ATI Nurse Logic Questions

A nurse is preparing to administer a tap water enema to a client. In which o f the following positions should the nurse place the client?

Left Lateral Position or Sims' is correct. The left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution.

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching?

Soybeans is correct. Food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance. Soybeans are a source of complete protein and should be included in the teaching.

A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

This is the site the nurse should palpate. McBurney's point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image; you had to identify the client's right side.

A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? Prescriptions: Clozapine (Clozaril) 100 mg PO twice daily//Nitroglycerin ointment (Nitropaste) ½ inch applied for 12H daily//Warfarin (Coumadin) 10 mg PO daily Labs: INR 2.4//Blood Glucose Level 144 mg/dl History and Physical: History of schizophrenia//History of angina Clinical Findings//Client reports insomnia, dry mouth, sore throat, headache//Temperature 37.6° C (99.8° F)//Respirations 20/min Heart rate 90/min//Blood pressure 144/94 mm Hq

Temperature 37.6° C (99.8° F) is correct. Sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine. Using the urgent versus nonurgent priority setting framework, this is the priority finding and should be reported immediately to the provider.

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse?

Place client in knee-chest position is correct. Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take.

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider?

Tachycardia is correct. Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.

A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.)

Urinary Tract is correct Surgical Wound is correct Respiratory Tract is correct Bloodstream is correct

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril?

Aspirin is correct. Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.)

Drooling, Stridor, Difficulty Swallowing, High-Grade Fever

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak?

Oliguria is correct. When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective?

"I feel very relaxed" is correct. Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective.

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching?

"This illness will not recur because my child has now had it" is correct. It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed. This statement by the parent is not appropriate and indicates a need for further teaching.

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief?

Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care?

Identify one's own beliefs and values is correct. To provide culturally competent care, it is essential to identify one's own cultural background, values, and beliefs, especially those that are related to health and health care. This is the most important action by the nurse.

A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first?

Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider?

Slurred speech is correct. Slurred speech is an early clinical finding associated with lithium toxicity and can precipitate the onset of seizures or coma. Using the safety and risk reduction priority setting framework, this finding jeopardizes the immediate physiological safety of the client and should be reported to the provider immediately.

A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?

2sp

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (Select all that apply)

Grape Juice and IceCream

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?

Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.

A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations?

Shakiness and diaphoresis is correct. The nurse should observe the client for shakiness and diaphoresis. These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.

A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder?

Unstable interpersonal relationships is correct. Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions.

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways?

Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector.

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

-The first action the client should be taught when using a 3-point crutch gait to go up stairs is to stand and bear weight on the unaffected leg. -The second action the client should be taught when using a 3-point crutch gait to go up stairs is to transfer body weight to the crutches. -The third action the client should be taught when using a 3-point crutch gait to go up stairs is to advance the unaffected leg between the crutches. -The fourth action the client should be taught when using a 3-point crutch gait to go up stairs is to shift weight from the crutches to the unaffected leg. -The fifth action the client should be taught when using a 3-point crutch gait to go up stairs is to align crutches on the stair.

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning?

Advocate is correct. A nurse advocate acts as a liaison between clients and providers in order to improve or maintain the quality of care that clients receive. The nurse is functioning in the role of the nurse advocate for the clients during the prenatal period.

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

CHOICE A // This area, known as the posterior cervical, is correct. While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.

A nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?

Hearing loss is correct. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect.

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low-pitched diastolic murmur?

This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.

A nurse is reviewing the electronic fetal heart rate tracing of a client who is in labor. Which of the following images exhibits variable decelerations?

This is an image of variable decelerations. Variable decelerations are caused from cord compression.

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching?

"I should eat low carbohydrate foods" is correct. Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet. This is not an appropriate statement by the client and indicates a need for further teaching.

A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?

1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.

A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?

3/4 cup of canned tomato juice is correct. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider?

A client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L is correct. This value is clearly abnormal and indicates that the client has hypokalemia, or decreased potassium. This is a common complication with the use of loop diuretics, such as furosemide. The nurse should also note that the client receives digoxin. Hypokalemia places the client at increased risk for digoxin toxicity, so this is the client who is at immediate risk for injury and whose laboratory findings should be reported to the provider.

A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion?

Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following?

Mood is correct. St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.

A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Labs: Hemoglobin 15.4 g/dL//Protein 7.2 g/dL//BUN 8 mg/dL//Glucose 72 mg/dL Physical Assessment: 2+ peripheral edema//Blood pressure 144/96 mm Hq//Increased urinary output//Respiratory crackles bilaterally History: Total hip arthroplasty 10 days ago//15-year history of diabetes mellitus//32-year history of heart failure

Restrict fluid intake is correct. Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?

Stand close to the client is correct. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back.

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? (harsh high-pitched sound heard on inhalation or expiration. )

Stridor is correct. Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. The breath sound on the audio clip is an example of stridor.

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading?

Using a cuff that is too wide is correct. Using a cuff that is too wide can result in a false low blood pressure reading.