ATI funds questions

A nurse is caring for a client has been sitting in a chair for one hour. Which of the following complications is the greatest risk of the client

Pressure injury

A nurse in a providers office is preparing to testify, is cranial nerve function. Which of the following direction should the nurse include when testing cranial nerve V? Select all that apply.

Clench your teeth, tell me when you feel a touch

A client is performing a mission assessment on a client. The nurse determines the clients radial pulse rate is 68 BPM in a simultaneous apical pulse rate is 84 BPM. What is the clients pulse deficit?

84-68 = 16

A nurse is preparing information for a change of shift report. Which the following information should the nurse include in the report

A bone scan scheduled for today

The nurse on a medical surgical unit is caring for a group of clients. for which of the following client. Should the nurse expect a prescription for fluid restriction

A client who has heart failure

Play nursery medical surgical unit is Jennifer a group of clients. The nurse should identify that which of the following clients is a risk for hypovolemia

A client who has nasogastric suctioning

A nurse is caring for a group of clients on a medical surgical unit for which of the following client care needs shut the nurse initiate a referral for social worker?

A client who has terminal cancer request hospice care in the home. A client ask about community resources available for older adults. A client request an electric wheelchair for use after discharge.

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients at the newly licensed nurse identify as experiencing chronic pain?

A client who is episodic back pain following a fall two years ago

A nurse orienting, a newly licensed nurse is reviewing the procedure for taking in telephone prescription which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process

Another nurse should listen to the phone call

A nurse is caring for a client who is postoperative period which of the following intervention should the nurse take to reduce the risk of thermos development? Select all that apply.

Apply elastic stockings, assist the client to change positions often

A nurse observes an assistive personnel reprimanding a client for not using the urinal properly. The a P tells the client that diapers will be use next time. The urinal is used in properly. Which of the following torts is the AP committing

Assault

Nurse is caring for a client who decides not to have surgery, despite significant blockages of the coronary arteries. The nurse understands that this class choice is an example of which of the following ethical principles.

Autonomy

A nurse is caring for a client who has 24 hours postoperative following and Gueno hernia repair. The clients tolerating clear liquids well, as active bowel sounds, and is expressing a desire for real food. The nurse tells a client I will call the surgeon and ask for a change in the diet. The surgeon here's a nurse is reporting prescribes a full liquid diet. The nurses which of the following levels of critical thinking.

Basic

A nurse is acquaintance a group of newly licensed nurse is what the rules of the various members of the healthcare team they will encounter on a medical surgical unit. When providing examples of the type of test, certified nursing assistance can perform, which of the following clients activities should the nurse include? Select all that apply

Bathing, ambulating, toileting, measuring vital signs

A nurse offers pain medication, do a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles.

Beneficence

A nurse is monitoring a client for adverse effects, following the administration of an opioid. Which of the following affects should the nurse identify as an adverse effect of opioids? Select all that apply.

Bradypnea, orthostatic, hypotension, nausea

A nurse is preparing to perform denture care for a client. Which of the following action should the nurse plan to take?

Brush the dentures with a toothbrush and denture cleaner

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

Carbon monoxide binds with hemoglobin in the body

A nurse is planning care for a client who is dehydration. Which of the following action should the nurse include?

Check the clients weight each morning

A client who has an indwelling catheter reports I need to urinate. Which of the following actions should the nurse take?

Check to see whether the catheter is Patent

A nurse is caring for a client has a history of falls. Which of the following actions is the nurses priority?

Complete a fall risk assessment

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? Select all that apply.

Immuno compromised individuals already increase risk for complications from food poisoning, clients, who are higher, should eat or drink only pasteurized dairy products, handling Ron fresh food separately can prevent food poisoning

A nurse is teaching a client who reports stress urinary incontinence which of the following instruction should the nurse include? Select all that apply

Decrease or avoid caffeine, avoid drinking alcohol

A nurse is caring for a client was a prescription for 24 hour urine collection. Which of the following action should the nurse take?

Discard the first voiding

A nurse is a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which the following critical thinking attitudes did the nurse demonstrate?

