NUR 339 ~ ATI Practice Assessment #2

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? a. Lactated ringers b. Dextrose 5% in 0.9%NaCl c. 0.45% NaCl d. Dextrose 10% in water

0.45% NaCl

A nurse is preparing to administer digoxin 8mcg/kg/day PO to divide equally every 12 hours for a preschooler who weights 33lbs. Available is digoxi. elixir 0.05 mg/Ml. How many mL should the nurse administer per dose?

1.2

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5 1/2 NS running at 75 ml/hr from 0700 until 1200. The IV runs at 30ml/hr from 1200 to 1500, the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?

1005mL

A nurse is preparing to administer amantiadine 150mg PO every 12hr. Available is amantadine 50mg/5mL syrup. How many mL should the nurse administer per dose?

15

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? a. "I will need to wipe my perineal area from back to front after urination" b. "I will need to empty my bladder regularly and completely" c. "I will need to drink apple cider vinegar each day" d. "I need to drink 8 cups of liquid each day"

I will need to wipe my perineal area from back to front after urination

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is scheduled for Physical Therapy (PT) at 900. Which of the following interventions should the nurse take? a. Encourage the client to use full weight bearing b. Identify the client's pain level and medicate if needed c. Teach the client which positions to avoid during PT d. Perform the client's morning care

Identify the client's pain level and medicate if needed

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (select all that apply) a. Restlessness b. grimacing c. moaning d. clenching e. Drowsiness

Restlessness, grimacing, clenching

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? a. Urine output of 175mL in the last 8hr b. Urine output of 2,200mL in the pas 24hrs c. First-voided urine in the morning has a strong odor d. Urine is cloudy after sitting in the urinal for 6hrs

Urine output of 175mL in the last 8hr

a nurse is assessing four clients for fluid imbalance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? a. a client who has a urine specific gravity of 1.010 b. a client who has a weight gain of 2.2kg (~4lbs) in 24hr c. a client who has a hematocrit of 45% d. a client who has a temperature of 39*C (102*F)

a client who has a temperature of 39*C (102*F)

A nurse is providing discharge teaching to a client following hip arthroplasty. Which fo the following pieces of furniture should the nurse instruct the client to sit in at home? a. a reclining chair with an ottoman b. a straight-backed chair with an elevated seat c. a couch with plush cushions d a rocking chair with a curved back

a straight-backed chair with an elevated seat

a nurse working on an orthopedic unit is caring for four clients. which of the following should the nurse identify as being at greatest risk for skin breakdown? a. an adolescent who has a cervical fracture and is in a halo brace b. a young adult who has a femur fracture and is in skeletal balanced suspension traction c. a middle adult who has a fractured radius and an arm cast d. an older adult who has a hip fracture and is in Buck's traction

an older adult who has a hip fracture and is in Buck's traction

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? a. nephrosclerosis b. uremia c. diverticulitis d. cystitis

cystitis

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for this client at this time? a. elevate the foot of the bed b. encourage the client to sit up as much as possible c. elevate the clients residual limb on a pillow d. have the client lie prone every 3 hours for 20 minutes at a time

have the client lie prone every 3 hours for 20 minutes at a time

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (select all that apply) a. increased heart rate b. increased blood pressure c. increased respiratory rate d. increased hematocrit e. increased temperature

increased heart rate, blood pressure, and respiratory rate

a nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicated an understanding of the teaching? a. "I should increase my caffeine intake" b. "I will take my duloxetine in the morning, so i have more energy to accomplish tasks" c. "low-impact aerobics can help reduce episodes of pain" d. "a course of chemotherapy treatment should provide a cure"

low-impact aerobics can help reduce episodes of pain

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? a. medicate the client for pain b. instruct the client on use of diuretics c. perform a neurovascular check of the extremities d. direct the client to perform exercises of the ankle and toes

perform a neurovascular check of the extremities

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? a. pitting edema around the stump dressing b. looseness of the stump dressing c. the dressing forms a cone shape over the stump d. figure-eight wrapping around the stump

pitting edema around the stump dressing

A nurse is planning care for a client who has manifestations of a clostridium difficile (C. Diff) infection. Which of the following actions should the nurse plan to take? a. place a surgical mask on the patient during transport b. place the client on contact precautions c. use an alcohol-based agent to perform hand hygiene when caring for the client d. obtain a blood specimen to test for C. Difficile.

place the client on contact precautions

a nurse is planning care for a client who is postoperative following a total hip arthroplasty. which of the following interventions should the nurse include in the plan of care? a. instruct the client to avoid movement of the affect leg b. prevent hip flexion of the affected extremity c. position the lower extremities so that they are touching d. Ensure that the client's heels are touching in bed

prevent hip flexion of the affected extremity

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? a. vital signs b. self-report of pain c. severity of the condition d. nonverbal behavior

self-report of pain

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? a. expect ringing in your ears b. take the medication with food c. store the medication in the refrigerator d. monitor for weight loss

take the medication with food

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation? a. The client has not been taking the medication properly b. the client is experiencing episodes of confusion c. the client has become addicted to the medication d. the client developed a tolerance to the medication

the client developed a tolerance to the medication

a nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a. urinary tract infection b. urinary incontinence c. urinary frequency d. urinary retention

urinary tract infection

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? a. urine specific gravity of 1.035 b. hematocrit 44% c. BUN 19 mg/dL d. sodium 155mEq/L

urine specific gravity of 1.035

A nurse is planning care for an older adult who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. use a transfer device to lift the client up in bed b. apply cornstarch to keep sensitive areas dry c. massage the skin over the client's bony prominences d. elevate the head of the bed no more than 45*

use a transfer device to lift the client up in bed