ATI practice B
A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. Gown b. N95 respirator c. Shoe covers d. Surgical cap
N95 respirator Pt is airborne precautions: N95 mask, negative air pressure room,
A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?a. "I had a bowel movement, but I was able to save the urine."b. "I have a specimen in the bathroom from about 30 minutes ago"c. "I flushed what I urinated at 7:00 am and have saved all urine since"d. "I drink a lot, so I will fill up the bottle and complete the test quickly"
"I flushed what I urinated at 7:00 am and have saved all urine since" pt should discard the first void and save all other voiding
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. "This type of hearing aid does not allow for fine tuning of volume." b. "I shouldn't have trouble keeping the hearing aid in place during exercises." c. "I expect to hear a whistling sound when I first insert the hearing aid." d. "I will be sure to remove my hearing aid before taking a shower."
"I will be sure to remove my hearing aid before taking a shower." water can damage hearing aids.
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse take? a. "You should have an eye examination every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should receive a a shingles vaccine when you are 70 years old." d. "You should receive a pneumococcal immunization when you are 65 years old
"You should receive a pneumococcal immunization when you are 65 years old
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (SATA)-Check the cord routinely for frays or tearing-Keep the unit atleast 1.2m (4 ft) away from a gas stove-Consider purchasing a generator for power backup-Observe for signs of Hypoxia-Select synthetic clothing and bedding
-Check the cord routinely for frays or tearing-Consider purchasing a generator for power backup-Observe for signs of Hypoxia
A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record? a. .3mg b 0.3mg c 0.30mg d. 3/10mg
0.3 mg zero should precede a decimal point as in 0.3mg, but should not follow a decimal point unless a whole number follows the zero as in 2.05 mg. -zero is missing in front of the decimal. -no trading zeros -dosage should be decimals not fractions
A nurse is calculating a client's fluid intake over the past 8 hrs. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?a. 2 cups of soupb. 1 quart of waterc. 8 oz of ice chipsd. 6 oz of tea
8 oz of ice chips ice chips turn into water= 4oz of water 4oz = 120ml
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading 0 if it applies. Do not use a trailing zero.)
8ml/hr x = desired x quantity have x= 800units/hr X 250ml 25000 units x= 8ml/hr
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? -A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.-A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes.-A client with a do-not-resuscitate (DNR) status has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family.-A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she would give her.
A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. veracity- nurse must tell the truth and never deceive others
A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. The tube aspirate has a pH of 7. b. An x-ray shows the end of the tube above the pylorus c. Bowel sounds are present on auscultation d. The client reports relief of nausea
An x-ray shows the end of the tube above the pylorus
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. Assign a staff member to feed the client b. Provide small-handled utensils for the client c. Thicken liquids on the client's tray d. Arrange the food in a consistent pattern on the client's plate
Arrange the food in a consistent pattern on the client's plate consistency helps facilitate self feeding. Staff can describe the location of food on the plate by using a clock pattern. -nurse should allow pt to feed themselves. Patients autonomy and ability to perform self care can be impaired by assigning nurse -large handled utensils is recommended -patient does not. have dysphagia
A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A parent who has... a. hx of physical abuse b. permanet pacemaker c. ulcerative colitis d. asthma
Astham some oils can cause bronchospasm.
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?a. Wear sterile gloves when removing the old dressingb. Warm the irrigation solution to 40.5 degrees C. (105F)c. Cleanse the wound from the center outwardd. Use a 20 mL syringe to irrigate the wound
Cleanse the wound from the center outward to prevent micro-organisms from outer skin surface, clean center outward. -35ml syringe is needed to irrigate wound,
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "Incident report completed" b. "Client climbed over the side rails" c. "Client found lying on floor" d. "Client was trying to get out of bed"
Client found lying on floor"
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medication from the facility in a plastic bag. b. evaluate the clients ability to self-administer medication c. report an identified discrepancy to the Joint Commission d. Compare prescriptions with medications the client received while at the facility.
