Bundle
A BUNDLE OF ATI RN EXAM 2023/2024
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ATI RN
A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? - ANSWERSHair loss on the lower... [Show More] legs A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - ANSWERS"I will use my hands rather than a washcloth to clean the radiation area. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply. - ANSWERSAvoid drinking fluids with meals Eat several small meals Consume high-protein snacks Avoid highly seasoned foods A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. - ANSWERS"I will need to do the breathing exercises every 1 to 2 hours after the surgery" "I will be sure to ask for pain medication before my knee starts to hurt too bad" "I will probably be going home with a walker" A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? - ANSWERSRemind the client to scan their complete range of vision during ambulation. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? - ANSWERSUrine specific gravity 1.045 A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? - ANSWERS A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? - ANSWERSHeart rate 110/min. A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy. Click to highlight the findings the nurse should report to the provider immediately. - ANSWERSPerineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? - ANSWERSDecreased viral load A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? - ANSWERSTry to walk at least three times per week for exercise. A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? - ANSWERSHistory of asthma A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? - ANSWERS"You should cut the opening of the skin barrier one-eighth inch wider than the stoma." A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? - ANSWERSSputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? - ANSWERSPain that increases with passive movement A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? - ANSWERSScan the bladder with a portable ultrasound. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? - ANSWERS"I will take my temperature once a day." A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? - ANSWERSA tingling sensation replacing the pain A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? - ANSWERSNaproxen A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? - ANSWERSBradycardia A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - ANSWERS"I will wear clean graduated compression stockings every day." A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? - ANSWERSIrrigate the indwelling urinary catheter. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? - ANSWERSRemain with the client for the first 15 min of the infusion. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? - ANSWERSInstruct the client on alternative therapies for pain reduction. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? - ANSWERSReport of sore throat A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? - ANSWERSPlace personal items, such as pictures, at the client's bedside. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? - ANSWERSInstruct the client to allow the machine to breathe for them. A nurse is providing teaching to a client who has a history of urinary tract infections (UTIS). Which of the following information should the nurse include in the teaching? - ANSWERSTake daily cranberry supplements.. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? - ANSWERSBUN 34 mg/dL A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? - ANSWERSBubbling in the water seal chamber has ceased. A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? - ANSWERSInstruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? - ANSWERSCheck that one finger fits between the cast and the leg. A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - ANSWERS24 mL The nurse is providing care for the client. The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. - ANSWERS12 % weight loss over 2 months Muscle guarding and tenderness in right lower quadrant of abdomen Abdominal firmness and rigidity Abdominal pain rate of 8 Hypoactive bowel sounds Report of anorexia Temperature of 38.5 C (101.4 F) A nurse is caring for a client. The nurse has completed their performing an assessment of the client and reviewing the client's EMR. (For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.) - ANSWERSAppendicitis - Pain location, temperature, GI concerns Crohn's Disease - Stool color, pain location, temperature, GI concerns A nurse is caring for a client. Complete the following sentence by using the lists of options. - ANSWERSAfter reviewing the findings in the client's medical record, the nurse should first address the client's ABDOMINAL FINDINGS followed by the client's PAIN RATING The nurse is providing care for the client. The nurse is planning care for the client. (For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.) - ANSWERSAnticipate - Obtain blood cultures, insert NG, obtain vitals Contraindicated - Bolus fluids The nurse is providing care for the client. A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. Which of the following actions should the nurse take? Select the 3 actions that the nurse should take. - ANSWERSAdminister gentamicin 100 mg IV. Administer client's PO medication with a sip of water. Ensure that the client has provided informed consent. The nurse is providing care for the client. A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.) - ANSWERS"I should schedule several rest periods throughout the day." "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit." A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? - ANSWERSCalcium A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? - ANSWERSIncrease fiber intake to at least 30 g per day. A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? - ANSWERSNonrebreather mask A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching? - ANSWERS"I can ask a friend to change my cats litter box." A nurse is caring for an client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? - ANSWERSKeep the client occupied with a manual activity. A nurse is caring for a client who presents to a clinic for a 1-week follow- up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - ANSWERSHeart rate 55/min A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? - ANSWERSAvoid placing plants or flowers in the client's room. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? - ANSWERSWarfarin A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? - ANSWERSPlace a tracheostomy tray at the bedside. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? - ANSWERS"This identifies if the pacemaker cells of my heart are working properly." A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? - ANSWERSWrap fingers with individual dressings. A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? - ANSWERSTroponin 18 ng/mL A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing? - ANSWERSUrine output 25 mL/hr A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? - ANSWERS"I am taking this medication to increase my energy level." A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - ANSWERS167 mL/hr A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? - ANSWERSInject the medication into the anterolateral abdominal wall. A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? - ANSWERSCreate complete outfits and allow the client to select one each day. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? - ANSWERSSuction machine A nurse is caring for a client. The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. - ANSWERSBUN level Chest x-ray Oxygen saturation level WBC count PCO₂ level A nurse is caring for a client. The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. - ANSWERSClient is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache" Crackles heard in posterior lungs Client is diaphoretic A nurse is caring for a client. A nurse is prioritizing client care. Complete the following sentence by using the lists of options. - ANSWERSThe nurse should first address the client's oxygen saturation followed by the client's temperature. A nurse is caring for a client. [Show Less]
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ATI RN
A nurse is caring for a client who states "I have to check with my wife and see if she thinks I am ready to go home" The nurse replies, "How do you feel ab... [Show More] out going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. pacing B. reflecting C. paraphrasing D. restating - ANSWERSB which of the following actions should the nurse take when using the communication technique of active listening (select all that apply) A. open posture B. write down what client says to avoid forgetting details C. establish and maintain eye contact D. nod in agreement with the client throughout conversation E. respond positively when giving feedback - ANSWERSA C E a nurse if caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. which of the following statements should the nurse use (select all that apply) A. you will do great. you just have to get used to it. B. what are you worried about going home C. your daily routines will be different when you go home D. tell me about your support system youll have after you leave the hospital E. let me tell you about a friend of mine with a colostomy who also enjoys swimming - ANSWERSC D E which of the following strategies should a nurse use to establish a helping relationship with a client A. make sure the communication is equally reciprocal between the nurse and client B. encourage client to communicate his thoughts and feelings C. give nurse-client communication no time limits D. allow communication to occur spontaneously throughout nurse-client relationship - ANSWERSB a nurse is caring for a school-age child who is sitting in a chair. to facilitate effective communication, which of the following actions should the nurse take A. touch childs arm B. sit at eye level C. stand facing child D. stand with relaxed posture - ANSWERSB A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication? A. Personal space B. Posture C. Eye contact D. Intonation - ANSWERSD A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating - ANSWERSD A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication? A. Offering advice B. Reflecting meaning C. Listening attentively D. Giving information - ANSWERSA A nurse is conducting therapy with several clients and their families. Effective communication with clients and families is based on: A. discussing in-depth topics with which the client feels comfortable. B. using silence to avoid unpleasant or difficult topics. C. attending to verbal and nonverbal behaviors. D. requiring the client and family to ask for feedback. - ANSWERSC When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response? A. "I think your son is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically." - ANSWERSD A nurse is caring for a 20-year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? a. Measure vital signs. b. Encourage HIV screening. c. Determine risk factors. d. Instruct the client to use condoms. - ANSWERSC A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (SATA) a. Help the client see the benefits of her actions. b. Identify the client's support systems. c. Suggest and recommend community resources. d. Devise and set goals for the client. e. Teach stress management strategies. - ANSWERSA B C E A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? a. Testicular examination b. Blood glucose c. Fecal occult blood d. Prostate-specific antigen - ANSWERSA A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? a. Cholesterol screening b. Nutrition presentation c. Medication therapy d. Cardiac rehabilitation - ANSWERSB A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? a. "So I don't need the colon cancer procedure for another 