ATI - Practice B

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?

Select a suction catheter that is half the size of the lumen

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions shoudl the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client recieved while at the facility

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?

"I can take echinacea to improve my immune system"

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statments by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00a.m. and saved all urine since"

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?

"We can talk about directives, and I can also give you some brochures about them"

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

"Maintain a consistent time to wake up each day"

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initinal pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach"

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 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 of the following statements should the nurse identify as an indication that he client understands the teaching?

"When descending stairs, I will first shift my weight to my right 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 reponses should the nurse make?

"You should have a fecal occult bood test every year."

A nurse is planning an educarional program for a group of older adults at a senoir living center. Which of the following recommendations should the nurse include?

"You should recieve a pneumococcal vaccine when you are 65 years old."

A nurse in the emergency department (ED) is caring for a client who reports abdominak pain. Nurses' Notes: 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation. 1230:Client transported for abdominal x-ray. 1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300:Procedure explained to client who verbalized understanding. Diagnostic Results: 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. Based on the client's clinical findings, which of the following actions should the nurse take? (Select all that apply)

- Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. - Administer a cleansing enema is correct. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. - Auscultate the client's bowel sounds is correct. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. - Perform a manual digital examination of the client's rectum is correct. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract.

A nurse in the emergency department (ED) is caring for a client. Nurses Notes: 1100:Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile. 1110:Provider at bedside; prescriptions received. 1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered. 1200:Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Medication Administration Record: 1115:Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Vital Signs: 1100:Temperature 39.2° C (102.6° F)Pulse rate 118/minRespiratory rate 18/minBlood pressure 92/68 mm HgOxygen saturation 95%Weight 44.9 kg (99 lb)BMI 17 Click to highlight the findings that indicate the client is malnourished

- Cachectic, with flaccid muscle tone is correct. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition. - Skin dry and scaly with bruises on extremities is correct. The client's dry, scaly, and bruised skin can be an indication of malnutrition. - Pulse rate 118/min is correct. The client's tachycardia can be an indication of malnutrition. - Abdomen distended is correct. The client's abdominal distention can be an indication of malnutrition. - BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse is providing discharge teaching for a client who has a new precription for a home oxygen concentrator. Which of th following instructions should the nurse provide to the client and his family? (Select all that apply)

- Check the cord routinely for frays or tearing - Consider purchasing a generator for power backup - Observe for signs of hypoxia

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 - Inject 5 units of air into the bottle of regular - Withdraw the correct dose of regular insulin - Withdraw the correct dose of NPH insulin

A nurse is caring for a client who has a spinal cord injury and has paraplegia. Nurses' Notes: Day 1:Client is alert and oriented.Client is repositioned every 2 hr.Passive range-of-motion exercises to lower extremities performed once each day. Day 5:Client is alert and oriented.Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day.Feet warm. Pedal pulses 2+ bilaterally.Plantar flexion contractures noted bilaterally.Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.

- Passive range-of-motion exercises to lower extremities performed once each day is correct. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. - Plantar flexion contractures noted bilaterally is correct. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. - Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct. The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply)

- Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. - Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. - Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

A nurse is admitting a client. Nurses' Notes: 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. 1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs: 1030:Blood pressure 110/68 mm HgHeart rate 110/min Respiratory rate 24/min Temperature 38.6° C (101.5° F)Oxygen saturation 91% on room air The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

- Place the client on droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. - Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. - Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. - Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

A nurse has accepted a verbal precription "for threee thenths 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 client's medical record

0.3 mg

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Nurses' Notes: 1000:Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat cult Vital Signs: 1000:Blood pressure 132/68 mm HgHeart rate 99/minRespiratory rate 20/minTemperature 38.3° C (101° F)Oxygen saturation 96% on room air Diagnostic Results: 1100:Positive throat culture for streptococci bacteria. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

- Request a prescription for an antibiotic medication is correct. The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection. - Initiate droplet precautions is correct. The nurse should identify that the client has streptococcal pharyngitis, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should initiate droplet precautions for the client. - Wear a mask within 1 m (3 feet) of the client is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should wear a mask when within 1 m (3 feet) of the client to prevent the spread of the infection. - Apply a mask on the client when they leave their room is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should apply a mask on the client when they leave their room to prevent transmission of the infection.

