ATI Basic Care & Comfort 1

A nurse is teaching the parent of a newborn about bottle feeding. Which statement indicates need for further instruction? a. I will keep my baby's head elevated while he is feeding b. I will allow my baby to burp several times during each feeding c. I will tip the nipple so air is present as my baby sucks d. My baby will have soft, formed yellow stools

c. I will tip the nipple

Which food should the nurse recommend that the client with hypothyroidism add to her diet? a. Ripe bananas b. Poached eggs c. Whole grains d. Baked chicken

c. Whole grains Pt should be increasing fluids and fiber to avoid constipation; ripe bananas and poached eggs for diverticulitis or UC/animal-based protein does not help with constipation

Which is an indication of infection at the pin sites for a client in skeletal traction? a. Serosanguineous drainage b. Mild erythema c. Warmth d. Fever

d. Fever

How many calories are contained in a food item that has 15g carbs, 4g protein, and 10g fat?

166 1g carbs/protein = 4 cal 1g fat = 9 cal

A nurse is caring for a client who has a prescription for a clear liquid diet. What should the nurse allow the client to have? a. Grape juice b. Lemon sherbet c. Milkshake d. Vanilla ice cream

a. Grape juice

A client with a decreased LOC is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which is a priority action by the nurse? a. Observe respiratory status b. Elevate HOB 30-45deg c. Monitor I&O q8h d. Check residual volume q4-6h

b. Elevate HOB

A nurse is caring for a client who is postop following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (select all that apply) a. Offer a back rub b. Remind client to use incisional splinting c. Identify pain level d. Assist client to ambulate e. Change position

a, b, c, e

Which of the following should the nurse recommend to the patient undergoing chemotherapy and losing weight to increase calorie and protein intake? (select all that apply) a. Top fruits with yogurt b. Add cream to soups c. Use milk instead of water in recipes d. Increase fluids during meals c. Dip meats in eggs and bread crumbs before cooking

a, b, c, e

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (select all that apply) a. Shoulders droop b. Facial muscles relax c. Respiratory rate increases d. Pulse is within expected range e. Client draws legs into fetal position

a, b, d

Which foods are sources of high fiber? (select all that apply) a. Kidney beans b. Blackberries c. Refined cereals d. Whole wheat bread e. Lean turkey

a, b, d

A nurse is caring for a client recovering from a CVA. Which information should the nurse teach the family about repositioning the client? (select all that apply) a. Remove pillows prior to positioning b. Elevate bed to waist height c. Position client toward edge of bed on the side client will face after turning d. Stand with feet wide apart e. Face direction of movement while positioning client

a, b, d, e

When assessing a client in skeletal traction, the nurse should expecting which findings? (select all that apply) a. Slight pain at insertion site b. Serous drainage on dressing c. Movement of pin at insertion site d. Elastic bandages secure around traction ropes e. Minimal edema around pin

a, b, e

A nurse is providing hygiene care for a client who is immobile. Which actions should the nurse take? (select all that apply) a. Check for personal items when changing linens b. Place clean gown on strongest arm first c. Keep bath water temp between 110-115 degF d. Shave hair in direction of growth e. Wash extremities from proximal to distal

a, c, d

Which strategies should the nurse teach to minimize back strain and avoid repeated episodes of low back pain? a. Avoid prolonged sitting b. Apply heat 10min/hr c. Sleep side-lying with flexed knees d. Sleep on a soft mattress e. Try padded shoe insoles

a, c, e Apply heat 20-30min 4x per day/firm mattress provides added support

Which action should the nurse take for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury? a. Apply bag for 30min at a time b. Reapply bag 30 min after removing it c. Allow room for air inside bag d. Place bag directly on skin

a. Apply for 30min at a time

Which action should the nurse take first for a client receiving enteral feedings through an NG tube? a. Aspirate stomach contents b. Hang feeding bag 12in above client c. Label bag with date and time of start of feeding d. Warm feeding to room temp

a. Aspirate stomach contents Check if it is actually being absorbed by client, assess risk of aspiration