2 or 3 years." b. "For now, I should continue to have a mammogram each year." c. "Because the doctor just did a Pap smear, I'll come back the next year for another one." d. "I had my blood glucose test last year, so I won't need it again till next year." - ANSWERSB A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique. b. The client is able to demonstrate the appropriate technique. c. The client states that he understands. d. The client is able to write the steps on a piece of paper. - ANSWERSB A nurse in a provider's office is collecting data from the mother of a 12-month-old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that he will postpone toilet training until her son is older. Learning has occurred in which of the following domains? a. Cognitive b. Affective c. Psychomotor d. Kinesthetic - ANSWERSB A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision." b. "Will you give me pain medicine after the surgery?" c. "Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say." - ANSWERSC A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. Encourage the client to participate actively in learning. b. Select instructional materials appropriate for the older adult. c. Identify goals the nurse and the client agree are reasonable. d. Determine what the client knows about stress incontinence. - ANSWERSD A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? a. Encourage the client to ask questions. b. Ask the client to explain how to select or prepare meals. c. Encourage the client to fill out an evaluation form. d. Ask the client if she has resources for further instruction on this topic. - ANSWERSB By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? a. reassess the client to determine the reasons for inadequate pain relief b. wait to see whether the pain lessens during the next 24 hours c. change the plan of care to provide different pain relief interventions d. teach the client about the plan of care for managing his pain - ANSWERSA A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective (Select all that apply) A. Respiratory rate of 22/min with even, unlabored respirations. B. "I can only walk three blocks before my legs start to hurt." C. Pain level 3 on a scale of 0-10 D. Skin pink, warm, and dry E. Urine output of 300mL/8 hr F. Dressing clean, dry, and intact. - ANSWERSA D E F A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: " The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it I checked with the client 40 min later and he said his pain is going away." The instructor should inform the student she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation - ANSWERSA A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse-initiated? (Select all that apply) A. Give morphine sulfate 1 to 2 mg IV every 1 hr as needed for pain. B. Insert an NG tube to relieve a client's gastric distention. C. Show a client how to use progressive muscle relaxation. D. Perform a daily bath after the evening meal. E. Reposition a client every 2 hr to reduce pressure ulcer risk. - ANSWERSC D E During an evaluation, the nurse must gather information about the client to... A. Identify whether the client outcomes have been met. B. Organize resources to proceed with implementing interventions C. Establish client-centered outcomes that are measurable and realistic. D. determine the priority of care and appropriate interventions. - ANSWERSA a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. which of the following actions should the nurse take to decrease the risk of another fall (select all that apply) A. place belt restraint on the client when he is sitting on the bedside commode B. keep bed in lowest position with all side rails up C. make sure clients call light is within reach D. proved nonskid footwear E. complete fall-risk assessment - ANSWERSC D E a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. which of the following statements by a nurse requires further instruction? A. I will place the client on his side B. I will go to the nurses station for assistance C. I will administer his meds D. i will prepare to insert an airway - ANSWERSB a nurse observes smoke coming from under the door of the staffs lounge. which of the following actions is the nurses priority? [Show Less]
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A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should t... [Show More] he nurse identify as an indication that the treatment was successful? Increase in hematocrit increase in respiratory rate Decrease in heart rate Decrease in capillary refill time - ANSWERSCorrect Answer: Decrease in heart rate Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. Incorrect Answers: Increase in hematocrit: Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. increase in respiratory rate Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. Decrease in capillary refill time Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range. A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? "The transfer of your family member is being done because the provider knows what's best." "Would you like it if we discussed the transfer with your family member?" "Why are you so concerned about this transfer?" "I know how you feel. My parent had to be transferred to a long-term care facility." - ANSWERSCorrect Answer: "Would you like it if we discussed the transfer with your family member?" This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality. Incorrect Answers: "The transfer of your family member is being done because the provider knows what's best." This is a defensive response which can hinder further communication. "Why are you so concerned about this transfer?" Asking a why question can make the recipient defensive which can hinder further communication. "I know how you feel. My parent had to be transferred to a long-term care facility." This is a sympathetic response, which can interfere with a therapeutic relationship. A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider? BUN 