Discipline

The nurse is collecting data from a client who is receiving IV therapy, and reports pain in the arm, chills, and not feeling well. The nurse, notes, warmth, Edina, and duration, and red streaking on my clients arms close to the IV insertion site. Which of the following action should the nurse plan to take first

Discontinue the infusion

A nurse is instructing assistive personnel about caring for a client who has a low platelet count. Which of the following instructions is priority for measuring vital signs for this client.

Do not measure the clients temperature rectally

A nurse is planning care for a client was on bedrest. Which of the following intervention should the nurse plan to implement?

Encouraged client to perform antiembolic exercises every two hours

A nurse is beginning a complete bed bath for a client. After moving the clients counted, placing a bath blanket over the body, which of the following areas should the nurse wash first

Face

Immerses care for a competent adult client who tells the nurse, I am leaving the hospital this morning whether the doctor discharges me or not. The nurse believes that this is not in the clients, best interest, and prepares to administer a PRN sedative medication. the client has not requested along with a scheduled morning medication. Which of the following types of tort is the nurse about to commit

False imprisonment

The nurse manager is discussing the Hyppa privacy rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? Select all that apply.

Family members should provide a code prior to receiving client health information. Communication of client information can occur at the nurses station. Client can request a copy of their medical records. A nurse can photocopy a clients medical record for transferred to another facility.

A charge nurse is reviewing with a newly hired nurse difference in manifestations of a localized versus a systematic infection. Which of the following are manifestations of a systematic infection? Select all that apply.

Fever, Malasia, increase in pulse and respiratory rate

Newly licensed nurse is considering strategies to improve critical thinking. Which of the following action should the nurse take? Select all that apply.

Find a mentor, use a journal to write about the outcomes of clinical judgment, review articles about evidence base practice

A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? Select all that apply

Frequent sexual intercourse, location of the urethra closer to the anus, frequent catheterization

A nurse is reviewing the laboratory test results for a client has an elevated temperature. The nurse should identify which of the following findings as a manifestation of dehydration? Select all that apply.

HCT 55% Blood sodium 150 mEq/L Urine specific gravity, 1.035.

A nurse is preparing to initiate bladder retraining program for a client has incontinence. Which of the following action should the nurse take? Select all that apply.

Have the client record of urination times, gradually increase, urination intervals, remind the clients to hold urine until the next scheduled urination time

A nurse is instructing a group of newly licensed nurse is about how to know, and what to expect when ethical dilemmas arise. Which of the following situation shut the newly licensed nurse is identify as an ethical dilemma?

Hey family has conflicting feelings about the initiation of enteral tube, feedings for their father who is terminally ill

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instruction should the nurse include? Select all that apply

Hold the cane on the right side, keep two points of support on the floor, after advancing the cane move the weak leg forward

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mmHg, and the client denies any history of hypertension. Which of the following action should the nurse take first?

How's the client if they are having pain?

A nurse educator is presenting in module on basic first aid for newly license, home health, nurses. The client who has a heat stroke, will have which of the following.

Hypotension

Inner scary for a client receiving dextrose 5% in .9% sodium chloride Ivy at 120 ml/hr. Which of the following statements made by the client should alert the nurse to suspect fluid overload? Select all that apply.

I feel as all my heart is racing, I feel a little short of breath, the nurse technician told me that my blood pressure was 150/90

A nurse and a surgeons office is providing free operative teaching for a client is scheduled for surgery the following week a client tells the nurse that I plan to prepare my advance directives before I come to the hospital. Which of the following statements made by the client should indicate to the nurse and understanding of advance directives.

I plan to write that I don't want them to keep me on a breathing machine

A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device.

I should tell the nurse if the pain doesn't stop while i am using this device

A nurse managers, reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by nurse requires further instruction.

I will go to the nurses station for assistance

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by nurse viewing the demonstration indicates understanding of the procedure.

I will insert the needle into the client skin at an angle of 10 to 30° with the bevel up

A nurse educator's teaching, newly licensed nurse is about safe medication administration. Which of the following statements indicates an understanding.

I will observe for adverse effects, I will monitor for therapeutic affects, I will refuse to give him medication if I believe it is unsafe

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by annoying to you indicates understanding of the preventative strategies.

I will replace any IV catheter when I suspect contamination during insertion

A nurse is caring for a client who reports a severe sore throat, pain when swallowing and swollen lymph nodes. The client is experiencing which of the following stages of infection?