A nurse is caring for a client who has a pressure injury. Nurses' Notes: Day 1:Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Vital Signs: Day 4:Temperature 38.3° C (101° F)Pulse rate 80/minRespiratory rate 20/minBlood pressure 128/64 mm HgOxygen saturation 93% on room air Diagnostic Results: Day 4:Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Hgb 13 g/dL (12 to 16 g/dL)Hct 38% (37% to 47%)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Prealbumin12 mg/dL (15 to 36 mg/dL) Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

- Temperature is correct. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. - WBC count is correct. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. - Prealbumin level is correct. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider. - Pain level is correct. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider. - Odor of wound is correct. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.

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 to the nearest whole number)

8 mL/hr

A nurse is calculating a client's fluid intake over he past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8oz of ice chips

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should indicate in the teaching that this therapy might be containdicated for which of the following cilents?

A client who has asthma

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 priniciple of veracity?

A client who is unaware of her recen cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

A nurse manager is overseeing the care activites on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPPA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client

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?

N95 respirator

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

A nurse is caring for a lient who has decreased mobility. Which of the following actions should the nurse take to decrese the client's risk of developing plantar flexion contractures?

Apply an ankle-foot device to the clients feet

A nurse in 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?

Arrang food in a consistent pattern on the client's plate

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 giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the folloing pieces of information is the priority for the nurse to provide?

Breath sounds

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?

Current medications

A nurse is assessing a client who recieved an IV fluid bolus for dehydration. Which of the following findings should the nurse idenify as an indication of fluid volume excess?

Distended neck veins

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 hears the following sound. This indicates which of the following?

Narrowed arterial lumen

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client

A nurse is preparing to administer multuple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visting

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet togther

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who is receiving pain medication through a patient-controlled naalgesia (PCA) pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep

A nurse is reviewing a clients medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the precription should the nurse verify with the proivder?

Medication dose

A nurse is planning teaching for a group of adolescents who each eacentlyt had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions

A nurse is completing an admission assessment for a client who repots vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid heart rate

A nurse is caring for a client 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?

Skin blanching

A nurse is caring for a client who has an NG tube and is receiving intermittent feeding through a open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees

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?

The caregiver insists on remaining in the room

A nurse is caring for a client. Medical History: Client is receiving chemotherapy for treatment of breast cancer. Diagnostic Results: Week 1:Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2:Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Complete the following sentence by using the lists of options.

The client is at risk for bleeding as evidence by the client's platelet count

A nurse in a medical-surgical unit is caring for six clients. Nurses Notes: 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis. Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed. Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed. Client 4: Client is admitted with a new diagnosis of heart failure. Client 5: Client has a stage 2 pressure injury on the left heel. Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Diagnostic Results: 0900: Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL) Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL) Client 3: Oxygen saturation 88% (95% to 100%) Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL) Client 6: Glycosylated hemoglobin 8% (less than 7%) Complete the following sentence by using the lists of options.

The first cliet the nurse should assess is client 3 followed by client 4

A charge nurse is observing a newly licensed nurse prepare a sterile feild for a dressing change. Which of the following 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 feild

A nurse is caring for a client who has a newly placed ileostomy. Nurses' Notes: 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Diagnostic Results: 1200:Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%) Complete the following sentence by using the lists of options.

The nurse should first address the stoma color followed by the skin around the stoma

A nurse is teaching an older adult client who is at ris for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

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 following actions should the nurse take?

Withhold the blood transfusion

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?

Witness the client's signature on the consent form

A nurse in a surgical suite notes documentation on a client's medical record that states that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place