21 mg/dL (10 to 20 mg/dL) Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 5.8 mEq/L (3.5 to 5 mEq/L) - ANSWERSCorrect Answer: Potassium 5.8 mEq/L (3.5 to 5 mEq/L) When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias. Incorrect answers: BUN 21 mg/dL (10 to 20 mg/dL) This BUN level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) This creatinine level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a a priority for the nurse to report to the provider. Sodium 132 mEq/L (136 to 145 mEq/L) This sodium level is slightly below the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? "Drink a cup of hot cocoa before bedtime." "Maintain a consistent time to wake up each day." "Exercise 1 hour before going to bed." "Watch a television program in bed before going to sleep." - ANSWERSCorrect Answer: "Maintain a consistent time to wake up each day." The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. Incorrect Answers: "Drink a cup of hot cocoa before bedtime." Cocoa contains caffeine, which is a stimulant that can interfere with sleep. "Exercise 1 hour before going to bed." Exercising within 2 hr of bedtime can interfere with sleep. "Watch a television program in bed before going to sleep." The client should avoid watching television in bed before going to sleep to reduce stimulation in order to promote rest. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of following actions should the nurse take? Pad the client's wrist before applying the restraints. Evaluate the client's circulation every 8 hr after application. Remove the restraints every 4 hr to evaluate the client's status. Secure the restraint ties to the bed's side rails. - ANSWERSCorrect Answer: Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury. Incorrect Answers: Evaluate the client's circulation every 8 hr after application. The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints. Remove the restraints every 4 hr to evaluate the client's status. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. Secure the restraint ties to the bed's side rails. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury. A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm. Extinguish the fire. Evacuate the client. Confine the fire. - ANSWERSCorrect Answer: Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. Incorrect Answers: Activate the emergency fire alarm. According to the RACE mnemonic, the second action in response to a fire is to activate the alarm. Extinguish the fire. According to the RACE mnemonic, the fourth action in response to a fire is to attempt to extinguish the fire. Confine the fire. According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire. A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? - ANSWERS107 mL/hr A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. - ANSWERSCorrect Answer: Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading. Incorrect Answers: Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. The nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for clients aged from 2 months to 7 years old. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. When assessing an adult client's abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? "We can talk about advance directives, and I can also give you some brochures about them." "You should set up a time to talk with your provider about that." "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." "Why do you want to discuss this without your partner here to plan this with you?" - ANSWERSCorrect Answer: "We can talk about advance directives, and I can also give you some brochures about them." With this statement, the nurse offers to provide the information the client needs in a direct and simple way. Incorrect Answers: "You should set up a time to talk with your provider about that." The nurse is passing the responsibility of discussing this topic with the client to the provider, which dismisses the client's concerns. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." The nurse is rejecting the client's needs by postponing a discussion about what is important to the client. "Why do you want to discuss this without your partner here to plan this with you?" Clients might interpret "why" questions as accusatory, and they can provoke feelings of mistrust and resentment. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family - ANSWERSCorrect Answer: During the admission process Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. Incorrect Answers: As soon as the client's condition is stable Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability. During the initial team conference Team conferences facilitate discharge planning, but they are not essential for initiating the planning process. After consulting with the client's family The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management? "I think I should take my pain medication more often, since it is not controlling my pain." "Breathing faster will help me keep my mind off of the pain." "It might help me to listen to music while I'm lying in bed." "I don't want to walk today because I have some pain." - ANSWERSCorrect Answer: "It might help me to listen to music while I'm lying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain. Incorrect Answers: "I think I should take my pain medication more often, since it is not controlling my pain." As a 2 on a scale of 0 to 10, this client's pain is mild. Additional analgesic medication is unnecessary at this time. "Breathing faster will help me keep my mind off of the pain." Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain. "I don't want to walk today because I have some pain." Postoperative clients need to ambulate even if they are having mild pain. