ATI NCLEX Challenge Final

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommended as being the highest in calcium.

3 oz canned salmon.

A nurse is providing care for four clients on a medical surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers?

A client who has protein calorie malnutrition A client who has right sided heart failure and 4+ edema to the lower extremities A client who has postoperative delirium

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include?

Avoid prolonged sitting Sleeping side lying position with flexed knees Try padded shoe insoles

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

A nurse is caring for a client who is 2 days postoperative following an above the knee amputation. Which of the following is an appropriate nursing intervention for this client at this time?

Have the client lie prone every 3 hours for 20 minute at a time.

A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome?

Hypoxemia

A nurse is teaching a client about manifestations that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis?

Raloxifene

A nurse is observing an AP changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Reaches over the bed to straighten the fitted sheet.

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Realign the client's position.

A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?

Renal stones

A nurse is talking to a client who is taking a calcium supplement for osteoporosis. The client tells the nurse she is experiencing flank pain. Which of the following adverse effects should the nurse suspect?

Renal stones

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and fiberglass cast. Which of the following instructions should the nurse include in the teaching?

Report any worsening or unrelieved pain.

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of fire emergency.

Rescue the clients. Pull the fire alarm. Confine the fire. Extinguish the fire.

A nurse is planning to discharge a client who has 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 providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching?

Rest frequently with your foot elevated

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

Skeletal traction is more appropriate than skin traction for reducing a fracture

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings?

Slight pain at the insertion site Serous drainage on the dressing Minimal edema around the pin

A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen?

Take the medication with food.

A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take?

Talk with the clients who have reported the LPN's lack of care.

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

The AP has the knowledge and skill to perform the task.

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a life-threatening situation.

A nurse at an extended-care facility is instructing a class of AP about the client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the client's use of a cane?

When the client moves, he should move the cane forward first

A nurse is caring for a client who is postoperative following a below the knee amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?

Wrap the residual limb with an elastic bandage in a figure eight configuration.

A nurse is preparing a client who is postoperative following a below the knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?

Wrap the stump with an elastic bandage in a figure eight configuration.

A nurse is providing discharge teaching to a client following hip arthoplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home?

A straight backed chair with an elevated seat

A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

A synthetic cast weighs less.

A nurse is planning to assign care activities to the AP on her team. Which of the following activities can the nurse assign to the AP?

Accompany a client who has depression to OT Check the position of a client in soft wrist restraints Sit with a client who has alcohol use disorder and whose last drink was five days ago.

A nurse is caring for a client with a new diagnosis of Paget's disease. Th nurse anticipates the provider will prescribe which of the following medications for this client?

Alendronate

A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an AP?

Ambulate an older adult client who has hypertension Weighing a client who has heart failure

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

Apply ice to the affected area

A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform?

Apply ice to the affected area. Apply a compression bandage Elevate the foot.

A nurse in an urgent care is caring for a clietn who fell and injured an ankle. The ankle appears swollen and ecchymotic. While the client waits for the technician to take crays, which of the following actions should the nurse take?

Apply ice to the ankle Apply compression bandage Elevate the foot

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms.

A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome?

Assembly line worker

A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?

Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?

Checking capillary refill distal to the cast

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected proximity?

Color (Pallor or Cyanosis)

A nurse is teaching a class about providing emergency care for clients who have a sports related injury. Which or the following information should the nurse include?

Compress the injury for 24 hr.

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?

Decreased muscle mass.

A nurse is caring for a client who has an acute ankle pain. Which of the following actions should the nurse take?

Encourage rest Place compression bandage on the ankle Elevate the ankle

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively.

A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury?

Inability to abduct the arm at the shoulder.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables.

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax.

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan?

Monitor the client's pedal pulses every hour.

A nurse is teaching a client about crutch walking using the three point gait. Which of the following statements by the nurse should be included in the teaching?

Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches.

A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?

Normal bone growth can be affected.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Perform a neurovascular assessment

A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Performs active ROM exercises of all extremities.

A nurse is teaching a client who has a fractured femur about fat emboli syndrome. Which of the following findings should the nurse include as a manifestation of a fat embolism?

Petechiae on the chest

A nurse is assessing the elastic bandage on the stump of a client who had right below the knee amputation. Which of the following findings should the nurse identify as a complication?

