Study Guide EXAM 3 ATI Select All That Apply

Pain: A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include?

- "You can be taught how to use TENS therapy at home." - "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." - "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."

Pain: A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include?

- Face - Legs - Consolability

Pain: A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)?

- Respiratory rate - Capnography - Oxygen saturation

A nurse is caring for a client with renal insufficiency and is taking medication that is primarily excreted through the kidneys. The nurse should monitor the client for which of the following?

Drug Toxicity

A nurse is speaking to a client who is taking sertraline and reports drinking grapefruit juice. The nurse explains that grapefruit juice inhibits an enzyme in the liver that is used to metabolize sertraline. The nurse should recognize the client's risk for which of the following?

Drug toxicity

A nurse is caring for a client who is receiving an IV medication and is about to switch to the oral form of the drug. The nurse should identify that the oral dose will be higher than the IV dose for which of the following reasons?

The oral form has decreased bioavailability because of the first-pass effect.

A nurse is reviewing drugs in a drug reference manual. The nurse should identify that drugs in the same class share which of the following similarities?

They have similar mechanisms of actions.

Pain: A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information?

- "A client's religious beliefs might affect the way they respond to pain." - "The client's past pain experiences are not related to their current pain and pain management." - "Pain control might be harder to achieve if the nurse and client speak different primary languages."

Pain: A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level?

- A 3-year-old toddler who has a fractured femur - A 14-year-old client who has severe cognitive and developmental delays - A 5-year-old preschooler who is experiencing pain during a sickle cell crisis

Mobility: A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

- A stable center of gravity increases stability and balance - A wide base lowers the center of gravity - Proper body alignment involves tightening the abdomen

Sensory Perception: A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching?

- A walking cane - A walker

Sensory Perception: A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss?

- Asks for questions to be repeated - Withdraws from social activities - Describes sounds as being muffled

Pain: A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control?

- Consider each client's cultural preferences. - Determine the effectiveness of nonpharmacological strategies. - Use a pain scale specific to each client's cognitive abilities.

Sensory Perception: A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect?

- Difficulty maintaining attention - Agitation - Hallucinations - Rambling speech

Sensory Perception: A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client?

- Ensure the client wears their hearing aids. - Use a sign language interpreter. - Communicate using paper and pen.- Face the client when speaking.

Pain: A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management?

- Fear of addiction - Belief that pain is an expected part of their illness - Inadequate pain assessment

Pain: A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort?

- Grimacing - Restlessness - Increased diaphoresis

Elimination: A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors?

- History of frequent respiratory infections - Consumes large amounts of dairy in their diet - Currently taking cephalexin for pneumonia

Sensory Perception: A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include?

- Inspect the feet every day. - Wear closed-toe shoes. - Manage glucose levels.

Sensory Perception: A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic?

- Loop diuretics - NSAIDS - Aminoglycoside antibiotics

A nurse is caring for a client who arrived at the emergency department following a bee sting. Which of the following indicates an anaphylactic reaction?

- Low blood pressure - Wheezing - Difficulty swallowing

Pain: A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions?

- Muscular pain - Backache - Menstrual discomfort

Sensory Perception: A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following decreases with age?

- Sour - Bitter - Salty

Pain: A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include?

- Stress - Culture - Social support - Disease severity

A nurse is caring for a client who is taking acetaminophen and codeine for pain relief. These analgesic medications interact with one another to cause an additive effect. The nurse should identify that which of the following characteristics of additive drugs interactions?

- The elderly are more at risk - Both drugs have similar actions

Pain: A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include?

- Transcutaneous electronic stimulating unit - (TENS unit) - Massage - Acupuncture - Cold therapy

Sensory Perception: A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss?

- Trauma to the outer ear - Inflammation - Cerumen buildup - Otitis media

Elimination: A nurse is caring for a group of client who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk?

- Uncircumcised infants - School-age children - Older adults

Hygiene: A nurse is reviewing oral hygiene practices with an assistive personnel which of the following information should the nurse include?

-A fluoride mouthwash should be used to promote oral health -The teeth should be brushed twice daily for two minutes -Poor oral hygiene can lead to gingivitis -use a soft bristle toothbrush for brushing the teeth

Hygiene: A nurse is reviewing a list of client care tasks with another nurse in which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene?

-The nurse's hands become visibly soiled -The nurse removes the meal tray of a client who has infectious diarrhea -The nurse empties the urinal of a client who has Clostridium Difícil

A nurse is reviewing a drug handbook prior to administering a drug to a client who has kidney disease. The handbook states that the drug can be administered by identifying certain risks. Which of the following terms describes these risks.

Precautions

Comfort, Rest, and Sleep: A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines?

Sensory overload Sleep deprivation