pn ati fundamentals assessment A
A nurse is caring for a client who has metastatic cancer & practices Catholicism. The client asks the nurse to discuss the afterlife w/ her. Which of the following statements by the nurse assists in the meeting the clients spiritual needs?
" Tell me what the afterlife means to you."
A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?
" The reduced muscle tone has relaxed the jaw muscles"
A nurse is reinforcing postop teaching with a client about how to turn, cough and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?
" This can help prevent pneumonia"
A nurse is speaking w/ a pt who has type 2 diabetes mellitus & a prescription for insulin. The pt verbalizes anger about having to take insulin. Which of the following responses should the nurse make?
"I see that you are angry. Lets sit down and talk."
A nurse is reinforcing dietary teaching w/ a pt who has chronic kidney disease & requires a low potassium diet. Which of the following food choices by the pt demonstrates an understanding of the teaching?
1 cup of applesauce
A nurse is reviewing the V/S of four PTs. Which of the following findings require further data collection by the nurse?
A client who has a pulse of 110/min
A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?
A stage 3 pressure injury on the coccyx
A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistant oral temperature of 38.9 * C (102 F). Which of the following interventions should the nurse include in the plan of care to treat the fever?
Administer acetaminophen
A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?
Administer an analgesic 30 minutes before starting the procedure.
A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent?
An 18 year old client who has acute appendicitis.
A nurse is caring for a post op client who is at risk for a thrombus formation. Which of the following interventions should the nurse delegate to an AP?
Apply thromboembolic stockings.
A nurse is assisting with the plan of care for a client who has aphasia following a stroke. which of the following interventions should the nurse use to assist the client with communication?
Ask the client close-ended question
A nurse is assisting with a client who has active Tb. Which of the following actions should the nurse plan to take?
Assign the client to a negative pressure airflow room.
A nurse is assisting w/ the plan of care for four pts. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
Assist a pt to get out of bed after a breathing treatment
A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?
Attend an exercise program
A nurse is explaining ethics & values to a newly licensed nurse. The nurse should explain that allowing a Pt to make a decision about treatment is an example of which of the following ethical principles?
Autonomy
A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess?
BUN 8mg/dL
A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?
Beneficence ( acting in the clients best interest)
A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of an NG tube?
Check the PH of the gastric aspirate.
A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age related changes?
Circulation becomes less efficient with age
A nurse is preparing to remove a clients peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?
Clamp the infusion tubing
A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?
Clean soiled areas of the body.
a nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities which of the following actions should the nurse recommend for the plan of care?
Compare the clients pedal pulses bilaterally every 4 hr.
A nurse is preparing to admin a topical med to a PT. Which of the following actions should the nurse take?
Compare the label of the med container w/ the med admin record x3.
A nurse is assisting with the admission of a pt who has brought her meds to the facility. Which of the following actions should the nurse take?
Compare the meds the provider has prescribed with the clients meds from home
A nurse is caring for a Pt who is refusing medical treatment. Which of the following actions should the nurse take?
Document the clients refusal of the treatment
A nurse has delegated various client care tasks to the assistive personnel on the care team. Which of the following actions by the AP should the nurse identify as correct?
Donning a mask to measure the vital signs of a patient with pertussis
A nurse is palpating the pulse located on the top of the pts foot. Which of the following pulses should the nurse document that she is palpitating?
Dorsalis pedis
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection?
Drain urine from the tubing before ambulation
A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?
Ensure that the client wears a surgical mask during transportation thoughout the facility.
A charge nurse smells smoke, enters the visitors restroom, and sees flames in the trashcan. What is the sequence of actions that the nurse should take?
Evacuate Alarm Confine Extinguish
A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?
Flashing smoke alarm
A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?
I will keep the crutch tips dry.
A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?
Internally rotate the clients's hips by using a trochanter roll.
A nurse is caring for a client who has a Clostridium difficile infection. which of the following solutions should the nurse use to perform hand hygiene while caring for this client?
Mild soap
A nurse is preparing to admin O2 to a Pt who has heart failure & is having severe difficulty breathing. Which of the following O2 delivery equipment should the nurse select to provide the highest concentration of O2 to the Pt?
Nonrebreather mask
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (S.A.T.A.)
Orthostatic hypotension Flat neck veins cool extremities
A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?
Pad bony prominences on the wrist.
A nurse is moving a client up in bed with assistance of a second nurse. Which of the following actions should the nurse take?
Place feet apart with the foot nearest the clients bed in front of the other foot.
A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include?
Place the client in a room near the nurses station. Ensure that the client is wearing non skid slippers. Reinforce teaching about how to use the call bell.
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?
Positive Chvostek's sign ( To elicit Chvostek's sign, the nurse should tap the client's facial nerve near the ear. If the client's facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels.)
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?
Precontemplation
A nurse is reinforcing pre-op teaching w/ a pt who does not speak the same language as the nurse. Which of the following actions should the nurse take?
Provide handouts written in the clients primary language
A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?
Provide privacy for the client.
A nurse is planning to transfer a patient from an acute care facility to a long term care facility. Which of the following information should the nurse plan to include in the transfer report?
Resolved health conditions
A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper?
Shred the paper in a secure container
A nurse is caring for a client who is alert and in a long term care facility. Which of the following actions should the nurse take to protect the client's privacy?
Speak with the client about his condition after the visitors have left.
A nurse is caring for a client who just died and practiced the islamic faith. Which of the following cultural practices should the nurse expect?
The client face should be toward mecca.
A nurse is collecting data from an older client. Which of the following should the nurse report to the provider?
The client reports urinary incontinence
A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates and understanding of the teaching?
The living will directs my medical care when I am unable to make decisions.
A nurse is reinforcing teaching about hospice care measures with the fam of a pt who is dying. Which of the following statements by a member of the clients family indicates an understanding of the teaching?
We will keep her room cool to help her breathe better
A nurse is caring for a client who has recently undergone a total bilateral mastectomy. which of the following statements by the client requires immediate action by the nurse?
When I look at myself in the mirror, I don't know if i can go on
A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?
When ascending stairs the client should first advance the unaffected leg.
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?
When lifting a heavy object keep it close to your body.
A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?
Young adults should receive a dental assessment every 6 months
A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take?
decrease rate of feeding
a client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?
let the client know that he is available and willing to listen
A nurse is caring for a Pt who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take?
measure the Pts gastric before each feeding
A charge nurse is reinforcing teaching with an assistive personel about performing pulse oximetry. Which of the following information should the nurse include in the teaching?
remove polish from the clients fingernail before applying the oximentry probe.
A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?
urine output of 200mL over 8 hr
A nurse is calculating the input and output for a client over the last 8 hours. The client is receiving a continuous IV infusion at 150mL/ hr and had 4 oz of juice and 0.5L of water. How many mL of fluid should the nurse document as the clients intake for the last 8 hr?
1820 mL