NCLEX challenge 7 ATI
A nurse is caring for a 9-year old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
"Tell me more about how you are feeling about your son's activities"
A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?
"You should report any tendon discomfort you experience while taking this medication"
A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?
Encourage intake of at least 3L of fluids per day
A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide. Which of the following statements by the nurse best describes the action of glipizide?
"Glipizide stimulates your pancreas to release insulin"
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?
"I don't eat shellfish because it gives me hives"
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?
"I give the insulin injections in my abdominal area"
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?
"I will need to wipe my perineal area from back to front after urination."
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
"Maintain stable blood glucose levels"
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?
"Restrict lifting objects greater than 10 pounds"
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report
having a decreased ability to perceive colors
A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?
Notify the surgeon
A nurse is caring for a client who is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes the whole milk on his breakfast tray with skim milk. Because of this substitution, the nurse should know that the client can add which of the following items to the oatmeal on his breakfast tray?
One tablespoon of low-fat margarine
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?
Overflow incontinence
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Place suction equipment at the client's bedside
A nurse is reviewing the medication list for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize which of the following medications can cause glucose intolerance?
Prednisone
A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?
Regular insulin
A nurse is serving on continuous improvement committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?
Review the events leading up to each medication administration error
A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride. The nurse should teach the client to avoid which of the following drinks while taking his medication?
Alcohol
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications of that client has an infection?
An increase in neutrophils Localized edema
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
Assess the client
A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?
Check the client's vital signs
A nurse is planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program?
Clients will have a decreased incidence of foot amputations.
A nurse is caring for a client who is receiving mydriatic eye drops, Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect?
Constipation
A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
Describe to the client the location of the food on the tray
A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse?
Determine if the client uses hearing aids
A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include?
Expect the NPH insulin to peak in 6 to 14 hours
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use?
Explore the client's feelings about dietary modifications
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?
Family history
A nurse is caring for a client who has diabetes and plans to administer his regular insulin subcutaneously before he eats breakfast at 0800. After checking the client's morning glucose level, which of the following actions should the nurse take?
Give the insulin at 0730
A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?
Specific characteristics of the medication
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?
The client should wear dark glasses while outdoors.
A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?
The medication should be applied on a regular schedule for the rest of the client's life
A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?
Tugging on the affected ear lobe
A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?
"Avoid eating tree nuts, such as almonds"
A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?
"Crushing the medication might cause you to have a stomachache or indigestion"
A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions?
"Discard the first bead of ointment before each application"
A nurse working for a home health agency is teaching a client who has Diabetes mellitus about disease management. Which of the following glycosylated hemoglobin values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?
6.3%
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
Apply a moisture barrier ointment to the client's skin
A nurse is preparing to use Z-track technique to administer a medication to a client. Which of the following is an appropriate action during this procedure?
Aspirate for 5 to 10 seconds
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week
A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include in the plan?
Avoid reading and writing
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia?
Blurred vision Tachycardia Moist, clammy skin
A nurse is providing dietary teaching to a client who has nephropathy secondary to diabetes mellitus and plans to make dietary adjustments. Which of the following instructions should the nurse include?
Consume less than 0.8g/kg of body weight of protein per day
A nurse is caring for a client who has type 1 diabetes mellitus and is not following the guidelines for therapy. Which of the following should the nurse consider as contributing factors to the client's nonadherence? (select all that apply)
Culture Literacy Dexterity Motivation
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?
Cystitis
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?
Diabetes mellitus
A nurse is preparing to administer medications to a client who states " I don't want to take those drugs." Which of the following actions should the nurse take?
Document that the client refuses the medications
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
Drink 3 L of fluid every day
A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?
Drop prescribed amount of medication into the conjunctival sac.
A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan?
Instruct the client to avoid drinking carbonated beverages
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?
Malpractice
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?
Monitor the client for hypoglycemia
A nurse in a clinic is assessing a client who has a new diagnosis of interstitial cystitis. The nurse should expect which of the following findings?
Negative urine culture
A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?
Vertigo
A nurse is providing teaching to a client who has a diabetes mellitus about carbohydrate intake needs when exercising. Which of the following foods should the nurse include as containing a 15g serving of carbohydrates?
1 cup milk
