ATI Break Quiz 5

a nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. the drop factor of the manual IV tubing is 15 gtt/mL. the nurse should set the manual IV infusion to deliver how many gtt/min?

30 gtt/min

a nurse is admitting a client who has tuberculosis. in addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? -protective -airborne -droplet -contact

airborne

a nurse is assessing a client's nutritional status. the nurse determines the client is consuming 500 calories more per day than his energy level requires. if his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 lb)? -5 weeks -5 months -10 weeks -10 months

10 weeks

a nurse is caring for a client who is at 38 weeks gestation and in thea ctive phase of the first stage of labor. the nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. which of the following actions should the nurse take? -slow the IV infusion rate -assist the client to a lateral position -assess the bladder for urinary retention -initiate an oxytocin infusion

assist the client to a lateral position

a nurse is implementing cold therapy for a client who has an ankle sprain. which of the following actions should the nurse take? -apply a cold pack to the edematous area -check capillary refill before applying an ice pack to the affected area -half-fill an ice pack with crushed ice -apply an ice pack for 60 min intervals

check capillary refill before applying an ice pack to the affected area

a nurse is caring for a client who had a nephrostomy tube inserted 8 hours ago. which of the following actions should the nurse include in the client's plan of care? -flush the nephrostomy tube every 4 hours with sterile water -clamp the nephrostomy tube intermittently to establish continence -check the skin at the nephrostomy site for irritation from urine leakage -monitor for and report any blood-tinged drainage to the provider immediately

check the skin at the nephrostomy site for irritation from urine leakage

a community health nurse is planning an educational program about hepatitis A. when preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? -children -older adults -women who are pregnant -middle-aged men

children

a nurse is assessing a client who has brief psychotic disorder. which of the following manifestations should the nurse expect? -evidence of self-mutilation -suicidal threats -disorganized speech -report of chronic depression

disorganized speech

a nurse is caring for a newborn immediately following birth. which of the following actions should the nurse take first? -weigh the newborn -instill erythromycin ophthalmic ointment in the newborn's eyes -administer vitamin K to the newborn -dry the newborn

dry the newborn

a charge nurse in an emergency department is making assignments for an assistive personnel (AP) during a shift with unexpected staff absences. which of the following assignments should the charge give to a float AP from the medical-surgical unit? -escorting clients from the emergency department to other areas of the facility for tests -sitting at the reception desk answering telephones and directing clients -restocking the examination rooms after each client is discharged -shadowing an AP who is regularly assigned to the emegency department

escorting clients from the emergency department to other areas of the facility for tests

a nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. which of the following actions should the nurse take first? -initiate bag-value-mask ventilation -provide the client with a communication board -obtain a blood sample for ABG analysis -document the ventilator settings

initiate bag-valve-mask ventilation

a nurse is assessing a toddler who has measles (rubeola). which of the following findings should the nurse expect? -koplik spots -parotitis -strawberry tongue -paroxysmal coughing

koplik spots

a nurse is caring for a client who has a brainstem injury. which of the following physiological functions should the nurse monitor? -understanding speech -respiratory effort -decision-making ability -temperature control

respiratory effort

a nurse is planning care for a client following a stroke. which of the following interventions should the nurse identify as the priority in the client's plan of care? -prevent depression in the client -refer the client to occupational therapy -support the client's family -monitor the client for increased intracranial pressure (ICP)

monitor the client for increased intracranial pressure (ICP)

a nurse is caring for a child who has Tourette's disorder. which of the following behaviors should the nurse expect? -multiple motor and vocal tics -areas of baldness on the scalp -instiable hunger -exaggerated startle response

multiple motor and vocal tics

a nurse is using the braden scale to predict the pressure ulcer risk of a client in a long-term care facility. using this scale, which of the following parameters should the nurse evaluate? -incontinence -mental state -nutrition -general physical condition

nutrition

a nurse is caring for a client whose adolescent child just died in a motor-vehicle crash. the client is crying inconsolably. which of the following actions should the nurse take? -suggest that the client call the facility's chaplain -provide a quiet place for the client to be alone -stay with the client and allow the client to cry -express sympathy for the client's loss

stay with the client and allow the client to cry

an assistive personnel (AP) is helping a nurse care for 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 uses soap and water to clean the perineal area -the AP tapes the catheter to the client's inner thigh -the AP hangs the collection bag at the level of the bladder -the AP ensures there are no kinks in the drainage tubing

the AP hangs the collection bag at the level of the bladder

a nurse is assessing a 6-year-old child who is immediately postoperative following a tonsillectomy. which of the following findings should the nurse report to the provider? -the child has a small amount of dark brown blood between the teeth -the child is swallowing frequently -the child has a heart rate of 118/min -the child refuses the application of an ice collar

