ATI Concept-based assessment online practice A Level 2

A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching?

A: "Maintain bone health by eating fruits, vegetables, and protein."

A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching?

A: "The adhesive bandages on my incision will fall off as the incision heals."

A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for the client?

A: Apply oxygen therapy to the client.

A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A: Call 911 and examine the amputation site. B: Apply direct pressure with layers of dry cloth .C: Elevate the extremity above the client's heart. D: Find the toe and wrap it in sterile gauze in a clean cloth. E: Place the toe in a bag and place the bag in 1 part ice and 3 parts water

A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client's ABG results are pH7.48, PaCO2 50 mm Hg, and HCO3 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances?

A: Metabolic alkalosis

A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain. The client has a heart rate of 66/min and a respiratory rate of 9/min. Which of the following medications should the nurse anticipate the provider will prescribe for the client?

A: Naloxone

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.)

A: Nocturia C: Dyspnea D: Hacking cough

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect?

A: Numbness of hands

A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect?

A: Progressive loss of peripheral vision

A nurse is teaching a male client who has hypertension about dietary guidelines to help manage his disorder. Which of the following instructions should the nurse include?

A: Reduce sodium intake to 1,500 mg/day or less.

A school nurse is teaching an adolescent who has diabetes mellitus about preventing hypoglycemia during and after baseball practice. Which of the following instructions should the school nurse include?

B: "Consume an extra snack before practice."

A nurse is teaching a client who has tuberculosis about taking rifampin. Which of the following instructions should the nurse include?

B: "Do not drink alcohol while taking this medication."

A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the teaching?

B: "I should make my abdomen rise with each inhalation."

A nurse is teaching a client who has asthma about using a metered-dose inhaler. Which of the following client statements indicates an understanding of the teaching?

B: "I'll take a deep breath and blow it out before I inhale the medication."

A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make?

B: "This medication causes adverse effects if the dosage is too high or too low."

A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). Which of the following instructions should the nurse include to promote elimination?

B: "Void as soon as you feel the urge."

A nurse is assessing a client who reports gastrointestinal distress. Which of the following findings should indicate to the nurse that the client has cholecystitis?

B: Abdominal pain that radiates to the right shoulder

A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis?

B: Client is taking atorvastatin.

A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer?

B: Discoloration and edema of the right ankle

A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take?

B: Encourage the client to use wide-grip utensils when eating with the right hand.

A nurse is teaching a client who is at moderate risk for osteoporosis about ways to help prevent this chronic disease. Which of the following instructions should the nurse include? (Select all that apply.)

B: Increase dairy product intake. C: Engage in weight-bearing exercises regularly. E: Reduce excessive caffeine intake

A nurse is caring for a middle adult female client who has atrial fibrillation and is taking warfarin. The nurse should recognize which of the following as an adverse effect of the medication and notify the provider?

B: Increased menstrual flow

A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

B: Metabolic alkalosis

A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?

B: Presence of strabismus

A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as a priority?

B: Protect the client from harm.

A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions should the nurse include in the client's plan of care?

B: Reframe situations in a positive manner for the client.

A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take?

B: Remain with the client until manifestations subside.

The nurse in an emergency department was caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit?

B: The sibling is curious about what will happen to the client's body.

A nurse is teaching disease management techniques to a client who has COPD. Which of the following instructions should the nurse include in the teaching?

B: Use pursed-lip breathing when feeling short of breath.

A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record?

B; Agoraphobia

A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching?

C: "I will base my peak flow meter score on the best of three attempts."

A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for a hearing aid. Which of the following client statements indicates an understanding of the teaching?

C: "I will make sure the hearing aid is off before inserting it in my ear."

A nurse is an emergency department is assessing a client who has type 1 diabetes mellitus. Which of the following findings should the nurse identify as an indication that the client has diabetic ketoacidosis?

C: Blood glucose 396 mg/dL

A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care?

C: Check for paresthesia of the affected leg.

A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect?

C: Decreased level of consciousness

A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.)

C: Elevate the affected area 15.24 cm (6 in) above the heart .E: Administer cefazolin intermittent IV bolus

A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include?

