ATI fundamentals
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care?
-provide oral hygiene frequently - measure the amount of drainage from the NG tube every shift -secure the NG tube to the client's gown
A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communications technique of clarifying?
"It sounds like your pain is intermittent."
A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water which each oral med. How many mL of water should the nurse document as intake for the 3 separate med the client receives during a 12 hr night shift?
1oz/30mL= 3 x 1oz/X mL X=90
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indications of infiltration?
Edema at the infusion site
A nurse is caring for a client who has a prescriptions for acetaminophen 325 mg PO for an oral temperature above 38.4C. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client?
F=(Cx9/5)+32 F=(38.4x9/5)+32 F=69.12+32 F=101.1
A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take?
Lower the client spot he floor and place a pad under the clients head
A nurse delegates the collections of client's temperature to an assistive personnel (AP). The nurse notes int he documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?
Right communication
A hospice nurse is visiting with a family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia?
The client watches television in her bed during the day.
A nurse is administering an IM injections to a 5-month-old infant. Which of the following injection sites should the nurse use?
Vastus lateralis
A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?
albumin
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
fidelity
A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?
independent moral development
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?
inspection
A nurse is presenting an in-service training sessions about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?
lactose
A nurse is performing a physical examination of a client. the nurse should use percussion to evaluate which of the following parts of the client's body ?
lungs
A nurse is providing discharge to a client who odes not speak the same language as the nurse. The client's neighbor, who speaks both arrives to drive the client home. which of the following actions should the nurse take?
obtain the services of an interpreter
A nurse is preparing to provide tracheostomy care for a client. Which go the following actions should the nurse perform first?
perform hand hygiene
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?
vitamin c and zinc
Methicillin-resistant S. aureus (MRSA)
wear a gown when in the clients room
according to Erickson, the development task of intimacy vs. isolation occurs during?
young adulthood
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulations (TENS) for pain management. The client ask the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?
"It modulates the transmission of the pain impulse."
A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which position for evaluation?
Sitting
A nurse is caring for a client who just received a diagnosis of cancer. The client states "I just don't know what I'm going to do now." Which off the following responses should the nurse make?
"Can you explain the concerns you're having right now?"
A nurse in an emergency departments is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
Grasp a skin fold on the chest under the clavicle, release it, and note wether it springs back
A nurse is caring for a middle-aged adult. The nurse should identify which of the following statements as na indications that the client has completed Erikson's developmental task for her age group?
"I think I have done a good job with y children since they are all independent now"
removing sutures?
"I will clip each suture close to the skin and pull it through from the other side"
A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should cover this client's pain status in which portion of the report?
assessment
A nurse rates a clients biceps reflex as 2+. which if the following characters should the nurse document about the clients reflexes?
average
