212 Consolidated ATI
A nurse is speaking with a client who reports experiencing frequent, severe migraines and asks, "Can you tell me about biofeedback?" Which of the following responses should the nurse make?
"Biofeedback measures skin tension and uses learned techniques to relieve pain."
A nurse is caring for a client who is about to receive a unit of packed RBs and states, "This is my third unit of blood today. I don't want to get some disease from all this blood." Which of the following responses should the nurse make?
"Donated blood is carefully screened for infectious diseases."
A nurse is teaching the adult child of a client about instilling eye drops in the client's right eye. Which of the following statements by the client's adult child indicates an understanding of the teaching?
"I will pull down her lower eyelid and drop the medication inside."
A nurse is caring for a client who has a prescription for a fluticasone propionate inhaler with a spacer. The client asks the nurse why a spacer is needed with the inhaler. Which of the following responses should the nurse make?
"More medication is delivered to the lungs when you use a spacer."
During a pain assessment, a nurse asks questions about the quality of an adult client's pain. Which of the following statements by the client refers to pain quality?
"My pain feels like I'm being stabbed by a knife."
A nurse is teaching a client who has type 1 diabetes mellitus about the peak time of neutral protamine Hagedorn (PH) insulin. Which of the following statements by the client indicates an understanding of the teaching?
"NPH insulin peaks in 6 to 14 hours."
A nurse is caring for a client who has a fractured humerus and received an opioid medication intravenously 1 hr ago for pain. Which of the following questions should the nurse ask to determine the intensity of the client's pain at this time?
"On a scale from 0 to 10, how do you rate your pain?'
A nurse is teaching a client who was recently diagnosed with type 1 diabetes mellitus how to check blood glucose levels. Which of the following instructions should the nurse include in the teaching?
"To collect a sample for testing, hold the test strip next to the blood on the fingertip."
A nurse is assessing a client's pain. Which of the following questions should the nurse ask the client to assess the quality of the pain?
"What does your pain feel like?"
A nurse is providing education to a client who has a prescription for a blood transfusion. Which of the following statements should the nurse include in the teaching?
"You must immediately report any symptoms like chills, nausea, or itching."
nurse is preparing to administer an intramuscular injection at the ventrogluteal site. Which of the following needle lengths should the nurse select for an adult of average size?
1 1/2 inches
A nurse is reviewing the results of routine laboratory tests performed as part of a client's annual physical examination. Which of the following values indicates a fasting blood glucose measurement that is outside of the expected reference range?
118 mg/dL
A nurse is caring for a client who has a new prescription for prednisone 12.5 mg by mouth daily. The medication is available in 5 mg tablets. How many tablets should the nurse administer for each dose?
2.5
A client drinks 8 oz of water. Which of the following is a correct conversion of the client's intake?
240 mL
A client drinks 8 oz of water. Which of the following is a correct conversion of the client's intake?
240 mL One fluid oz equals 30 mL; therefore, 8 fluid oz equals 240 mL.
Which of the following clients is exhibiting medication tolerance?
A client who requires an increased dose of a medication to achieve continued therapeutic benefit
A nurse is caring for a client who has a chest tube in place that is attached to a water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema?
A dry, crackling sound at the insertion site when palpated
A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted?
A nontunneled percutaneous central catheter
A nurse is assessing a client 5 hr after the insertion of a chest tube that is attached to a water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider?
About 150 mL/hr drainage over the past 2 hr
Which of the following actions demonstrates correct use of one of the Ten Rights of Medication Administration?
Administering a client's medication by the route the provider has prescribed
Which of the following represents the correct administration of the prescribed medication?
Amoxicillin 1 g PO prescribed; two 500-mg tablets given
A nurse has a handwritten prescription that is difficult to read. Which of the following actions should the nurse take to avoid an error in medication administration?
Call the provider for clarification of the prescription.
A nurse is caring for a client prescribed IV morphine via PCA with a demand of 1 mg every 15 min and a 4 mg/hr lockout. The client reports unbearable pain after attempting six demand doses within the last hour. After assessing the client's pain, which of the following actions should the nurse take?
Check the IV site and PCA pump for proper functioning.
A nurse is preparing to initiate the transfusion of a unit of packed RBs to a client. After the unit of blood has arrived, which of the following procedures will help the nurse protect the client against the possibility of a blood-group incompatibility?
Comparing the ID numbers on the blood unit with those on the order form and the client's wristband
A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority?
Confirm the client's identity using two methods.
A nurse is caring for a client who is 6 hr postoperative and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system?
Continuous bubbling in the water-seal chamber
A nurse is reviewing a group of prescriptions. Which of the following should the nurse identify as an example of a complete prescription?
Digoxin 1.25 mg PO daily
A nurse is preparing to administer a client's medication. The client states the medication makes them feel nauseated and refuses to take it. Which of the following actions should the nurse take?
Document the reason for refusal along with the date and time in the client's medical record.
A nurse is caring for a client who has COPD. For which of the following inhalation medication delivery methods should the nurse assess the client's ability to inhale deeply?
Dry powder inhaler (DPI)
A nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at -40 cm of water. Which of the following closed-chest drainage systems should the nurse prepare for this client?
Dry suction- control system
Which of the following actions should a nurse take prior to starting a blood transfusion?
Ensure that informed consent has been obtained from the client.
A nurse is preparing to assess the pain level of a 4-year-old child. Which of the following pain assessment tools should the nurse use?
FACES
A nurse started a transtusion of packed RBs for a client 1 hr ago. The citent has suddenly developed shaking chills, muscle stiffness, and a temperature of 38.6° C (101.5° F). The client appears flushed and reports a headache and "nervousness." The nurse should identify that the client has most likely developed which of the following types of transfusion reaction?
