NUR 313-Final Exam (Final ATI)

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher. **Rationale: FIRST ACTION PRIORITY

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration

Edema at the infusion site

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag two-thirds full with ice. **Rationale: makes it possible to mold the bag around pt ankle.

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. Which of the following responses should the nurse make?

"All of this equipment can be frightening." **Rationale: this statement is therapeutic because the nurse is reflecting on the pt's statement. The pt is feeling fearful, and this response shows that the nurse understands those feelings which encourages the pt to communicate more.

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs" **Rationale: the pt has 3 points on the ground at ALL times.

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which information should the nurse include?

A 10 month old infant can pull up to a standing position. **Rationale: an 8-10 month old can pull himself to a standing position.

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "you are not putting that hose down my throat." Which statements should the nurse make?

"I can see that this upsetting you." **Rationale: the nurse is using therapeutic communication techniques of reflecting and restating, which encourages communication by the client. Nurse should avoid "why" questions (barrier/judgmental communication)

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed." **Rationale: therapeutic communication that is nonjudgmental and encourages the partner to express their feelings.

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you." **Rationale: the nurse should ask an open-ended question that encourages the pt to elaborate about the problems pt is having.

A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has an rx for a transfusion of packed RBC's. **Rationale: administration of blood is a procedure that CARRIES RISK, therefore, the pt MUST SIGN a consent form PRIOR to the procedure.

A nurse on a surgical unit is receiving a client who has abdominal surgery from the post-anesthesia care unit. Which of the following assessments should the nurse make first?

Airway **Rationale: ABC's is PRIORITY -airway, breathing, circulation

A nurse is using the SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

Assessment **Rationale: The nurse provides info about assessment findings in the portion of the report. **THIS INCLUDES: VITAL SIGNS, PAIN ASSESSMENT, & CHANGES IN ASSESSMENT FINDINGS.

A nurse in a provider's office is assessing a client who has heart failure. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Bounding pulse

A newly licensed nurse is preparing to administer medications to a client. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit **Rationale: a nurse must have knowledge about meds to administer them safely. Nurse should become familiar with the meds by looking it up in book.

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use. **Rationale: proper use of the spirometer loosens secretions in the pt's lungs. The pt should cough deeply to facilitate removal of secretions from lungs.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing. **Rationale: PRIORITY ACTION reduce risk that poses greatest threat to the pt. An open wound places the pt at risk for peritonitis and exposed organ tissue could dry out.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium **Rationale: calcium is necessary for nerve conductions and muscle contractions. When pt has low calcium levels, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the pt's ear. **Tap cheek, IF FACIAL MUSCLE TWITCHING follows this stimulus it means its a positive Chvostek's sign and indication of hypocalcemia.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults. **Rationale: primary prevention includes health education about disease prevention. Teaching pt's about self breast exam is secondary prevention and focuses on measures that ID early stages of condition.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. Which of the following ethical principles is the nurse demonstrating?

Fidelity **Rationale: the nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin **Rationale: foods allowed on a clear liquid diet are those that are clear and liquid at room temperature **Ice-cream and cream of rice are examples of FULL liquid diet not clear liquid diet

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning?

Have client demonstrate the procedure. **Rationale: psychomotor is movement and skills to demonstrate understanding (tactile) physical activities associated with cognitive understanding.

A nurse is caring for a client who is receiving a blood transfusion. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic **Rationale: this happens when the pt's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a reaction.

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The nurse should plan care based on which of the following factors

Impaired peristalsis of the intestines **Rationale: normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the pt to ambulate to promote peristalsis.

A nurse is planning to ASSESS the abdomen of a client who reports feeling bloated for several week. Which methods of assessment should the nurse use first?

Inspection **ABDOMEN ASSESSMENT ORDER: 1.) Inspect 2.) Auscultation 3.) Percussion 4.) Palpation

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which adverse effect?

Liver damage **Rationale: this med in large doses can be toxic to the liver. Acetaminophen is an analgesic for pain and fever.

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss **Rationale: at the close of a relationship, even one that is planned, loss is an expected feeling for both the pt and the nurse, it is important for both the nurse and the pt to terminate the relationship without feelings of guilt or anxiety.

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take

Lower the client to the floor and place a pad under the client's head. **Rationale: to reduce the risk of injury to the pt

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client. which action should the nurse take next?

Observe the rate, depth, and character of the client's respirations. **Rationale: ADPIE-before the nurse can plan action assessing or collecting additional data provides the nurse with knowledge for next appropriate decision.

a nurse is caring for a client who has fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces

Oil retention **Rationale: softens the stool and makes procedure less painful for the pt.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position. **Rationale: promotes drainage from the pt's left lower lobe.

A nurse is providing oral care for a client who is unconscious which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure. **Rationale: reduces the risk of aspiration of fluids and secretions.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side. **Rationale: facilitates the flow of the enema solution into the sigmoid and descending colon.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5g/kg of body weight per day.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session. **Rationale: to maintain the pt's joint mobility the nurse should repeat each motion 3-5 times.

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg Test **Rationale: inability to maintain balance is a positive Romberg Test.

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client. **Rationale: the nurse should avoid appearing to be in a hurry. Sitting at the bedside with pt gives the pt the nurse's full attention during the feeding.

A nurse in the ER is caring for a client who has abdominal trauma. Which ASSESSMENT findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia **Rationale: due to DECREASE in circulating blood volume that happens with internal bleeding the oxygen carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output along with increasing the RR. **hypovolemia: abnormally low fluid volume in the circulatory system. Symptoms include: tachycardia and hypotension.

An AP is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder. **Rationale: the AP should place the drainage bag BELOW the level of the bladder to ensure proper drainage by gravity.

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

Tie the restraint with a quick-release knot. **Rationale: so that it can be untied easily in case the pt's well-being requires quickly removing the restraints.

a nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3 **Rationale: this finding is ABOVE the expected reference range and is an indication of infection. **NORMAL WBC: 5000-10,000 mm3

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which activity should the nurse recommend to the client?

Washing dishes **Rationale: this requires a LOW LEVEL of activity and is appropriate for this pt.

A client is being discharged home with oxygen therapy via nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity. **Rationale: oxygen is high combustible gas, avoid any spark contact.

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which action should the nurse take?

Wear gloves when changing the client's gown.

A nurse is reviewing measures to prevent back injuries with AP. which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support.