ati practice B (23)
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which instructions should the nurse provide to the client and their family?
-Check the cord routinely for frays and tearing -consider purchasing a generator for power backup -observe for signs of hypoxia
A nurse in the emergency department is caring for a client who reports abdominal pain. Based on the client's clinical findings, which actions should the nurse take?
-assist client to left side lying position with right knee flexed -administer cleansing enema -auscultate client's bowel sounds -perform manual digital examination of client's rectum
A nurse is caring for a client who has COPD. 3 findings that require follow-up
-breath sounds-crackles -oxygen saturation-85% on RA -temperature (101.5)
A nurse is caring for a client in a medical-surgical unit. What indicates an improvement in the client's condition
-granulation tissue covers the wound bed -no odor present -pressure injury smaller -tunnels measure smaller -pain decreased since last assessment
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
-inject 10 units of air into the bottle of NPH insulin -inject 5 units of air into the bottle of regular insulin -withdraw the correct dose of regular insulin from the bottle -withdraw the correct dose of NPH insulin from the bottle
A nurse is caring for a client who had a spinal cord injury and has paraplegia. Findings that require intervention by the nurse
-passive range of motion exercises to lower extremities performed once each day -plantar flexion contractures noted bilaterally -left heel with 1.3 cm x 1.3 cm area of nonblanchable erythema, skin is intact
A nurse is assessing an older adult client's risk for falls. Which assessment should the nurse use to identify the client's safety needs?
-pupil clarity -visual fields -visual acuity
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. What actions should the nurse take?
-stop the infusion -elevate the client's left arm -apply heat to the client's left hand
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include?
-wear a N95 mask when caring for the client -Place a container for soiled linens inside the client's room -Place the client in a negative airflow room -remove mask after exiting the client's room
A nurse in a medical-surgical unit is caring for six clients. The first client the nurse should assess is ______ followed by ________
1st-client is 1 day postoperative. Reports pain as 8 on a scale of 0-10. Morphine 5 mg subcutaneous administered as prescibed 2nd-client is admitted with a new diagnosis of heart failure
A nurse is calculating a client's fluid intake over the past 8 hr. Which items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
8 oz of ice chips (half the volume once melted)
A nurse is caring for a group of clients on a medical-surgical unit. Which situations does the nurse demonstrate the ethical principle of veracity?
A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively
A nurse is performing a Romberg test during the physical assessment of a client. Which techniques should the nurse use?
Have the client stand with their arms at their sides and their feet together (this test identifies alterations in balance)
A nurse is caring for a client who requires an NG tube for stomach decompression. Which actions should the nurse take when inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the esophagus
A nurse is caring for a client who has recently started using behind the ear hearing aid. Which statement should the nurse identify as an indication that the client understands the use of this assistive device?
I will be sure to remove my hearing aid before taking a shower
A nurse is providing discharge instructions to a client who will be using a walker. Which statement by the client indicates the teaching has been effective?
I will hire someone to trim the tree that overhangs the front porch stairs
A nurse is providing teaching to a client who is on protective isolation precautions. Which client statement indicates an understanding of the teaching?
I will wear a face mask when leaving my hospital room
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Make sure two fingers can fit under the sleeves
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?
Place the client's arm in a dependent position
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which is an appropriate response?
That must be frustrating to you. How can I help you right now?
A nurse is evaluating a client's use of a cane. Which actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of their body
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which actions by the newly licensed nurse requires intervention by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the client's statements?
The pain is like a dull ache in my stomach
A nurse is caring for a client who asks about the purpose of advance directives. Which statement should the nurse make?
They indicate the form of treatment a client is willing to accept in the event of a serious illness
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which responses should the nurse make?
We would give you oxygen through a tube in your nose
A nurse is caring for a client who has terminal liver cancer. Which statement should the nurse identify as an indication that the client is experiencing spiritual distress?
What could I have done to deserve this illness?
A nurse is teaching a client whose left leg is in a cast about using crutches. Which statement should the nurse identify as an indication that the client understands the teaching?
When descending stairs, I will first shift my weight to my right leg (unaffecting leg)
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening What does that involve? Which of the following responses should the nurse take
You should have a fecal occult blood test every year
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which findings should the nurse identify as a potential indication of a skin malignancy?
a mole with asymmetrical appearance
A nurse is caring for a client who has herpes zoster and asks the nurse about he use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is contraindication for which of the following therapies?
acupuncture
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
administer the medication into the abdomen
A nurse is caring for a client who is receiving a unit of packed RBCs. The client has manifestations of ________ as evidenced by the client's ________
allergic reaction, itching
A nurse is caring for a client who has decreased mobility. Which action should the nurse take to decrease the client's risk of developing plantar flexion contractures?
apply an ankle-foot orthotic device to the client's feet
A nurse is caring for a client who has a respiratory infection Which techniques should the nurse use when performing nasotracheal suctioning for the client?
apply intermittent suction when withdrawing the catheter
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the interventions should the nurse implement to prevent infection?
apply transparent dressing over the IV insertion site and securement device
A nurse is preparing to administer an injections of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which action should the nurse take?
ask another nurse to observe the medication wastage
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
assess the client for orthostatic hypotension
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
auscultate lung sounds
A nurse is caring for a client who is at risk for hypokalemia. Which foods should be included in the client's diet?
avocados
A nurse is caring for a female client. The client is at risk for ______ as evidenced by the client's ________
bleeding, platelet count
A nurse is giving a change of shift report about a client they admitted earlier that day who has pneumonia. Which pieces of information is the priority for the nurse to provide?
breath sounds
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which actions should the nurse take first?
check the client for injuries
A nurse is caring for a client who has a prescription for wound irrigation. Which action should the nurse take?
cleanse the wound from the center outward
A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which actions should the nurse take first?
determine the client's learning style
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following a major abdominal surgery. Which actions is the nurse's priority?
determine the reasons why the client is refusing to use the incentive spirometer
A nurse is assessing an adult client who has been immobile for the past 3 weeks. Which of the findings should the nurse intervene?
erythema on pressure points
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which components of the prescription should the nurse verify with the provider?
medication dose
A nurse is caring for a group of clients. Which action should the nurse take to prevent the spread of infection?
place a client who has tuberculosis in a room with negative-pressure airflow
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which method should the nurse use as a psychomotor approach to learning?
practice sessions
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
press gently on the tragus of the client's ear
A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which of the following actions should the nurse take?
reassure the client that this is an expected response to grief
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which actions should the nurse include?
regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which actions should the nurse plan to take?
select a suction catheter that is half the size of the lumen
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which findings at the IV site should the nurse identify as indicating infiltration?
skin blanching
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which findings should the nurse identify as a potential indication of elder abuse?
the caregiver insists on remaining in the room
A nurse is caring for a client who has dementia. Which intervention should the nurse take to minimize the risk for injury to the client?
use a bed exit alarm system
A nurse is planning strategies to manage time effectively for client care. Which strategies should the nurse implement?
use the planning step of the nursing process to prioritize client care delivery
A nurse is teaching a client and their family how to care for the client's tracheostomy at home. Which instruction should the nurse include in the teaching?
use tracheostomy covers when outdoors
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which types of activity should the nurse recommend?
walking briskly
