ATI practice exam A

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." -for a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home

"I'll check the wires and cables on my TV to make sure they are in good working order." -oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks.

A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year." -colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse is providing care to four clients. which of the following situations requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid. -the nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

Acupuncture -the nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skins surface, which could increase the risk of further infection.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries -the first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration -the nurse should gently shake the liquid medication to ensure the medication is mixed.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus -Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tubes passage into the trachea

a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position -by using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

Place the client in a room with negative-pressure airflow -the nurse should place the client in a room with negative pressure airflow to meet the requirements of airborne precautions. wear gloves when assisting the client with oral care. -the nurse should wear gloves when assisting with oral care to meet requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever her hands might come in contact with a clients body fluids, such as saliva, and the mucous membranes in the mouth use antimicrobial sanitizer for hand hygiene. -the nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. The nurse should also wash her hands with soap and water when her hands have visible soiling.

a nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position -the nurse should place the clients arm in a dependent position because the veins will dilate due to gravity

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen -the nurse should select a suction catheter that is half the size f the lumen to prevent hypoxemia and trauma to the mucosa

A nurse is caring for a client who has a prescription for 5 unites of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the the following types of activity should the nurse recommend?

Walking briskly -weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis, walking engages older adult clients in this preventive and therapeutic strategy

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion -the principle of autonomy ensures that a client who is competent has the right to refuse treatment.

a nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

allow extra time for the client to respond to questions -older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

fried egg. -for a client who is prescribed a mechanical soft diet, the nurse should remove fried eggs from the meal tray. Fried eggs are not part of a mechanical soft diet. Eggs that are poached or scrambled are allowed on a mechanical soft diet and are an acceptable replacement for this item.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

narrowed arterial lumen -arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

remove the stockings at least once per shift -the nurse should remove the stocking once per shift to check the client's circulation and skin integrity.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the clients procedure, which of the following precautions should the nurse take?

wrap monitoring cords with stockinette and tape them in place. -many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the clients skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.