ATI practice

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make?

"Call me when you are ready, and I will return with the medication" rationale: the nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration

a nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Administering high-flow oxygen prior to the procedure rationale: the nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia use sterile technique. The nurse should instruct the newly licensed nurse to insert the catheter gently without applying suction to reduce the risk of hypoxia and tissue damage

a nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Asking another nurse to observe the disposal of an unused portion of the medication rationale: the nurse should ask another nurse to witness the disposal of a controlled substance to maintain safe control of the narcotic

The nurse is caring for a client who is receiving total parenteral nutrition (TNP) which of the following actions should the nurse take?

Check the clients capillary blood glucose level every 4 hours rationale: the nurse should check the blood glucose level every 4 hours due to the client's risk of hyperglycemia while receiving TPN

a nurse is assessing a client who has fluid-volume excess. Which of the following sure the nurse expect?

Crackles in the lung fields rationale: manifestations of fluid volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain

while admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document rationale: a durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so

A nurse caring for a client who had the HOB elevated to a 45 degree angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?

Fowlers rationale: low fowlers position means 30 degrees of elevation, semi-fowlers is 45-60 degrees, and high fowlers is 60-90 degrees of elevation. Prone position the client is laying on the abdomen supine the client is lying flat on the back

a nurse is initiating seizure precautions for a client who has a seizure disorder. which of the following pieces of equipment should the nurse have readily available at the clients bedside?

Oxygen equipment rationale: oxygen equipment should be at the clients bedside who is on seizure precautions. The nurse should be able to apply oxygen via mask or nasal cannula to a client who experiences a seizure

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

Support the clients decision rationale: the nurse has the responsibility to support the clients decision and respect the clients right of refusal. The nurse should notify the provider of the clients decision and document the refusal in the clients medical record

a nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate?

airborne rationale: airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles airborne precautions require: a private room, negative air pressure airflow exchange in the room of at least 6 to 12 exchanges per hour, depending on the age of the structure, if splashing or spraying is possibly wear a full face (eyes, nose, mouth) protection, clients who have an airborne infection should wear a mask while outside room or home, masks and respiratory protection devices for caregivers AND visitors (use N95 or high-efficiency particulate air (HEPA) respirator if the client is known or suspected to have TUBERCULOSIS

a nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling catheter in place. Which of the following actions should the nurse take?

clamp the tubing below the collection port rationale: the nurse should clamp the tubing below the collection port to allow fresh, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup

a nurse is providing teaching about proper care to a client who has a new colostomy. which of the following pieces of information should the nurse include in the teaching?

cleanse the skin around the stoma with warm water rationale: the nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence to the pouch change the colostomy bag before a meal. instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma

a nurse is preparing to administer medications to a client who is unconsious. The nurse should bring the medication administration record (MAR) to the clients bedside and perform which of the following verification procedures?

compare the medical record number and name on the MAR with the clients identification band rationale: the nurse should compare the medical record number and name on the MAR to the clients wrist band

a nurse is caring for a client who is producing large amounts of urine. the nurse should document this finding as which of the following?

diuresis rationale: diuresis and polyuria is the excretion of a high volume of urine. Oliguria is a diminishing urine output despite an acceptable fluid intake dysuria is painful or difficult urination often as a result of a UTI

a nurse is assessing a client who reports N/V for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

increased heart rate rationale: an increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes and dark yellow urine

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

place the wheelchair at a 45-degree angle to the bed rationale: positioning the wheelchair at a 45 degree angle allows the client to pivot, lessening the amount of rotation required

a nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. which of the following actions should the nurse take?

provide more water with the feedings rationale: the elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to the feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein

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? (SATA)

provide oral hygiene frequently, measure the amount of drainage from the NG tube every shift, secure the NG tube to the clients gown Rationale: frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be disloged if not secured properly Single-lumen NG tubes are used for intermittent suction, and the machine is set at 80 to 100 mmHg. higher suction can traumatize the gastric lining The client could aspirate on an oil-based lubricant like petroleum jelly into the lungs which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to prevent or relieve dry skin

a nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

upon the client's admission to the care facility rationale: The nurse should begin discharge planning at the time that the client is admitted to the facility

a nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. which of the following explanations should the nurse give the AP?

using a cuff that is too small will result in an inaccurately high reading rationale: Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. BP readings can be falsely high if the cuff is too small for the client