A nurse receives report at the start of shift. Who should the nurse plan to see first? a. A client who had a Cesarean birth 4h ago and reports pain b. A client with preeclampsia with a BP of 138/90 c. A client who had a vaginal birth 24h ago and reports no bleeding d. A client who is scheduled for discharge following laparoscopic tubal ligation

a. Client who had C-section 4h ago and reports pain Hierarchy of needs = assessment of pain/physiological needs of a surgical client are priority actions

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which statement to the nurse indicates a need for further teaching? a. I only need to catheterize myself twice a day b. I carry a water bottle with me because I drink a lot of water c. I use a suppository every night to have a bowel movement d. I do wheelchair exercises while watching TV

a. I only need to catheterize myself twice a day

A nurse is teaching a client with insomnia abut promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. I will walk briskly for 30min before bedtime b. I will no longer have a glass of wine before bedtime c. I will have a cup of hot cocoa immediately before bedtime d. I will do my muscle relaxation techniques each afternoon

a. I will walk briskly for 30min before bedtime

What is the best choice of food for a client who is recovering from an IBD exacerbation and is to start a low-lactose diet? a. Soy milk b. Cheddar cheese c. Low-fat yogurt d. Cottage cheese

a. Soy milk

Which intervention should the nurse use to help maintain skin integrity for an older adult client at risk of developing pressure ulcers? a. Use transfer device to life client in bed b. Apply cornstarch to keep sensitive areas dry c. Massage skin over bony prominence d. Elevate HOB no more than 45deg

a. Transfer device

A nurse is assessing a client who has narcolepsy. What findings should the nurse expect? (select all that apply) a. Lack of REM sleep b. Sudden attacks of sleep c. Hallucinations at onset of sleep d. Sleep apnea e. Urge to move legs when trying to sleep

b, c

A nurse is providing postmortem care for an adult client. Which of the following actions should the nurse take? (select all that apply) a. Place client flat lying on bed b. Determine whether client will have autopsy c. Cover body with clean sheet and place arms outside of it d. If client had significant trauma, discourage viewing by family/friends e. Give client's personal belongings to family

b, c, e

Which high-potassium foods should be avoided by a client with chronic kidney disease? a. Green beans b. Tomatoes c. Bananas d. Asparagus e. Raisins

b, c, e

Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (select all that apply) a. Client with lactose intolerance b. Client who had a cerebrovascular accident c. Client who is 4h postop following leg amputation with general anesthesia d. Client who has had prolonged diarrhea e. Client who has had radiation therapy for head and neck cancer

b, c, e

A nurse is providing palliative care to a client whose partner asks why music therapy might help her. Which of the following responses should the nurse make? (select all that apply) a. Increases basal metabolic rate b. Helps verbally express emotions c. Improves appetite and decreases nausea d. Works as distraction, can alleviate pain e. Helps facilitate movement in clients with mobility limitations

b, d, e

A nurse is teaching the parent of an infant with heart failure about nutritional needs. Which statement indicates an understanding of the teaching? a. I will feed my baby on a schedule every 4h b. I will add Polycose to each bottle c. I will allow my baby to take as much time as needed to finish the bottle d. I will limit my baby's crying to 15min prior to each feeding

b. Add Polycose Polycose increases calories per oz, allowing infant to consume more cal in less volume; should feed q3h/do not allow too much time as it will stress and fatigue the infant/avoid allowing infant to cry as this will burn calories

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. This is most likely an indication of which of the following conditions? a. Upper respiratory infection b. Pulmonary edema c. Atelectasis d. Delayed gastric emptying

b. Atelectasis Prolonged bedrest with few position changes and ineffective coughing are risk factors for atelectasis

A nurse is teaching a client how to decrease nausea associated with chemotherapy and radiation. Which statement indicates an understanding of the teaching? a. I will eat smaller meals if I feel nauseated b. I will eat foods that are served at room temp c. I will drink more liquids with my meals d. I will increase the amount of unsaturated fats in my diet

b. Eat foods at room temp Hot foods may contribute to nausea so eat them at room temp or chilled; don't eat if nauseous/liquids can cause over-distention and add to nausea/unsaturated fats are difficult for digestive system to break down