Illness

A nurse is assessing an the adult clients internal ear canals, with an auto scope as part of a head and neck examination. Which of the following action should the nurse take? Select all that apply

Insert the speculum slightly down and forward, make sure the speculum does not touch the ear canal, use the light to visualize the tympanic membrane in a cone shape

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? Select all that apply.

Inspect the feet daily, use moisturizing lotion on my feet, wear cotton socks

A nurse is caring for a client who is at high risk for aspiration. Which of the following action should the nurse take?

Instruct the client to tuck their chin when swallowing

A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority?

Move clients who are nearby

A nurse is providing discharge instructions to a client was a prescription for oxygen used at home. Which of the following information should the nurse include? Select all that apply.

Nail polish should not be used in your client who is receiving oxygen, a no smoking sign should be placed on the front door, if I extinguisher should be readily available in Home

A nurse is caring for a client has a new prescription for antihypertensive medication. Prior to administering the medication the nurses there's no electronic data base to gather information about the medication. Any effects I might have on this client. Which of the following components of critical, thinking as a nurse using when he reviews medication information.

Knowledge

A nurse is caring for a client who fell at a nursing home. The client is orient to person, place, and time and can follow directions. Which of the following action should the nurse take to decrease the risk of another fall? Select all that apply.

Make sure that the clients call light is within reach, provide the client with nonskid footwear, complete a fall risk assessment

A nurse is caring for a client is about to wanna go and elective surgical procedure. The nurse should take which of the following actions regarding informed consent? Select all that apply.

Make sure the surgeon obtain the clients consent Witness the client signature on the consent form

A nurse is discussing occurrences that require a completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? Select all that apply.

Medication error, needlesticks, omission of prescription

A nurse is instructing a group of newly licensed nurses about the responsibilities, organ, donation, and procedument involved. When the nurse explains that all clients waiting for a kidney transplant, have to meet the same qualifications, the newly licensed nurse should understand that this aspect of care delivery is an example of which of the following ethical principles?

Nonmaleficence

A nurse is caring for a client in the emergency department, who has an oral body temperature of 101 F, pulse rate 114 bpm, and respiratory rate 22 bpm. The client is restless with warm skin. Which of the following intervention should the nurse take? Select all that apply.

Obtain culture specimens before initiating antimicrobials, encourage the client to rest and limit activity, assist a client with oral hygiene frequently

A goal for a client has difficulty with self feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team?

Occupational therapist

A nurse is collecting data from a client is reporting pain despite taking analgesia. Which of the following action should the nurse take to determine the intensity of the clients paint?

Offer the client a pain scale to measure their pain?

A nurse prepares an injection of morphine to administer to a client reports pain, then asked a second nurse to give the injection because another assigned client needs to use a bed pan. Which of the following action should the second nurse take

Offered to assist the client who needs the bedpan

A nurse in a senior center is counseling. A group of older adults about the nutritional needs in considerations. Which of the following information should the nurse include? Select all that apply.

Older adults are more prone to dehydration than younger adults are, older adults need the same amount of most vitamins and minerals as younger adults do, mini older men and women need calcium sublimation

A nurse is reviewing a clients prescribe medication's at the beginning of the dayshift. Which of the following 9 AM medication can be given any time between 7 AM and 11 AM? Select all that apply.

Once daily multivitamin, a subcutaneous injection prescribed once weekly

In our such a caters, conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates an understanding?

Once my infant starts to push up, I will remove the mobile from over the crib

A nurse is assessing a client thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply.

Palpating the thyroid in the lower half of the neck, filling the thyroid I sent as a client swallows, finding symmetric extension off the trachea on both sides of the midline

A nurse discovers a small paper fire in a trashcan in a clients bathroom. The client has been taken to safety. An alarm has been activated which of the following action should the nurse take?

Place wet towels along the base of the door to the clients room

A nurse is caring for a client who has severe acute respiratory syndrome. The nurse knows that healthcare professionals are required to report communicable infectious diseases. Which of the following illustrates the rationale for reporting? Select all that apply.