Pitting edema around the stump dressing

A nurse in a long-term facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which off 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 assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings?

Positive Phalen's sign

A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include?

Report any numbness or pain in your toes.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. Which of the following explanations should the nurse provide?

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

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?

This procedure will replace my joint to improve function

A nurse is reviewing factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis?

Thyroid hormones

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

You should advance your weak leg forward to the cane, then move your string leg

A nurse is teaching a client who is scheduled for a dual energy xray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

You will need to remove all jewelry before the test

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Administer antibiotics to the client

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

Ability to self-feed with the use of adaptive equipment

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Buck's extension traction will relieve muscle spasms.

A nurse is assessing a client who is 24 hour postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of acute compartment syndrome?

Dyspnea

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect?

Contractures of the extremities Crackles in the lungs Pressure ulcers

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform?

Coordinator Evaluator Energizer

A nurse is assessing a client who has Paget's disease of the bone. Which of the following findings should the nurse expect?

Cranial enlargement Skeletal pain Waddling gait

A nurse is assessing a client who has a rotator cuff injury. Which of the following findings should the nurse expect?

Difficulty with abduction of the arm at the shoulder

A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following factions should the nurse take?

Discuss initiating hospice care with the client and family.

A nurse is teaching a client who has prosthetic limb due to a right below the knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

Dry the prosthesis socket completely before applying to the limb

A nurse is assisting an older adult client who sometimes loses er balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Gait belt

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take fist to recognize the AP's contributions to client care?

Give positive feedback directly to the AP

A nurse is providing teaching for a client who is scheduled for a myelogram. Which of the following statements indicates the client understands the teaching?

I will need to keep my head elevated after the procedure.

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?

I will reduce my intake of vitamin K rich foods.

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 manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take to resolve the conflict?

Identify the problem

A nurse id presenting a class about fall prevention to a group of assisted living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

It is a good idea to use handrails in the bathroom

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?

Localized erythema

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair.

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Lower the client to the floor

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism. The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs

A nurse is delegating client assignments for the shift. Which of the following tasks should the nurse delegate to an AP?

Measure and record intake and output for a client

A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

Prevent hip flexion of the affected extremity.

A nurse is teaching a client who has pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?

Swollen calf

A nurse is teaching a client who will receive a prosthetic leg. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

The technician will complete the prosthesis fitting at the same time the surgeon removes the staples.

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

The weights rest against the foot of the bed.

A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?

Thyroid hormones.

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take?

Use a gait belt to stand and pivot the client.

An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency care?

Wrap the part in dry sterile gauze Put the severed part in a dry, waterproof plastic bag Elevate the extremity Prevent contact of the severed part with water

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis?

You will do special exercises in advance of getting your prosthesis

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as cause of constipation?

Excessive laxative use. Ignoring the urge to defecate. Inadequate fluid intake.

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin dies from bone cancer recently. Which of the following actions should the nurse take?

Explain that the provider will see him and determine a course of action

A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following is a trigger for the formation of vitamin D in the body?

Exposure to sunlight

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

Fat embolism.

A nurse notes increasing edema in the calf of a client who has multiple fracture of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

Acute compliant syndrome.

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

Muscle spasms

A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend?

Flaxseed

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

A nurse is caring for a client who has osteoarthritis and asks about the use of glucosamine. Which of the following statements should the nurse make?

Glucosamine might increase bleeding

A nurse is assessing a client who reports numbness and pain in his right and middle fingers. During the history, the nurse learns that the client is a textbook editor whose work involves a great deal of keyboarding. Suspecting carpal tunnel syndrome, the nurse should ask the client to do which of the following?

Hold the wrist at a 90-degree flexion.

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 in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?

I need to talk to you about the unit policies regarding client assignments.

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the AP and the nurses on next shift reports the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve conflict?

I need to talk to you about unit expectations regarding delegating and completing tasks.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes.

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?

Kyphosis

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?

Pallor of the toes.

An occupational health nurse is instructing workers at an industrial facility about emergency procedures to take in the event of a traumatic amputation of a finger. Which of the following guidelines should the nurse include for preserving an amputated part for possible surgical reattachment?

Wrap the amputated finger in dry sterile gauze Put the amputated finger in a sealed, waterproof plastic bag Prevent the amputated finger from contacting water