkalemia

B

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? a. increased appetite b. elevated temperature c. bradycardia d. drowsiness

B

A nurse is providing discharge education for a female client diagnosed with Chlamydia. Which statement made by the client would indicate the need for further instruction? a. symptoms of reinfection may include yellow vaginal discharge b. i will return to the clinic in one month for re-screening c. i will refrain from sexual intercourse until completion of antibiotics d. possible complications to monitor for include pelvic inflammatory disease

B

A nurse is providing education about a new prescription for nitroglycerin to a client who is diagnosed with angina. which of the following statements by the client indicates a need for further teaching? a. ill make sure that the medication container is kept tightly sealed b. I'm lucky i have a prescription that allows me to buy pills in bulk quantities c. ill keep my pills in the medicine cabinet when i am home d. ill go to the emergency room if my chest pain doesn't go away

B

A nurse is reinforcing teaching with a client who is prescribed bus-irons. Which of the following statements by the client indicates an understanding of the teaching? a. i will only be on this medication 4-6 months because it can lead to physical dependence b. i can have 1-2 alcoholic beverages each week c. i will need to stop taking xanax two weeks before i can begin taking this medication d. i can have 6-8 oz of grapefruit juice each day

B

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly listened nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor? a. faxing laboratory results to a clients provider b. discussing changes in a clients plan of care with his friend who is a nurse on another unit c. describing a clients level of independence to the care manger arranging home health services d. remaining in the room with the client while he reviews his own medical records

B

a nurse discovers that a client who is diagnosed with dementia received the wrong medication. which of the following should be the nurses first action? a. inform the nurse manager b. determine the clients condition c. notify the provider d. complete an incident report

B

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine ear drops for pain relief. which of the following actions by the nurse is appropriate when administering the ear drops? a. place the child on the affected side for several minutes upon completion of instillation b. warm refrigerated drops to room temperature prior to instillation c. pull the pinna of the ear upward and back during instillation d. massage the area posterior to the ear after instillation

B the pinna of a client under the age of 3 should be pulled downward and back

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium. Which of the following serum lithium levels indicates the clients dosage is appropriate for maintenance therapy? a. 0.25 b. 0.75 c. 1.5 d. 2.25

B- level is between 0.8-1.4

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine. Which of the following findings indicates the client is experiencing an adverse effect of the medication? a. weight loss b. WBC 2,800 c. HR 64 d. insomnia

B- this level will always be monitored very closely especially when first starting this medication

While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? a. resposition the client every 4 hrs b. cover the area with a transparent wound barrier c. massage areas surrounding the redness d. wash the area with hot water every 8 hrs

B- this will prevent contamination and reduce friction to the area

A nurse is caring for a client who has been prescribed an indwelling urinary catheter. when preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? a. to the left b. to the right c. away from the body d. toward te body

C

A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? a. chill formula prior to administration b. verify feeding tube placement c. reduce the rate of feedings d. place the client supine during feedings

C

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post- procedure complication? a. hypothermia b. polyuria c. headache d. seizures

C

A nurse is caring for a client with a diagnosis of sepsis with a temp. of 105.5 F. The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an unlicensed assistive personnel? a. obtain a fan for the clients use b. assess the clients skin for any reddened c. report shivering by the client d. bathe the client to keep the skin damp

C

A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? a. silver colored striae b. unilateral nipple inversion present since menarche c. dimpling of the tissue in the upper outer quadrant d. visible symmetrical venous patterns

C

a nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. which of the following findings require further intervention? a. vesicular rash b. resp rate 54 c. abdominal distention d. HR 142

C

a nurse is instructing a client with a right fractured tibia on the correct technique for using a three- point gait with crutches. Which of the following should be included in teaching? a. partial weight is placed on the right foot moving the crutch at the same time as the right leg b. weight is placed on both legs, and crutches are placed one stride in front and then legs swing to the crutches c. weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated d. weight is evenly distributed with each leg being moved alternately with the opposing crutch

C

a nurse is reinforcing teaching about transdermal nitroglycerin to a client who has stable gain. which of the following statements by the client indicates teaching has been effective? a. i should leave the patch on for 16-20 hours each day b. i will apply a new patch in the same location each day c. the patch should be effective within an hour of being applied d. the medication is not absorbed as well when placed on the abdomen

C

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? a. a preschooler with a hip spica cast who is being discharge today b. an infant scheduled for a surgical repair of a ventricular septal defect tomorrow c. a toddler with a fractured femur who has been in Bryants traction for 5 days d. an adolescent who is 2 days postoperative following an appendectomy