Compare prescriptions with medications the client received while at the facility.
A nurse is preparing to administer 0.5mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration b. Transfer the medication to a medicine cup c. Place the client in a semi-fowler's position prior to medication administration d. Verify the dosage by measuring the liquid before administering
Gently shake the container of medication prior to administration shake liquid medication to ensure all medication is mixed. -liquid medication should not be transferred to cup. -nurse to place pt in semi-fowlers positions when administering the medication
A nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?a. Assign the client to a room with a negative airflow systemb. Use alcohol-based hand sanitizer when leaving the client's roomc. Clean contaminated surfaces in the client's room with a phenol solutiond. Have family members wear a gown and gloves when visiting
Have family members wear a gown and gloves when visiting
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. high Fowler position b. increase carbs c. massage reddens areas with unscented lotion d. Have the client use a trapeze bar when changing positions
Have the client use a trapeze bar when changing positions avoids friction and shearing.
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? a. I can take echinacea to improve my immune system b. I can take feverfew to reduce my level of anxiety c. I can take ginger to improve my memory d. I can take ginkgo biloba to relieve nausea
I can take echinacea to improve my immune system echinacea is taken to promote immunity and reduce risk of infection -feverfew promotes wound healing, decreases inflammation associated with arthritis. -Valerian & chamomile reduce anxiety -ginger relieves N, V and aid in digestion. -Ginkgo biloba improve memory, reduce stress
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include is within the RN scope of practice? a. Insert an implanted port b. Close a laceration with sutures c. Place an endotracheal tube d. Initiate an enteral feeding through a gastrostomy tube
Initiate an enteral feeding through a gastrostomy tube -implanted ports or central venous access device -physician, surgeon, APN -close wounds- surgeons or physician -endotracheal tube-physicians & clinicians with special training
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 air into NPH insulin Inject air into Regular insulin Draw Regular insulin (clear) Draw NPH insulin (cloudy)
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? a. Instruct the family refrain from pushing the buttons for the client while she is asleep b. Inform the client that because she is on PCA, vital signs will be taken every 8 hours c. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10 d. Increase the basal rate and shroten the lock-out interval time if the client's pain level is too high
Instruct the family refrain from pushing the buttons for the client while she is asleep
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse uses as a psychomotor approach to learning?a. Role Playb. Group discussionsc. Question-answer meetingsd. Practice sessions
Practice sessions
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. Use a resuscitation bag with 80% oxygen prior to the procedure b. Select a suction catheter that is half the size of the lumen c. Place the end of the suction catheter in water-soluble lubricant d. Adjust the wall suction apparatus to a pressure of 170 mm Hg
Select a suction catheter that is half the size of the lumen The nurse should select a suction catheter half the size of the lumen to prevent hypoxemia & trauma to the mucosa. -client should be preoxyegnated to 100% not 80%. -lubricant catheter with sterile water or 0.9% Sodium chloride to decrease trauma to mucosa -pressure should be set at 120 mm Hg, anything higher than 150 can cause hypoxemia and trauma
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program for regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics
Walking briskly weight-bearing exercise helps maintain bone mass & prevents osteoporosis.
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the patient is experiencing spiritual distress? a. "What could I have done to deserve this illness?" b. "I blame medical science for not curing me" c. "Where is my daughter at a time like this?" d. "Will i ever begin to feel in charge of my life again?"
What could I have done to deserve this illness? Questions patients life and meaning to life.
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the followingactions should the nurse take? a. Ask the client to consider a direct donation b. Withhold the blood transfusion c. Request a consultation with the ethics committee d. Ask the client's family to intervene
Withhold the blood transfusion Principle of autonomy, pt is competent and has the right to refuse.