the child is swallowing frequently

a nurse is caring for a client following a hip arthroplasty. the nurse places an abduction pillow on the client for which of the following purposes? -to raise the bed linens off the client's feet to prevent plantar flexion -to keep the client's heels off the bed to prevent pressure ulcers -to position the client off the operative site while in bed -to prevent dislocation of the hip during position changes or movement

to prevent dislocation of the hip during position changes or movement

a nurse in a provider's office is observing children playing in the waiting room. the nurse should expect to identify parallel behavior in which of the following age groups? -infants -toddlers -preschoolers -school-age children

toddlers

a nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. which of the following findings should the nurse report to the provider? -deep tendon reflexes 2+ -blood pressure 150/96 mmHg -urinary output 20 mL/hr -respiratory rate 16/min

urinary output 20 mL/hr

a nurse is teaching a client who is postpartum and breastfeeding. which of the following statements should the nurse include? -"you will need to wait 3 months before resuming sexual intercourse" -"you don't need to use contraception until you are 4 months postpartum" -"as long as you breastfeed, you will experience an overproduction of vaginal lubrication" -"a reduction in sexual interest could indicate postpartum depression"

"a reduction in sexual interest could indicate postpartum depression"

a nurse is providing teaching to a client with hypertension and type 1 diabetes mellitus who has a new prescription for metoprolol. which of the following statements by the client indicates an understanding of the teaching? -"i might have difficulty recognizing when my blood sugar is low" -"i will have a lower risk of developing an infection while i take this medication" -"i should be concerned about losing excess weight while i take this medication" -"i could have more problems with high blood sugar while taking this medication"

"i might have difficulty recognizing when my blood sugar is low"

a nurse is teaching a client who has low back pain about heat therapy. which of the following statements by the client indicates an understanding of teaching? -"i need to place a towel between the heating pad and my skin" -"i'll need to turn up the temperature if i can't feel the heat" -"i'll sleep on top of the heating pad to increase the heat pentration" -"keeping the heat continuously on my back will help it heal"

"i need to place a towel between the heating pad and my skin"

a nurse is teaching a client who has type 2 diabetes mellitus about foot care. which of the following statements by the client indicates an understanding of the teaching? -"i will apply moisturizer between my toes" -"i will soak my feet daily" -"i'll be sure to wear cotton socks every day" -"i'll use a heating pad to warm my feet"

"i'll be sure to wear cotton socks every day"

a nrse is providing teaching to a client who has type 2 diabetes mellitus about the pathophysiology of the disease. which of the following statements by the client indicates an understanding of the teaching? -"my cells are resistant to the effects of insulin" -"my body breaks down sugars too efficiently" -"my pancreas does not produce insulin" -"my body produces antibodies against pancreatic beta cells"

"my cells are resistant to the effects of insulin"

a nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. the client asks the nurse, "why is there so little bleeding?" which of the following responses should the nurse make?

"the bleeding is minimal until I discontinue your IV medication"

a nurse is providing discharge teaching to parents whose infant had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. which of the following statements by the parents indicates an understanding of the teaching? -"we will check his abdomen daily for signs of fluid accumulation" -"we will notify the doctor right away if he has a fever" -"we should keep a helmet on him when he's awake" -"we can expect him to have occasional seizure episodes"

"we will notify the doctor right away if he has a fever"

a nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? -assess and document the client's vital signs -restart the IV with a 22-gauge needle -verify with another nurse the blood type and Rh of the packed RBCs -hang a bag of lactated Ringer's IV solution -change IV tubing to a set that has a filter

-assess and document the client's vital signs -verify with another nurse the blood type of Rh of the packed RBCs -change IV tubing to a set that has a filter

a nurse is performing an admission assessment on a client who has major depressive disorder (MDD). which of the following findings should the nurse expect the client to report? -difficulty sleeping for several weeks -inability to concentrate on simple tasks -desire for sexual activity with multiple partners -absence of bathing for several days -lack of enjoyment from a long-time hobby of gardening

