ATI Testing and Remediation Beginning

A nurse is assisting with admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorezapam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective? "I am wide awake now." "My mouth is very dry." "I feel very relaxed." "My heart is racing."

"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 in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benedryl) 25mg every 6 hours as needed. Available is diphenhydramine 12.5mg/5ml syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?

2 tsp

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? 1/2 cup of white rice 1 slice of wheat bread 1 cup of 2% milk 3/4 cup of canned tomato juice

3/4 cup of canned tomato juice 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 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? 1/2 inch 5/8 inch 1 inch 1 1/2 inch

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 caring for a client who is scheduled 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? Anger Acceptance Bargaining Denial

Bargaining Clients or families might promise to improve or change habits as a part of the grieving process.

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 Hyper-resonance Resonance Tympany

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 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) Cooked oatmeal Grape juice Applesauce Ice cream Smooth peanut butter

Grape Juice Ice Cream A full liquid diet is comprised of liquids and foods that turn to liquid at body temperatur, and is prescribed for clients who are unable to tolerate solid or semisolid foods.

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? Respiratory depression Hearing loss Hypertension Bradycardia

Hearing loss 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 examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes.

Hot spot A (behind neck)

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? Percussion Palpation Auscultation Inspection

Inspection 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 in a providers 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 Immunity Memory Vitality

Mood 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 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 Visible subcutaneous fat Nonblanchable redness Exposed muscle

Partial thickness skin loss. Staging of pressure ulcers includes: depth of tissue involved, description of exudates, dimensions of wound, & condition of surrounding skin. A stage II pressure ulcer typically presents as an abrasion or blister.

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? Exhibit 1 Serum Laboratory Results: Hemoglobin 15.4 g/dL Protein 7.2 g/dL BUN 8mg/dL Glucose 72mg/dL Exhibit 2 Physical Assessment: 2+ peripheral edema Blood pressure 144/96 mm Hg Increased urinary output Respiratory crackles bilaterally Exhibit 3 Health History: Total hip arthroplasty 10 days ago 15-year history of diabetes mellitus 32-year history of heart failure

Restrict fluid intake

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? Lithotomy Dorsal recumbent Prone Sims'

Sims' This position allows the enema to flow along the curve of the sigmoid colon & rectum naturally, which improves retention of the solution.

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? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.

Stand close to the client. 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 is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions taken by the nurse when taking the blood pressure can result in an inaccurately low reading? Wrapping the cuff loosely around the arm Using a cuff that is too wide Leaving client's arm unsupported Taking client's blood pressure immediately after client sits down

Using a cuff that is too wide 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.

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

Vector Lyme disease is transmitted by ixodid, or deer ticks, which is a vector.

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

left lateral recumbent position is the best position for detecting a low-pitched diastolic murmur.