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. Describe the procedure to the client b. Witness the client's signature on the consent form c. Inform the client of alternatives to the procedure d. Tell the client which team members will assist with the procedures
Witness the client's signature on the consent form Nurse is responsible for witnessing signature & making sure patient is competent to give consent. The provider/surgeon is responsible for explaining procedure, explaining alternatives, informing pt who all will participate in the procedure.
A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. Ensure sterilization of non disposable items with ethylene oxide b. Wrap monitoring cords with stockinette and tape them in place c. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. Wear hypoallergenic latex gloves that contain power
Wrap monitoring cords with stockinette and tape them in place prevent contact with cords/devices that contain latex by covering them with non latex barrier material like stockinette, and using non latex tape to secure them
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 make? a. Ill get a blood sample from you and send it for screening test. b. beginning at age 60, you should have a colonoscopy c. You should have a fecal occult blood test every year d. the recommendation for a sigmoidoscopy is every 10yrs.
You should have a fecal occult blood test every year Colorectal cancer who are at an average risk begins at age 45. -blood test is not for colorectal cancer. Double contrast barium enema every 5years is an option. -At age 50 colonoscopy recommended Q 10yrs -flexible sigmoidoscopy Q 5yrs.
A community health nurse is checking BP for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. A client who is 52 years old b. A client who smokes one pack of cigarettes each day c. A client who walks for 30 mins a day d. A client who drinks one glass of wine 3x a week
a client who smokes one pack of cigarettes each day
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply.) a. place client in a room w/ negative-pressure airflow b. wear gloves when assisting client w/ oral care c. limit each visitor to 2hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene
a, b, e. airborne precaution
A nurse is preparing to delegate client care task to an assistive personnel. (AP). Which of the following tasks should the nurse delegate?a. Ambulating a client who is postoperativeb. Inserting an indwelling catheter for a clientc. Demonstrating the use of an incentive spirometer to a clientd. Confirming that a client's pain has decreased after receiving an analgesic
ambulating a client who is postoperative
A nurse is caring for client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures? a. place pillow under clients knee b. position trochanter roll under each of the clients hips c. advise client to wear rubber-soled slippers d. apply ankle-foot orthotic device to clients feet
apply ankle-foot orthotic device to clients feet Device will maintain dorsiflexion (ankle-foot orthotic device or foot board placed perpendicular to the mattress) -pillow under knees relieves pressure on heels -trochanter roll should be placed under buttocks and along hips to prevent external rotation of hips while pt is supine -slippers have no impact while pt is in bed
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?a. Rock the client up to a standing positionb. Pivot on the foot that is the farthest from the chairc. Assess the client for orthostatic hypotensiond. Apply a gait belt to the client
assess pt for orthostatic hypotension risk for falling
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? a. Auscultate lung sounds b. Measure urine output c. Monitor blood pressure readings d. Monitor electrolyte levels
auscultation lung sounds ABC, lung sounds monitor for fluid overload.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Urine has an unusual odor.Urine specific gravity is 1.035.Bladder scan shows 525 mL of urine.Urine is positive for ketones.
bladder scan shows 525 mL of urine pt with a catheter should have continuous flow of urine and should not accumulate urine in bladder.
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? a. touch the face w/ a cotton ball b. apply vibrating tunning fork to the clients forehead c. have the client stand with their arms at their sides and feet together d. perform direct percussion over the area of the kidney
c Romberg test helps identify balance.
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. Current flow sheet b. Acuity ratings c. Current medications d. Incident reports
current medication include all medication to ensure client safety and continuity of care
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, heady pulse c. slow capillary refill d. distended neck veins
distended neck veins fluid overload: distended neck veins, edema, tachycardia, crackles in lungs, dyspnea, bounding pulse, increase Bp.
