2500 Unit 2 ATI
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client? "Are there any specific factors that you think are affecting your ability to sleep?" "Can you describe your bedtime routine to me?" "Do you have difficulty staying awake when you are driving?" "When did you begin to have trouble sleeping"
"Do you have difficulty staying awake when you are driving?"
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? "I don't take napes throughout the day" "I go to bed and get up routinely at the same time each day." "I have a small snack and take a bath before going to bed each day" "I watch television until i fall asleep at night"
"I watch television until i fall asleep at night"
What is therapeutic magnesium level?
1.3-2.1 mEq/L
A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's totally intake for the shift?
1720 mL
A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? 25 mg/dL 13 mg/dL 10 mg/dL 18 mg/dL
25 mg/dL (expected range is 10-20 mg/dL)
What is therapeutic potassium level?
3.5-5.0 mEq/L
A nurse is calculating a clients fluid output for a 12-hr period. It includes Jackson=Pratt (JP) drainage 35 mL, NG suction 120 mL, and incontinence pads sighting 240 g, 275 g, 310 g, and 270 g. The dry weight of the incontinence pads is 90 g. The nurse should record how many mL of output on the client's record?
890 mL
What is therapeutic chloride level?
98-106 mEq/L
A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention? A client who has an elevated BUN A client who reports painful urination A client who reports urinary frequency A client who has glucose in his urine
A client who reports urinary frequency
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? Apply a moisture barrier ointment to the clients skin Clean the clients skin and perineum with hot water after each episode of incontinence Check the clients skin every 8hr for signs of breakdown Request a prescription for the insertion of an in dwelling urinary catheter
Apply a moisture barrier ointment to a client's skin
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? Determine the time the client last received pain medication Measure the clients vital signs, including temperature Ask the client to rate her pain on a scale from 0-10 Reposition the client and offer her a back rub
Ask the client to rate her pain on a scale from 0-10
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the clients plan of care? Auscultate breath sounds at least every 2 hrs Perform ROM exercises at least 2-3 times daily Make sure the client has an intake of 2,000-3,000 mL of fluid per day Apply antiembolic stockings
Auscultate breath sounds at least every 2 hrs
A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? Liver Milk Beans Eggs
Beans
A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? Check that the client lifts the walker and then places it down in front of her Walk in front of the client to guide her in moving the walker Have the client move one leg forward with the walker Make sure that the upper bar of the walker is level with the clients waist
Check that the client lifts the walker and then places it down in front of her
A nurse is providing dietary teaching for a client who is Asian-American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care? Stop the instructions to see what is on the floor Emphasize the significance of the information Move closer to the client for eye contact Continue with the discussion
Continue with the discussion
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply) Contractures of the extremities Polyuria Diarrhea Crackles in the lungs Pressure ulcers
Contractures of the extremities Crackles in the lungs Pressure ulcers
A nurse is providing teaching to a client who has cancer about foods that prevent protein—energy malnutrition. Which of the following foods should the nurse include in the teaching (select all that apply) Cottage cheese Milkshakes Tuna fish Strawberries and bananas Egg and ham omelet
Cottage cheese Milkshakes Tuna fish Egg and ham omelet
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes?? Decrease gastric motility Decreased skin elasticity Increased pain threshold Increase metabolic rate Increase cardiac output
Decreased gastric motility Decreased skin elasticity Increased pain threshold
A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? Delivers a constant rate of a specific concentration of oxygen Delivers a high concentration of oxygen Delivers a low concentration of oxygen Restricts the clients ability to eat, speak, or drink
Delivers a low concentration of oxygen
A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating? Assign an assistive personnel to feed the client Explain to the client that her tray is here and place her hands on it Describe to the client the location of the food on the tray Ask the client if she would prefer a liquid diet
Describe to the client the location of the food on the tray
A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? Determine if the client can bear weight Place a transfer belt on the client Position the bed at an appropriate height Assist the client to a seated position
Determine if the client can bear weight
A nurse is caring for a client who requests prescription pain medication. Which of the following actins should the nurse perform first? Reposition the client Administer the medication Determine the location of the pain Review the effects of the pain medication
Determine the location of the pain
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? Document restraint checks and client status every 2 hr Educate the clients family about restraint use Obtain the providers prescription renewal every 72 hr Implement passive ROM exercises Release the restraint and reposition the client every 4 hr
Document restraint checks and client status every 2 hr Educate the clients family about restraing use Implement passive ROM exercises
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? Explain to the client what is about to happen Make sure the room temperature is cool Provide music as an environmental distraction Inform the client that the provider will examine sensitive areas first
Explain to the client what is about to happen
A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene? Closes the door to the clients room Measures the clients vital signs routinely Asks a group of nurses in the hall to speak quietly Flushes the client's toilet after emptying the urinary catheters drainage bag
Flushes the clients toilet after emptying the urinary catheters drainage bag
A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? Gait belt Jacket harness Four-wheel walker Cane
Gait belt
A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? Increased insulin production Decreased RBC production Decreased sodium excretion Increased calcium excretion
Increased calcium excretion
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? Place the wheelchair at a 90* angle to the bed Lock the wheels of the bed and the wheelchair Acquire the help of several people to lift the client Elevate the bed to a position of comfort for the nurse
Lock the wheels of the bed and the wheelchair
A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? Occupational therapist Psychiatric social worker Recreational therapist Psychiatric clincal nurse specialist
Occupational therapist