-difficulty sleeping for several weeks -inability to concentrate on simple tasks -absence of bathing for several days -lack of enjoyment from a long-time hobby of gardening

a nurse is caring for a client who is receiving lidocaine for localized pain, the nurse should recognize that which of the following actions will help prevent systemic toxicity of this medication? -applying a heating pad following administration to increase blood flow to the area -applying the medication to intact skin -applying a large amount of the medication at once to avoid frequent reapplication -applying the medication to large areas for maximum spread

applying the medication to intact skin

a nurse is caring for a client who is 2 days postoperative following a gastric bypass. the nurse notes that bowel sounds are present. which of the following foods should the nurse provide at the initial feeding? -vanilla pudding -apple juice -diet ginger ale -clear liquids

clear liquids

a nurse is caring for a client during her first prenatal visit and notes that she is lactose-intolerant. which of the following foods should the nurse include on a list of calcium sources for this client? -collard greens -cottage cheese -orange juice -broccoli

collard greens

a nurse is preparing to administer an epinephrine IV bolus to a client. which of the following should the nurse verify before initiating the IV medication? -concentration of the formulation -reversibility of the medication -potential barriers to absorption -gastric emptying time

concentration of the formulation

a nurse is caring for a client who is postoperative following abdominal surgery. which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated? -cover the incision with a moist sterile dressing -have the client lie on his back with his knees flexed -call the client's surgeon -reassure the client

cover the incision with a moist sterile dressing

a nurse is reviewing the laboratory data for a client who has Alzheimer's disease and a new prescription for memantine. the nurse should identify that which of the following findings increase the client's risk for reduced clearance of the medication? -alanine aminotransferase (ALT) 60 international units/L -creatinine clearance 25 mL/min -HbA1c 5% -BMI 31

creatinine clearance 25 mL/min

a nurse is planning care for a young adult client who has a terminal illness which of the following concepts of death should the nurse consider for this client? -death is unacceptable under any circumstances -magical thinking helps avoid thoughts of death -death is viewed as an interruption of what might have been -death is a natural consequence of a deteriorating body

death is viewed as an interruption of what might have been

a nurse is monitoring the blood pressure of an older adult client. the nurse should understands that which of the following age-related changes can contribute to an increase in systolic blood pressure among older adults? -decreased cardiac output -decreased elasticity of the blood vessels -fewer nephrons in the kidneys -thickening of heart valves

decreased elasticity of the blood vessels

a nurse in a long-term care facility is promoting reminiscence among older adult clients. which of the following actions should the nurse take? -establish a weekly pet therapy visitation program -place a calender and a clock in each resident's room -institute a daily storytelling hour -encourage all clients to eat their meals in the dining room

institute a daily storytelling hour

a nurse receives the morning change-of-shift report and delegates several tasks to an assistive personnel (AP) on the team. which of the following tasks should the nurse instruct the AP to perform first? -obtain the morning capillary blood glucose tests -bathe a client scheduled for physical therapy at 0900 -distribute the breakfast trays -fill pitchers with fresh water and ice

obtain the morning capillary blood glucose test

a nurse is planning care for a toddler who has acute gastroenteritis and was recently admitted. which of the following should the nurse plan to provide for the child? -oral rehydration solution -bananas or applesauce -chicken or beef broth -hypertonic IV solution

oral rehydration solution

a nurse is caring for a client immediately following application of a plaster cast. the nurse should monitor for and report which of the following findings as an indication of compartment syndrome? -sensation of heat on the surface of the cast -paresthesias of the extremity -pruritus of the extremity -musty odor noted from cast materials

paresthesias of the extremity

a nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. this fracture is located on which of the following bones? -sphenoid -occipital -parietal -frontal

parietal

a nurse is assessing a client who is experiencing post-traumatic stress disorder (PTSD) following a traumatic event. which of the following medications should the nurse expect the provider to prescribe? -bupropion -phenelzine -mirtazapine -paroxetineme

paroxetine

a nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. which of the following actions should the nurse plan to take? -hyperventilate the client with 100% oxygen prior to obtaining the specimen -applying ice to the site after obtaining the specimen -perform an allen's test prior to obtaining the specimen -release the pressure applied to the puncture site 1 min after the needle is withdrawn

perform an allen's test prior to obtaining the specimen

a nurse is preparing to perform postural drainage for a client. which of the following actions should the nurse take? -give the client a bronchodilator immediately after the procedure -position the client for drainage of secretions by gravity -schedule postural drainage following meals -instruct the client regarding the importance of fluid restrictions

position the client for drainage of secretions by gravity

a nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. which of the following actions should the nurse anticipate taking? -discharge the client to home -administer betamethasone -perform an amnioinfusion -prepare for delivery of the infant

prepare for delivery of the infant

a nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. which of the following actions should the nurse perform? -instruct visitors to maintain a distance of at least 1 m (3 ft) from the client -wash hands with antimicrobial soap after leaving the client's room -use dedicated equipment for the client -keep the doors to the client's room closed at all times

use dedicated equipment for the client