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment
droplet droplet: influenza, rubella, meningococcal pneumonia, streptococcal pharyngitis. Airborne: varicella, TB, measles Contact: vancomycin-resistant enterococci, methicilin-resistant staphylococcus aureus, scabies PE: allogeneic hematopoietic stem cell transplant
A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower extremity pulse strength of 2+ c. fluid intake of 3,000ml per day d. one bowel movement every other day
erythema on pressure points
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? a. dissolve each medication in 5ml of sterile water b. draw up medication together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15ml of sterile water
flush the tube with 15ml of sterile water flush before administering meds and b/w each med. flush tube with 30-60 sterile water after last medication.
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? A. "Drink a cup of hot cocoa before bedtime" (NO)B. "Maintain a consistent time to wake up each day" (MAYBE)C. "Exercise 1 hour before going to bed" (NO)D. "Watch a TV program in bed before going to sleep"
maintain a consistent time to wake every day.
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse heard the following sound. This sound indicates which of the following? *SOUND* a. Narrowed arterial lumen b. Distended jugular veins c. Impaired ventricular contraction d. Asynchronous closure of the aortic and pulmonic valves
narrowed arterial lumen bruit are blowing sounds. blood is flowing through an occluded/narrowed artery. -no sound produced when veins are distended -S3/S4 produced and typically heard over aortic area not the neck -S2 splitting = hear 2 dub. Best heard over aortic.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the pas 3 days. Which of the following findings should the nurse expect? a. Neck vein distension b. Urine specific gravity 1.010 c. Rapid heart rate d. BP 144/82 mm Hg
rapid heart rate tachycardia indicates fluid volume deficit -urine specific gravity is 1.005- 1.030; anything higher than 1.030 is fluid volume deficit -hypotension is expected, not hypertension
A nurse is caring for a patient who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?a. Purulent exudateb. Warmthc. Skin blanchingd. Bleeding
skin blanching infiltration: skin blanching, edema, coolness at site. phlebitis: warmth infection: purulent exudate anticoagulation: bleeding
A nurse is caring for a client who has a NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse feeding bag with water between feedings b. tell the client to keep the HOB elevated at least 30 c. make sure enteral feeding is at room temp d. wipe the top of the formula can w/ alcohol
tell the client to keep the HOB elevated at least 30 Priority action nurse should take when using airway, breathing, circulation approach to client care is to prevent aspiration of the general feeding. a, c, & d are correct, however there is another priority.
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? a. The caregiver is the client's financial power of attorney b. The client is in a wheelchair with the wheels locked c. The client reports receiving a full bath twice each week d. The caregiver insists on remaining in the room
the caregiver insists on staying in the room. if caregiver refuses to leave, it can be an indication.
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 following client statements?a. "I'm having mild pain."b. "The pain is like a dull ache in my stomach."c. "I notice that the pain gets worse after I eat."d. "The pain makes me feel nauseous."
the pain is like a dull ache in my stomach -pt is describing severity -pt describes aggravating factors -pt describes manifestation that accompanies pain
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?
to obtain an accurate Bp measurement, nurse should inflate cuff 30 mm Hg beyond last palpable pulse. (122 mm Hg)
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. we can talk about advance directives, and I can also give you some brochures about them. b. ""You should set up a time to talk with your provider about that." c. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." d. "Why do you want to discuss this without your partner here to plan this with you?"
we can talk about advance directives, and I can also give you some brochures about them.
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands that teaching? a. when descending stairs, I will first shift my weight to my right leg. b. I should place my crutches 12 inches in front and to the side of each foot c. as I sit down, I will hold one crutch in each hand d. I will make sure the shoulder rests are snug against my armpits
when descending stairs, I will first shift my weight to my right leg. -place crutches 15cm (6in) in front and side of each foot. -just before sitting, hold crutches by their hand bars in one hand -shoulder rest should be 2.5-5cm 1-2in below axillae.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the patient's plan of care? a. wrap blankets around all four sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside
wrap blankets around all four sides of the bed padding four sides prevents injury to patient. -inserting an object into pt's mouth can cause injury -pt should be turn on their side so tongue doesn't block airway.