A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply) Offer the client a back rub Remind the client to use incisional splinting Identify the client's pain level Assist the client to ambulate Change the clients position
Offer the client a back rub Remind the client to use incisional splinting Identify the clients pain level Change the clients position
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promotes wound healing? One cup of brown rice Once cup of orange juice Once cup of puréed avocado One cup of lentils
One cup of lentils
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Pain Hearing loss The clients culture Motor impairment
Pain
A nurse is caring for a client who has not voided for 8 hr following the removal of n in dwelling urinary catheter. Which of the following actions should be the nurse take first? Increase fluids Perform a bladder scan Insert a straight catheter Provide assistance to bathroom
Perform a bladder scan
A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an index ATI on that the client is ready to ambulate? Need assistance raising her legs to put on socks Demonstrates mild dyspnea when eating breakfast Performs active ROM exercises of all extremities Develops fatigue when assisting with morning hygiene care
Performs active ROM exercises of all extremities
A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)? Admission assessment of a new client Scheduling a diagnostic study for a client Evaluating changes to a clients pressure ulcer Teaching a client insulin injection technique
Scheduling a diagnostic study for a client
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? Vital signs Self-report of pain Severity of the condition Nonverbal behavior
Self-report of pain
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? Sodium 126 mEq/L Potassium 3.6 mEq/L Magnesium 1.9 mEq/L Chloride 99 mEq/L
Sodium (therapeutic sodium level is 136-145 mEq/L)
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client fort he procedure? Nurse Anesthesiologist Surgeon Surgical suite nurse
Surgeon
A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? Bradypnea Somnolence Pallor Tachycardia
Tachycardia
A nurse in a long-term care facility is caring for an older adult client who has dementia and beings to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Remind the client to tell the nurse when he has to urinate Use adult diapers to prevent frequent clothing changes Take the client to the bathroom every 2 hr Request a prescription for an in dwelling urinary catheter
Take the client to the bathroom every 2 hr
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? Warm the feeding solution to body temperature Place the client in low Fowler's position Discard any residual gastric contents Test the pH of gastric aspirate
Test the pH of gastric aspirate
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determine the intensity of the client's pain? Vital sign measurement The client's self/report of pain severity Visual observation for nonverbal signs of pain The nature and invasive nests of the surgical procedure
The client's self-report of pain severity
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? The clients ability to communicate The clients current weight-bearing status The clients height The type of equipment used in previous transfers
The clients current weight-bearing status
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? Use a stiff toothbrush to clean the client's teeth Use the thumb and index finger the clients mouth Turn the client on his side before starting oral care Apply petroleum jelly to the client's lips after oral care
Turn the client on his side before starting oral care
A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? Urinary tract infection Urinary incontinence Urinary frequency Urinary retention
Urinary tract infection
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? Urine output of 175 mL in the past 8 hr Urine output of 2,200 mL in the past 24 hr First-voided urine in the morning has a strong odor Urine is cloudy after sitting in the urinal for 6 hr
Urine output of 175 mL in the past 8 hr (notify provider if clients urinary output is less than 30mL/hr)
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take? Raise the client's bed to the nurse's waist level Use a gait belt to stand and pivot the client Instruct the client to place his hands around the nurses neck during the transfer Place the chair on the clients weak side
Use a gait belt to stand and pivot the client
A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer? Enlist help from another staff member Adjust the bed to an appropriate height Use a powered standing-assist lift Avoid movements that twist the spine
Use a powered standing-assist lift
A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend Tennis Walking Running Jumping rope
Walking
A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will walk briskly for 30 minutes before bedtime" "I will no longer have a glass of wine before bedtime" "I will have a cup of hot cocoa immediately before bedtime" "I will do my muscle relaxation techniques each afternoon"
"I will no longer have a glass of wine before bedtime"
A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? "I'll urinate a little then stop." "I'll use the cleansing wipe from front to back." "I'll clean the inside of the container with a wipe." "I'll use each cleansing wipe twice."
"I'll use the cleansing wipe from front to back."
A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching? "Look down at your feet before moving the crutches" "Place on crutch forward with the opposite foot and then place the second crutch forward followed by the second foot" "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches" "Support your body weight on the underarm crutch pads"
"Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches"
A nurse is filling our an incident report after finding a client lying on the floor. Which of the following information should the nurse include? "The client attempted to climb over the side rails and fell" "The client was lying on the floor next to his bed." "The client was restless and trying to get out of bed all evening." "The presence of a bed alarm could have prevented the client from falling."
"The client was lying on the floor next to his bed."
A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record?
1140
A nurse is calculation the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record?
1170
A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? Dilated pupils Dysrhythmias Diarrhea Gastric ulcer
Dysrhythmias
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse i inter probe to which of the following locations? Finger Earlobe Toe Skin fold
Earlobe
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? Encourage the client to ambulate frequently Encourage coughing and deep breathing Encourage the client to increase fluid intake Encourage regular use of the incentive spirometer
Encourage the client to increase fluid intake (1,500 to 2,500 mL/day)
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Poor skin turgor Bradycardia Hypotension Pale yellow urine Flare neck veins
Poor skin turgor Hypotension Flat neck veins
A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? One nurse lifting as the client pushes with his feet Two nurses lifting the client under the shoulders One nurse lifting clients legs as the client uses a trapeze bar Two nurses using a friction-reducing device
Two nurses using a friction-reducing device