Planning and evaluating control and prevention strategies, determining public health priorities, I'm sharing, proper medical treatment, monitoring for common source outbreaks

A nurse is instructing a group of assistive personnel in measuring a clients respiratory rate. Which of the following guidelines should the nurse include? Select all that apply

Play some clients, semi Fowlers position, have a client arrest in arm across abdomen, observe, one full respiratory cycle before counting the rate

A nurse that I clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asked the client if there has been any accompanying nausea and vomiting. Which of the following characteristics is a nurse attempting to determine?

Presence of associated manifestations

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the inter-professional care team can assist the client in understanding the medication's affects? Select all that apply.

Provider. Pharmacist. Registered nurse.

A charge nurse is assigning a client care for four clients. Which of the following task should the nurse assigned to a PN?

Providing nasopharyngeal suctioning for a client who has pneumonia

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client record? Select all that apply.

Put the date and time on all entries. Document objective data, leaving out opinions.

A nurse on a medical surgical unit has received change of shift report and will care for for clients. Which of the following Tasha the nurse assigned to an assistive personnel

Reapplying a condom catheter for a client who is urinary incontinence

A nurse manager is assigning care of a client is being admitted from the packet following thoracic surgery. The nurse manager should I sign the client to which of the following staff members?

Registered nurse

A nurse is receiving your providers prescription by telephone or morphine for a client is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all that apply.

Repeat the details of the prescription back to the provider, have another nurse listen to the telephone prescription, obtain a provider signature on the prescription within 24 hours

A nurse is noticed several occasions in the past week when another nurse on the unit seem drowsy and unable to focus on the issue at hand. Today the nurse was found asleep in the chair in the break room not during a break time. Which of the following action should the nurse take?

Report the observations to the nurse manager on the unit

A nurse receives a prescription for an antibiotic for a client who is cellulitis. The nurse, Texas clients medical record, discovers with a client is allergic to the antibiotic, and calls provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes, did the nurse demonstrate?

Responsibility

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? Select all that apply.

Right supervision and evaluation, right direction, and communication, right circumstances

A nurse reviewing a clients house to record notes a new prescription for lisinopril 10 MGPO once every day. The nurse should identify that as which of the following types of prescription.

Routine

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following action should the nurse include in the clients plan of care?

Schedule rest periods during morning care

A client has a cerebrovascular accident has persistent problems with dysphasia. The nurse is caring for a client should initiate a referral with which of the following members of the interprofessional care team?

Speech language pathologist

A nurse is performing an admission assessment of a client who is hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? Select all that apply.

Tachycardia, syncope, decreased skin turgor

A nurse is delegating the ambulation of a client who had knee arthroplasty five days to go to an AP. Which of the following information should the nurse share with the AP? Select all that apply.

The client ambulates wearing slippers over antiembolic socks. The client is a front wheeled walker when ambulating. The client had pain medication 30 minutes ago.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following intervention should the nurse include? Select all that apply

Wear a mask when providing care within 3 feet of the client. Place a surgical mask on the client transporting on to another department is unavoidable, wear a gown when performing care that might result in contamination from secretions

Immersed in the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements made by Nintendo, he indicates an understanding of the manifestations of infiltration? Select all that apply.

The temperature on the IV site is cooler, the Ivy dressing is damp, the tissue around in venipuncture site is swollen

A nurse is evaluating a clients understanding of the use of a sequential compression device. Which of the following client statements indicates a clients understanding?

This device will keep my blood pumping through my legs

A nurse is performing a head and neck examination for an older adult client. Which of the following age related findings should the nurse expect? Select all that apply

Tooth loss, glare intolerance, thickened eardrums

A nurse is caring for a client who has had a cough for three weeks and it's beginning to cough up blood. The client has manifestations of which of the following conditions.

Tuberculosis

A nurse is performing mouth care for a client who is unconscious. Which of the following action should the nurse take?

Turn the client's head to the side

A nurse is caring for a client who requires a low residue diet. The nurse should expect to see which of the following foods on the clients meal tray,

Vanilla custard

A nurse is caring for a client who ask what their Snellen eye test results mean. The clients visual acuity is 20/30 . Which of the following responses should the nurse make?

Your eyes see a 20 feet what visually unimpaired eyes see at 30 feet

The nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy?

carbohydrates