ATI 112 Comp Practice

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack."

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will wear synthetic clothing and woolen socks when using my oxygen."

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

"I'll apply ice to my ankle today and tomorrow."

A nurse instructs a female client about collecting a nmidstream urine sample. Which of the following client statements indicates an understanding of the procedure?

"TIl use the cleansing wipe from front to back."

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

"The area surrounding the insertion site feels warm to the touch."

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Reach around the pack and open the top flap away from the body.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply).

Relief of urinary retention

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Bathe a client who had an amputation 2 days ago. Assist a client to ambulate using a gait belt. Feed a client who had a stroke 3 months ago.

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Bend at the knees when picking up an object.

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.)

Broth Grape juice Lemon gelatin

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?

"Consensus evolves in this stage."

A nurse is orientating a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team."

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I can detect the presence of carbon monoxide by a metallic odor."

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make?

"I decline the opportunity at this time."

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I have a set of my brother's crutches in my basement I can also use."

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 teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will place a bath seat in my shower to use when I bathe."

A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?

"I'll sit with my knees lower than my hips."

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Which of the following statements should the preceptor make?

"Personal liability coverage is not mandatory, but you should consider purchasing your own coverage."

A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make?

"Please explain what you mean by the word 'nervous."

A nurse is planning to discharge a client who had quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?

"Respite care allows the primary caregiver time away from day-to-day care responsibilities."

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

"The client was lying on the floor next to his bed."

A nurse is caring for a client whose partner asks to speak with the nurse. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Which of the following responses should the nurse make?

"What have you done in the past to cope with this issue?"

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive- pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?

208

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Discard the tablet and obtain another dose of medication.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions?

Include any relevant statements the client made about the ulcer.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning?

Industry vs. inferiority

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

Interpersonal

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leaye a nightlight on in the ciient's room.

A obtain nurse is the blood preparing to specimen? obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen?

Left forearm

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

Lock the medication in a room and finish preparing it after returning from the emergency.

A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship?

Narrative interaction

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

Negligence

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team?

Occupational therapist

A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent?

Offering false reassurance

A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client?

Oral surgeon

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag

A nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront this client. Which of the following approaches should the nurse use when using confrontation?

Point out inconsistencies in the client's behavior.

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Protective

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Provide the client with a diet high in protein.

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

Remove all metal necklaces.

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

Removing the abdominal dressing

A nurse is performing care activities for a client in the zone of touch that requires his consent. Which of the following activities should the nurse perform in this zone? (Select all that apply.)

Removing the client's dentures Palpating for pedal edema Counting a radial pulse

A nurse is assessing a client who is experiencing prostatic hypertrophy. which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

Report of feeling pressure Tenderness over the symphysis pubis Distended bladder Voiding 30 mL frequently

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the client's family

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan?

Request a meal tray without pork.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?

Shivering

A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

Sudden attacks of sleep Hallucinations at the onset of sleep

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate.

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting his goal?

The client faces the direction of movement when sliding an object across the floor.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan?

The client's self-report of pain severity

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

The nurse has already considered alternatives to restraints.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse is caring for a client within the intimate zone of the client's personal space. The nurse should perform which of the following activities in this space? (Select all that apply.)

Auscultating heart sounds Changing a dressing

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

"I will begin upon the client's admission to the facility."

A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

"I will come back later and we can talk."

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving?

Denial

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids.

A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communication techniques is the nurse using?

Asking for an explanation

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Assess the client.

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity?

Assigning tasks to an assistive personnel (AP)

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?

Auscultate breath sounds at least every 2 hr.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working.

A nurse is caring for a client who is about to have a colonoscopy. The client states, "I am so nervous about what the doctor might find during the test." The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" With this question, the nurse is using which of the following communication techniques?

Clarification

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Complete a neurological check.

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the provider to question the dosage.

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

Education Gender Perception

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Elicit information from the client.

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use?

Explore the client's feelings about dietary modifications.

A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take?

Explore the client's feelings.

A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to describe one physical effect. The nurse is focusing on which of the following elements of the communication process?

Feedback

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

Gloves

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include?

The nurse may serve as a witness to informed consent for organ donation.

A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship?

They are more direct when discussing issues.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

This service began with the client's admission to the hospital.

A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include?

Tie linen bags securely at the top.

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nurses using a friction-reducing device

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Use attentive listening with the client.

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Use soap and water to wash the catheter after each use.

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water.

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene?

Washes and rinses her hands for 10 seconds

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Water heater temperature 54.4C Throw rugs

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?

When asking if the client took his medications this morning

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 client's signature.