Febrile nonhemolytic
A nurse is caring for a client who has type 1 diabetes mellitus and reports feeling anxious and having palpitations. The glucometer reads 50 mg/dL. Which of the following actions should the nurse take?
Give the client 4 oz of apple juice
A nurse is caring for a client who has type 1 diabetes mellitus and reports feeling anxious and having palpitations. The glucometer reads 50 mg/dL. Which of the following actions should the nurse take?
Give the client 4 oz of apple juice.
A nurse is planning to administer a dose of morphine sulfate IV for a client who is postoperative. Which of the following pain management protocols should the nurse use when caring for this client? о
Have an opioid antagonist available during the administration.
A nurse is caring for a client who has a chest tube in place. Which of the following strategies should the nurse use to help promote comfort for the client?
Have the client splint the affected side during coughing.
A nurse is preparing to administer acetaminophen 1,000 mg PO every 12 hr for a client who has arthritic pain. The nurse should monitor the client for which of the following adverse effects?
Hepatotoxicity
A nurse is caring for a client who is receiving a medication that typically causes drowsiness. While assessing the client, the nurse notes that the medication has caused the client to become hyperactive. Which of the following terms describes the client's unexpected response to the medication?
Idiosyncratic effect An idiosyncratic effect is an uncommon, unexpected, or individual medication response thought to result from a genetic predisposition.
A nurse is preparing to administer a subcutaneous injection to a client. Which of the following should the nurse assess first?
If the client has allergies to the medication
A nurse is preparing to administer several medications to a client who is receiving enteral feedings through a small bore nasogastric tube. Which of the following actions should the nurse take to ensure the medications are administered correctly?
Infuse each medication by gravity and flush with water before and after instillation.
Which of the following describes a medication's generic name?
It is the same as its nonproprietary(noncommercial) name.
A nurse is planning education for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate?
Keep the collection device upright at all times.
A nurse is reviewing self-administration of insulin using a pre-filled pen with a client who started using the pen the previous week. The client asks what can be done to help reduce injection pain. Which of the following instructions should the nurse give the client?
Keep the pen at room temperature for a few minutes.
nurse is preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation?
Make sure the air vent is open.
A nurse is caring for a client who was admitted to the emergency department for severe pain following a fall from a ladder. The client reports taking an opioid prescription for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question?
Naloxone
A nurse is preparing to administer medications for a client who has a nasogastric tube. Which of the following actions should the nurse take prior to administering the medications?
Observe the amount of residual volume left in the stomach.
Which of the following terms indicates that a medication is given via an injection?
Parenteral
A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. Which of the following actions should the nurse take to locate the site of iniection?
Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest.
A nurse is caring for two clients who are 2 hr postoperative following the same procedure. Which of the following factors should the nurse expect to be similar for both clients?
Prescriptions containing guidelines for pain medication administration
A nurse is preparing to instill antibiotic ear drops into the ear of a 2-year-old child. Which of the following techniques should the nurse use when administering ear drops to this client?
Pull the client's auricle down and back to open the canal when administering the ear drops.
A nurse is preparing to administer several PO medications to a client. The client states they can only take one pill at a time. Which of the following actions should the nurse take?
Remain at the bedside until the client has taken all of the medications.
A nurse is preparing to administer an insulin injection to a client. Which of the following actions should the nurse take?
Rotate the injection sites.
A nurse is caring for a client who has a left hip fracture and is prescribed a morphine IV bolus as needed for pain. The nurse should monitor the client for which of the following adverse effects?
Sedation
A nurse is preparing to administer hydrocodone to a client who reports throbbing pain following a back injury. The nurse should document the client is experiencing which of the following types of pain?
Somatic
A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse observes areas of urticaria on the client's skin. Which of the following actions should the nurse take?
Stop the blood transfusion
A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed-chest drainage system?
Submerge the end of the chest tube in 1 inch of sterile water.
A nurse is documenting a client's response to a pain medication. Which of the following is an example of correct documentation regarding the client's response to pain?
The client reports pain decreased 30 min after medication administration to 3 on a scale of 0 to 10.
A nurse is teaching a client who has type 1 diabetes mellitus about the use of an insulin pump. Which of the following information should the nurse include in the teaching?
The risk for developing DKA can be increased with the use of an insulin pump.
A nurse is preparing to administer an intradermal injection. Which of the following actions should the nurse take to ensure proper technique?
Use a tuberculin syringe with a 5/8-inch, 25 gauge needle.
A platelet transfusion is indicated for a patient who
has thrombocytopenia.
A nurse is caring for a client who has type 1 diabetes mellitus and is in need of a long-acting insulin preparation. The nurse anticipates receiving a prescription for which of the following insulins?
insulin glargine
Which of the following routes of medication administration has no barriers to absorption?
intravenous
A client who is anticipating total hip replacement is considering autologous transfusion. When teaching this client about autologous transfusion, it is important to emphasize that
it reduces the risk of mismatched blood.
When administering a transfusion of packed red blood cells, it is important to
make sure the entire unit is transfused within 4 hr.
A nurse is administering aspirin 81 mg PO daily to a client who has a history of myocardial infarction. The medication is scheduled for 0800. Which of the following scenarios demonstrates proper use of one of the Ten Rights of Medication Administration?
nurse documents that the aspirin was given at 0825
A nurse is teaching a client who has a new diagnosis of type 2 diabetes mellitus about metformin. The nurse should explain that this type of medication works by which of the following mechanisms?
reducing hepatic glucose production
A nurse is preparing a blood transfusion for a client who has type A blood. The nurse should know that the client can safely receive blood from blood group O because
type O blood contains no A antigens.