pt 2 Fundamental PN ATI 2023
nurse is reinforcing teaching about heat therapy with a client who has low back pain. Which of the following statements by the client indicates an understanding of the teaching?
"I need to place a towel between the heating pad and my skin."
A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?
"I will shake the inhaler well right before I use it."
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse caring for this client? (Select all that apply.)
-New prescriptions .-Arterial blood gas results -Tracheal secretion characteristic
A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?
2 A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions.
A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?
Absent bowel sounds with distention
A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis?
Albumin
A nurse is collecting data from a client who has mixed aphasia. Which of the following strategies should the nurse use to help facilitate communication with this client?
Ask simple, short questions
A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?
Ask why the client is refusing the pain medication
A nurse is caring for a client who has a stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?
Check the client's pain level
A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take?
Check the medication dose and the client's identification
A nurse is caring for a client who has a prescription for the collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen?
Collect the specimen once the client rises in the morning
A nurse is collecting data from a client whose potassium level is 2.8 mEq/L. Which of the following findings should the nurse expect?
Decreased bowel sounds
A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?
Depressed deep-tendon reflexes
A nurse is caring for a client with a BMI of 29 who expresses a desire to lose weight. Which of the following actions should the nurse take first?
Determine the client's intention to change current eating habits
A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?
Diuresis
A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?
Document this as an expected finding
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Elevate the client's head of bed 45° before the feeding
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse take to reduce the client's risk for aspiration?
Elevate the head of the bed by 30° to 45°
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
Encourage the client to express his thoughts about death and dying.
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief
Encourage the client to listen to soft music
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open
A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's computer orientation class until next week. Which of the following actions should the nurse take?
Explain that sharing access codes is against policy and refer the resident to the supervisor
A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age?
Eye examination every 2 years
A nurse is administering 3 liquid medications through a client's nasogastric tube. Which of the following actions should the nurse take?
Flush the tube with water before and after instilling each medication
A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?
Fowler's
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take
Hyperoxygenate the client before suctioning
A nurse is reinforcing teaching with a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
I can still use my TENS unit even though I'm pushing the PCA button."
A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
I should expect my heart rate to take longer to return to normal after exercise as I get older."
A nurse is assisting with the planning of an in-service training session about various dietary practices. Which of the following pieces of information should the nurse recommend including in the teaching?
Kosher diets involve restrictions regarding how food must be prepared.
A nurse is assisting with planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse suggest?
Limit drinking liquids when eating food
A nurse is planning to reinforce teaching for a client who is learning to self-inject a medication subcutaneously. The nurse does not speak the client's language, so arrangements are made for a medical interpreter from the facility to assist. Which of the following actions should the nurse take when working with the interpreter and the client
Make sure the client and the interpreter are culturally compatible
A nurse is caring for a client who requires the insertion of a nasogastric tube. Which of the following actions should the nurse take when preparing to insert the tube?
Measure the distance from the nose to the earlobe to the xiphoid
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
Notify the provider about the client's decision
A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as a part of an effective conference?
Other health care professionals are in attendance at the conference.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications?
Plasma volume expanders
A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?
Record the amount of medication wasted on the controlled substance inventory record
nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
Remove the restraints individually
nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of her meals. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?
Speech-language pathologist
A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about this procedure before. Which of the following actions should the nurse take?
Stop reinforcing the teaching and check with the surgeon about informed consent
A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings 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 caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide?
Tell me what I can do to help you overcome your fear of giving yourself injections."
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
Temporal
A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?
The client holds the cane on the unaffected side.
A nurse is helping a client perform range-of-motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform?
Touching his chin to his chest
nurse is inserting an indwelling urinary catheter into the penis of a client. Which of the following actions should the nurse take?
Use the nondominant hand to grasp the penile shaft
nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
Using a cuff that is too small will result in an inaccurately high reading."
A nurse is caring for a client who reports using several herbal supplements. Which of the following actions should the nurse take?
Verify that the herbal supplements do not interact with medications the provider has prescribed
A nurse is collecting data from a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
What do you think caused the onset of your pain?"
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Wiping the labia minora in an anteroposterior direction
A nurse is reinforcing teaching for a client about performing range-of-motion exercises of the wrist. To have the client demonstrate adduction, which of the following instructions should the nurse give?
With your palm facing down, move your wrist sideways toward your thumb."
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?
Would you like to talk about how you feel?"
A nurse is reinforcing teaching with a client who needs to reduce cholesterol levels. Which of the following foods should the nurse suggest that the client add to his diet?
carrot
A nurse is reviewing the laboratory results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse initiate?
contact
A nurse is in the facility's cafeteria when she notices a person grasping at the front of the neck in apparent distress. Which of the following behaviors should the nurse identify as an indication that the person requires an abdominal thrust intervention immediately?
inability to speak