A nurse is teaching a client who has left hemiparesis how to use a cane. Which instruction should the nurse include? a. Remove rubber tip b. Hold cane on right side to provide support for weaker leg c. Place cane approx 61cm (24in) in front of feet before advancing d. Advance right leg and cane together to support weaker leg

b. Hold on right side

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. I wish I didn't have to attach the electrodes to my skin b. It's unfortunate that I have to be in the hospital for this treatment c. I'll need to shave the hair off the skin where I place the electrodes d. I hope I don't have to take as many pain pills

b. It's unfortunate that I have to be in the hospital for this treatment TENS are portable; do have to be attached to skin/hair should be removed/reasonable to expect less pharmacological intervention

The nurse should base pain management interventions for a postop patient primarily on which method of determining pain intensity? a. Vital sign measurement b. Client's self-report of pain severity c. Visual observation for nonverbal signs of pain d. Nature and invasiveness of procedure

b. Self-report

Which statement by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? a. I flavor my meat with lemon juice b. I eat two eggs for breakfast each morning c. I cook my food with canola oil d. I take an omega-3 supplement each day

b. Two eggs each morning

Which nursing actions are appropriate for preventing skin breakdown of a client with spinal cord injury and paralysis? (select all that apply) a. Massage over erythematous bony prominences b. Implement turning schedule q4h c. Use pillows to keep heels off bed surface d. Keep skin dry with powder e. Minimize skin exposure to moisture

c, e

Which food should a client with dumping syndrome avoid? a. Rice b. Poached eggs c. Fresh apples d. White bread

c. Fresh apples Avoid fresh fruits - choose canned/well-cooked fruits instead

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration in the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? a. Inspect site for reduced swelling b. Monitor client's pulse rate c. Ask client to rate pain d. Have client perform ROM of affected arm

c. Ask client to rate pain

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? a. Reposition the client b. Administer the medication c. Determine the location of the pain d. Review the effects of the pain medication

c. Determine location

Which pain scale should be used to determine an infant's level of pain? a. FACES b. OUCHER c. FLACC d. PANAD

c. FLACC

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and breastfeeding. Which statement indicates a need for further teaching? a. I will breastfeed every 2h b. I will apply ice packs to my breasts after feeding c. I should apply hot packs to my breasts during feeding d. I should crush cabbage leaves and place them on my breasts

c. Hot packs

A nurse is caring for a toddler who is having difficulty sleeping during hospitalization Which of the following actions should the nurse take to promote sleep? a. Explain source of fears b. Turn off light c. Provide bedtime rituals d. Encourage play exercises in the evening

c. Provide bedtime rituals Familiarity will decrease insecurity and fears; reasoning is still too immature for comprehension/child may need a night light to decrease fear/stimulating physical activity should occur during the daytime

Which action should the nurse take for oral care of an immobile patient? a. Use stiff toothbrush to clean client's teeth b. Use thumb/index finger to hold mouth open c. Turn client on side before starting oral care d. Apply petroleum jelly to lips after oral care

c. Turn client on side

When determining that Bryant traction is appropriately assembled, the nurse should observe which of the following? a. Skin straps maintain leg in extended position b. Weights are attached to a pin inserted into the femur c. Padded sling is under knee of affected leg d. Buttocks is slightly elevated off bed

d. Buttocks slightly elevated a = Buck's, b = 90/90, c = Russell

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? a. Trochanter roll b. Sheepskin heel pad c. Abduction pillow d. Footboard

d. Footboard Footboard keeps feet from dropping (contracture); trochanter roll used to keep hips in neutral position and prevent external rotation/heel pads prevent development of ulcers on heels/abduction pillow keeps hips abducted to prevent dislocation after arthroplasty

What should indicate to the nurse that a 6-month old infant is experiencing pain following a procedure? a. Decreased HR b. Decreased RR c. Increased formula consumption d. Increased crying episodes

d. Increased crying episodes

Which of the following clients is at greatest risk for skin breakdown? a. Adolescent with a cervical fracture in a halo brace b. Young adult with a femur fracture in skeletal balanced suspension traction c. Middle adult with a fractured radius in an arm cast d. Older adult with a hip fracture in Buck's traction

d. Older adult

A nurse is teaching a client which foods to include in low-fiber diet. Which statement indicates the client understands the teaching? a. A fresh pear would be a good snack option b. I can prepare refried beans for supper c. Bran cereal would be a good breakfast choice d. I should choose white rice as a side dish

d. White rice