ATI Nurse Logic 2.0 Testing and Remediation Beginner

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.

Client stands, bearing weight on unaffected leg. Client transfers body weight to the crutches. Client advances the unaffected leg between the crutches. Client shifts weight from crutches to the unaffected leg. Client aligns crutches on the stair.

A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over ares of consolidation during percussion?

Dullness

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?

Partial thickness skin loss

A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? Exhibit 1 Serum Laboratory Results: Hemoglobin 15.4 g/dL Protein 7.2 g/dL BUN 8mg/dL Glucose 72mg/dL Exhibit 2 Physical Assessment: 2+ peripheral edema Blood pressure 144/96 mm Hg Increased urinary output Respiratory crackles bilaterally Exhibit 3 Health History: Total hip arthroplasty 10 days ago 15-year history of diabetes mellitus 32-year history of heart failure

Restrict fluid intake

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading?

Using a cuff that is too wide

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective?

"I feel very relaxed."

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking is the results don't come back positive for cancer/" This statement indicates that the client is in which of the following stages of grief?

Bargaining

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes.

Hot Spot A (towards the back of the neck)

A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?

3/4 cup of canned tomato juice

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following?

Mood

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?

Stand close to the client.

A nurse us preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?

1 1/2 inch

A nurse is preparing to auscultate a client's heart. Which of the following positions is the best for detecting a low-pitched diastolic murmur?

Lying on side

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?

Sims'

A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?

2 tsp

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet?

Grape juice and ice cream

A nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?

Hearing loss

A nurse is collecting data on a newly admitted client who us reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first?

Inspection

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath shounds?

Stridor

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways?

Vector