217- ATI practice A

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

107 mL/hr

A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings. Which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take. -Perform passive ROM exercises once a day -Assist the client to dangle their legs at the bedside prior to standing -Delegate the application of SCDs to assistive personnel -Massage the clients lower legs to promote circulation -Teach the client to shift their weight every hour when sitting -Administer analgesic prior to planned activities -Encourage the client to bear down when moving up in bed

-Administer analgesic prior to planned activities -Assist the client to dangle their legs at the bedside prior to standing -Delegate the application of SCDs to assistive personnel

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? SATA -Assist the clients with a partial bed bath -Measure the clients BP after the nurse administers an antihypertensive medication -Test the clients swallowing ability by providing thickened liquids -Use a communication board to ask what the client wants for lunch -Irrigate the clients indwelling urinary catheter

-Assist the clients with a partial bed bath -Measure the clients BP after the nurse administers an antihypertensive medication -Use a communication board to ask what the client wants for lunch

A nurse in the ED is caring for a client. Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again. -Cachectic, with flaccid muscle tone. -Skin dry and scaly with bruises on extremities. -Oriented x 3, able to move all extremities. -Pulse rate 118/min -Respiratory rate 18/min -Abdomen distended -Temperature 39.2° C (102.6° F) -BMI 17

-Cachectic, with flaccid muscle tone. -Skin dry and scaly with bruises on extremities. -Pulse rate 118/min -Abdomen distended -BMI 17

A nurse is providing teaching for a client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching? -Increase intake of high calcium foods -Eat probiotic foods such as yogurt -Avoid alcohol while experiencing diarrhea -Eat raw vegetables -Eat three large meals a day -Avoid caffeine while experiencing diarrhea -Drink hot liquids several times a day -Drink carbonated beverages to replace lost fluids -Follow a low fiber diet

-Eat probiotic foods such as yogurt -Avoid alcohol while experiencing diarrhea -Avoid caffeine while experiencing diarrhea -Follow a low fiber diet

The nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? -I have been weighing myself every other morning. -I am trying to decrease my intake of foods with potassium -I am limiting my sodium intake to 2 grams daily -I am eating fewer potato chips and more fruit for snacks -I lie down and rest after meals -I know to call my doctor if I gain 3 pounds or more in 2 days

-I am limiting my sodium intake to 2 grams daily -I am eating fewer potato chips and more fruit for snacks -I know to call my doctor if I gain 3 pounds or more in 2 days

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA -Place the client in a room with a negative-pressure airflow -Wear gloves when assisting the client with oral care -Limit each visitor to 2-hr increments -Wear a surgical mask when providing client care -Use antimicrobial sanitizer for hand hygiene

-Place the client in a room with a negative-pressure airflow -Wear gloves when assisting the client with oral care -Use antimicrobial sanitizer for hand hygiene

A nurse is admitting a client. The nurse is reviewing the clients medical record. Which of the following actions should the nurse take? SATA -Place the client on droplet isolation precautions -Apply oxygen at 2 L/min via nasal cannula -Request a prescription for an antipyretic medication -Wear an N95 mask when providing care to the client -Request a prescription for an antihypertensive medication -Remain 1 m (3 feet) from the client

-Place the client on droplet isolation precautions -Apply oxygen at 2 L/min via nasal cannula -Request a prescription for an antipyretic medication -Remain 1 m (3 feet) from the client

A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. -Temperature -WBC count -Prealbumin level -Hemoglobin level -Blood pressure -Pain level -Odor of wound -Bowel sounds

-Temperature -WBC count -Prealbumin level -Pain level -Odor of wound

A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding click on the finding again. -Neurological assessment -Incisional drainage -Urinary output -Reported pain level -Gastrointestinal assessment -Vital signs

-Urinary output -Reported pain level -Vital signs

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1. Place a name tag on the body 2. Obtain the pronouncement of death from the provider 3. Remove tubes and indwelling lines 4. Wash the clients body 5. Ask the clients family members if they would like to view the body

2, 3, 4, 5, 1

A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside their room if there is construction in the area

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?

Assist the client to an upright position

A nurse is caring for a client who has a sodium level of 125 mEq/L (136 to 145 mEq/L). Which of the following findings should the nurse expect?

Abdominal cramping

A nurse is caring for a client who is postoperative. When the nurse prepares to change the clients dressing, they say, "Every time you change my bandage it hurts so much." Which of the following interventions is the nurses priority action?

Administer pain medication 45 minutes before changing the clients dressing

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding their daily routine

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the clients plate

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine

A nurse enters a clients room and finds them on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Client found lying on floor

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the clients home medications with the providers prescriptions

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

A nurse is assessing a client who received an IV bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning?

During the admissions process

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting

A nurse is caring for a client who has limited mobility in their 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

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid

A nurse is assessing a clients readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

I can concentrate best in the morning

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system

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 am and have saved all urine since

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

I want you to tell me about measures available to keep me comfortable

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while the client is asleep

a nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain?

Is your pain sharp or dull

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

It might help me to listen to music while I'm lying in bed

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the clients wrists before applying the restraints

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

People in middle adulthood often find satisfaction in nurturing and guiding young people

A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurses report to the provider?

Potassium 5.8 mEq/L (3.5 to 5 mEq/L)

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid heart rate

A nurse is talking with the partner of a client who has dementia. The clients partner expresses frustration about finding time to manage a household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload

A nurse is lifting a bedside cabinet to move closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it

A nurse is using an open irrigation technique to irrigate a clients indwelling catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the clients urine output

A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher

A nurse is caring for a client who has a new diagnosis of seizure disorder. Complete the following sentence by using the list of options. The nurse should first address the client's ______ followed by the clients _____?

The nurse should first address the clients physical safety followed by the clients positioning.

A nurse in an emergency department is caring for a client. Physical Exam 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids Vital signs 1200: Temp 38.4 C (101.1 F), HR 126/min, RR 28/min, BP 92/54 mm Hg, O2 Sat 93% Nurses notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "Im going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to clients family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by clients family. Updated them on situation. Complete the following sentence by using the options list. The nurse should first ______ followed by _____.

The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

Use the complete name of the medication magnesium sulfate

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

We can talk about advance directives and I can also give you some brochures about them

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

Wear a gown when caring for the client

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

Withhold the blood transfusion

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The clients family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

Would you like it if we discussed the transfer with your family member

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the clients plan of care?

Wrap blankets around all four sides of the bed

A nurse in a surgical suite notes documentation on a clients medical record that they have 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

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

You should receive a pneumococcal vaccine when you are 65 years old