ATI Questions 5
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I will make sure to replace my pouch around 4 hours after i eat"
A nurse is reinforcing teaching with an older adult client who has constipation. What statement should the nurse include in the teaching?
"Sit on the toilet 30 minutes after eating a meal"
A nurse is beginning a therapeutic relationship with a client. What action should the nurse perform to convey empathy when using the therapeutic communication technique of active listening?
Assume an open position
A nurse is collecting data from a client. Which of the following findings should the nurse identify as an indication of protein -calorie malnourishment? Select all that apply
Dry, brittle hair Edema Poor wound healing
A nurse is contributing to the planning of an in-service session about nutrition. What piece of information should the nurse recommend for the teaching?
Protein serves as an energy source for the body when carbs/fat stores are unavailable or depleted
A nurse is inserting an NG into a client who begins to cough and gag. What action should the nurse take?
Pull the NG tube back slightly
A nurse is collecting data from a client as part of a neurological exam. To promote safety during the exam, the nurse stands nearby for what test?
Romberg
A nurse is reviewing the lab data of a client who has a fever and watery diarrhea. What result should the nurse report to the provider?
Sodium 150 -expected range is 135 to 150
As part of a neurological exam, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. What ability is the nurse evaluating?
Stereognosis
A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. What finding should the nurse identify as infiltration of the IV infusion site?
Taut skin around the IV catheter site that is cool to the touch
A nurse is reinforcing teaching with a group of clients about nutrition. What definition of the RDA should the nurse include?
The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups
A nurse is administering an IM injection to a 5-month-old infant. What injection site should the nurse use?
Vastus lateralis
A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the previous shift. What action should the nurse take?
call the provider to clarify the dosage
A nurse is explaining Piagets theory of cognitive development to a group of day care providers for employees' children at an acute-care facility. What activity should the nurse include as an example of concrete operational thinking?
collecting and trading game cards
A nurse is collecting data during a neurological exam of a client. When asking the client to stick out his tongue, Which of the following cranial nerves is the nurse testing?
cranial nerve XII
A nurse is reinforcing teaching with a client about how to obtain a capillary finger-stick blood sample. What action by the client requires the nurse to intervene?
elevates the finger above heart level
A nurse is instilling antibiotic ear drops for a client who has an ear infection. What action should the nurse take?
have the client lie on the side opposite the infected ear
A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health-care associated infections (HAIs). Which of the following routes of infection should the nurse manager identify as an iatrogenic HAI?
infection acquired from a diagnostic procedure - iatrogenic hai directly result from a procedure
A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?
moro
A nurse is using the Braden scale to predict the pressure ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?
nutrition
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. What action should the nurse take?
remove the restraints individually
A nurse on a medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priority to keep near the client AT ALL TIMES?
suction equipment
A nurse is reinforcing teaching with a client about the use of a straight -legged cane. what action indicates understanding
the client holds the cane on the unaffected side
A nurse is helping a client perform ROM exercises of the neck. For evaluating neck flexion, what motion should the nurse instruct the client to perform?
touching his chin to his neck
A nurse is planning to administer pain medication to a client who has post op pain following abdominal surgery. What action should the nurse take first?
use pain scale to determine clients pain level
A nurse is preparing to irrigate a client's wound. What action should the nurse take?
warm the irrigating solution to 98.6