D

A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? a. living wills requires a written prescription from the provider to be legal b. living wills allow the client to designate a health care proxy c. living wills ensure hospitals provide emergency care regardless of health coverage d. living wills detail treatment wishes of the client in the event of terminal illness

D

A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mothers colostomy? a. its quite simple. ill make sure her colostomy bag is clean before she leaves and you'll have no problems b. is the colostomy care the only reason your mother is going the be living with you? c. a home health nurse will be stopping by tomorrow. If you have any questions you can ask her d. what part of your mothers care concerns you?

D

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. which of the following is acceptable for the nurse to include in discussion with the client? a. acupuncture is loosely regulated by the federal government b. acupuncture has been discredited by scientific research c. acuputure is thought to be effective only as a placebo d. acupuncture has been proven to reduce pain and increase function

D

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse I don't think I am going to have the surgery. Everybody has to die sometime. which of the following responses by the nurse is appropriate? a. clients having this surgery are always scared b. why have you changed your mind about the surgery c. you shouldn't worry, everything will be fine d. tell me more about your concerns

D

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? a. dorsal recumbent b. orthopneic c. side-lying d. supine

D

A nurse is caring for a school age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? a. provide a toy doctors kit to play with b. keep all syringes and needles out of sight until needed c. use an approach that is firm but direct d. allow the child to manipulate the medical equipment

D

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? a. spongy gums that are receding b. fissures at eyelids corners c. easily plucked hair d. deep reddish- colored tongue

D

A nurse is providing staff development. the nurse understands that which of the following may impede learning? a. self- directed b. proven learner c. intrinsic motivation d. self- confidence

D

A nurse is reinforcing teaching about a new prescription for cromolyn sodium metered dose inhaler to a school age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? a. i will be sure to use the nebulizer four times per day b. i can't use my cromolyn nebulizer for a sudden asthma attack c. it will be several weeks before I notice an improvement in my asthma d. i will use my cromolyn neubilizer before using my albuterol inhaler

D

A nurse is reinforcing teaching to a client who has aphasia. which of the following actions by the nurse is appropriate when communicating with the client? a. raising her voice level when speaking to the client b. asking the client open- ended questions c. clarifying client statements with the family as needed d. having the client use eye blinks to indicate yes or no

D

A school nurse has requested the school board remove a piece of playground equipment due to a documented increased in injuries that can be linked back to it. The nurses actions are an example of which of the following? a. deontology b. morality c. prinicplism d. advocacy

D

when the nurse takes morning medication to a client, the client states i have never seen that one before. which of the following is the most appropriate action for the nurse to take? a. recheck the medication with the medication administration record b. tell the client that the medication must be new and to go ahead and take it c. administer the rest of the medications and recheck the one that was questioned d. return to the nurses station and check all medications against orders

D

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? a. rapid weight gain b. tar- colored stools c. lethargy d. dark urine

D- this is a progressive process that leads to destruction of the biliary tree; dark urine is because of conjugated bilirubin escaping from the liver and being excreted in the urine

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? a. rubella b. measles c. hep. A d. rocky mountain spotted fever

a- droplet b- airborne, negative- pressure airflow c- standard d- standard

a nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?

answer = 2.5 mL 132/ 2.2 = 60 kg 5 mg X 60 kg = 300 300 mg / 3 doses = 100 mg 100 mg/ 40 mg X 1 mL= 2.5 mL

A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen 300 mg every 4 hrs as needed. The acetaminophen liquid suspension that has been prescribed provides 120mg/ 5mL. how many teaspoons should the nurse teach the parents to administer per dose?

answer = 2.5 tsp. 300mg/120mg = 2.5 mg 2.5mg X 5 mL= 12.5 mL 1 tsp = 5mL 12.5 mL / 5= 2.5 tsp.

A nurse is caring for a client who is pregnant with a single fetus and has a BMI of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? a. 10-15 lb b. 15-20 lb c. 25-35 lb d. 35-45 lb

c

A nurse is caring for a school age client who was diagnosed with sickle cell anemia and has been admitted for a vaso- occlusive crisis. which of the following findings has the highest priority? a. hct 32% b. WBC 16 c. slurred speech d. yellowed sclerae

c

what is caused by increased blood flow, enhancing the visibility of oxyhemoglobin?

erythema - red

A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin?

pallor- white