C: Elevate the wrist above heart level.

A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi?

C: Encourage intake of at least 3 L of fluid each day.

A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect?

C: Facial eruption

A nurse is assessing a client who has been taking antacids frequently for gastrointestinal distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect?

C: Hypermagnesemia

A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching?

C: Increase fiber intake to at least 30 g per day.

A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?

C: Initiate droplet precautions for the child.

A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching?

C: Morbid obesity is measured as a BMI over 40.

A nurse is assessing a client who has social phobia and reports feeling fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe?

C: Paroxetine

A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances?

C: Respiratory acidosis

A nurse in an emergency department is assessing a client who is experiencing mild hypothermia. Which of the following manifestations should the nurse expect?

C: Slurred speech

A nurse is planning care for a client who has pneumonia. WHich of the following interventions should the nurse include in the plan?

C: Teach the client how to cough up secretions.

A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider?

C: The catheter tubing has multiple red clots.

A nurse is assessing a client who has a potassium level of 2.6 mg/dL and is receiving potassium chloride by continuous IV infusion. Which of the following findings should the nurse identify as an indication that the potassium infusion has brought the client's potassium level back to the expected reference range?

C: The client's hand grasp becomes stronger.

A nurse is caring for a toddler who sustained a left lower leg fracture in a motor vehicle crash. The toddler, who has light-pigmented skin, received a cast 24 hours ago. Which of the following assessment findings from the casted leg should the nurse report to the provider?

C: The toddler's toe movement is limited.

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching?

D: "I should add 1 teaspoon of rice cereal to my infant's formula."

A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following client statements indicates an understanding of the teaching?

D: "It might take 4 to 6 weeks for my vision to fully improve."

A nurse is providing discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching?

D: "Perform Kegel exercises several times throughout the day."

A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management?

D: "Place your child in an oatmeal bath using tepid water for 15 minutes."

A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect?

D: Absence of tears

A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death?

D: Adolescents often alienate themselves from their peers when grieving.

A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? (Select all that apply.)

D: Believes death is a temporary type of sleep E: Believes that their own thoughts can cause death

A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective?

D: Brisk skin turgor

A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect?

D: Brittle hair

A nurse in a provider's office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse's intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.)

D: Coagulation time

A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include?

D: Drink 120 mL (4 oz) of fruit juice.

A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect?

D: Follows directions

A nurse is admitting a client who has just been diagnosed with active tuberculosis and has experienced a 5.9 kg (13 lb) weight loss during the past 3 weeks. Which of the following actions should the nurse take first?

D: Initiate airborne precautions.

A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication?

D: Lipase 185 units/L

A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan?

D: Monitor for hypertension.

A nurse is assessing a client who has COPD and is receiving nebulized acetylcysteine. Which of the following findings should the nurse expect if the medication has been effective?

D: Mucus is thin and white in color.

A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds. Which of the following medications should the nurse anticipate the provider might prescribe for the client?

D: Protamine

A nurse is admitting a client who has an acute bacterial wound infection and a temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take?

D: Set the temperature of the client's room to 22.2° C (72°

A nurse is teaching about foot care with a group of older adults who have type 1 diabetes mellitus. Which of the following information should the nurse include in the teaching?

D: Trim toenails straight across to prevent ingrown toenails.

A nurse in an emergency department is assessing a client who reports severe constipation. The nurse should identify which of the following findings as an indication that the client might have a small-bowel obstruction?

D: Visible peristaltic waves in the upper abdomen

A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition. Which of the following actions should the nurse take? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer the prescribed regular insulin

A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings should the nurse expect?

A: Circumoral tingling

A nurse is providing discharge planning for a client who has gestational diabetes. Which of the following interventions should the nurse identify as a priority?

A: Determine the client's knowledge regarding gestational diabetes.

A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take?

A: Encourage the client to repeat what the nurse has said.

A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect?

A: Hypoglycemia

A nurse is assessing a client who reports a new onset of joint pain and stiffness. Which of the following findings should the nurse identify as an indication of osteoarthritis?

A: Joint pain improves with rest.