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distention Urine specific gravity 0.99 (1.01 to 1.025) Rapid heart rate Blood pressure 144/82 mm Hg - ANSWERSCorrect Answer: Rapid heart rate Tachycardia is manifestation of fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Incorrect Answers: Neck vein distention Neck vein distension is a clinical manifestation of fluid volume excess. Urine specific gravity 0.99 (1.01 to 1.025) The urine specific gravity is expected to be greater than 1.025 for a client who has a potential fluid volume deficit. A decrease urine specific gravity may indicate overhydration or excess of fluid volume. Blood pressure 144/82 mm Hg Hypotension is an expected finding for a client who has fluid volume deficit. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Rinse the feeding bag with water between feedings. Tell the client to keep the head of the bed elevated at least 30°. Make sure the enteral formula is at room temperature. Wipe the top of the formula can with alcohol. - ANSWERSCorrect Answer: Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. Incorrect Answers: Rinse the feeding bag with water between feedings. The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority. Make sure the enteral formula is at room temperature. The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority. Wipe the top of the formula can with alcohol. The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro-organisms that could contaminate the formula; however, there is another action that is the priority. A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? Limit the adolescent's visitors. Select the food choices for the adolescent. Allow the adolescent to make decisions regarding their daily routine. Encourage the adolescent's guardian to assist with personal hygiene. - ANSWERSCorrect Answer: Allow the adolescent to make decisions regarding their daily routine. [Show Less]
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A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record w... [Show More] hich of the following client statements? "I am having mild pain" "The pain is like a dull ache in my stomach" "I notice that the pain gets worse after I eat" "The pain makes me feel nauseous" - ANSWERS"The pain is like a dull ache in my stomach" A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm Extinguish the fire Evacuate the client Confine the fire - ANSWERSEvacuate the client A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distention Urine specific gravity 1.010 Rapid Heart rate Blood pressure 144/82 mmHg - ANSWERSRapid heart rate A nurse has accepted a verbal prescription for "thee tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? .3 mg 0.3 mg 0.30 mg 3/10 mg - ANSWERS0.3 mg A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 ml to infuse at 800 units/hour. At what rate should the nurse set the infusion pump? - ANSWERS8 ml/hour A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5 C (105 F) Cleanse the wound from the center outward Use a 20 ml syringe to irrigate the wound - ANSWERSCleanse the wound from the center outward A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? Purulent exudate Warmth Skin blanching Bleeding - ANSWERSSkin blanching A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "When descending the stairs, I will first shift my weight to my right leg" "I should place my crutches 12 inches in front and to the side of each foot" "As I sit down, I will hold one crutch in each hand" "I will make sure the shoulder rests are snug against my armpits" - ANSWERS"When descending the stairs, I will first shift my weight to my right leg" A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Rinse the feeding back with water between feedings Tell the client to keep the head of the bed elevated at least 30 degrees Make sure the enteral formula is at room temperature Wipe the top of the formula can with alcohol - ANSWERSTell the client to keep the head of the bed elevated at least 30 degrees A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse verify with the provider? Medication name Route of administration Medication dose Frequency of administration - ANSWERSMedication dose A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume" "I shouldn't have trouble keeping the hearing aid in place during exercise" "I expect to hear a whistling sound when I first insert the hearing aid" "I will be sure to remove my hearing aid before taking a shower" - ANSWERS"I will be sure to remove my hearing aid before taking a shower" A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? "Incident report completed" "Client climbed over the side rails" "Client found lying on the floor" "Client was trying to get out of bed" - ANSWERS"Client found lying on the floor" A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Seal unused medications from the facility in a plastic bag Evaluate the client's ability to self administer medications Report an identified discrepancy to The Joint Commission Compare prescriptions with medications the client received while at the facility - ANSWERSCompare prescriptions with medications the client received while at the facility A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? Describe the procedure to the client Witness the client's signature on the consent form Inform the client of alternatives to the procedure Tell the client which team members will assist with the procedure - ANSWERSWitness the client's signature on the consent form A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? "You should have an eye examination every 2 years" "You should receive a tetanus booster every 5 years" "You should receive a shingles vaccine when you are 70 years old" "You should receive a pneumococcal vaccine when you are 65 years old" - ANSWERS"You should receive a pneumococcal vaccine when you are 65 years old" A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Ask the client to consider a direct donation Withhold the blood transfusion Request a consultation with the ethics committee Ask the client's family to intervene - ANSWERSWithhold the blood transfusion A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? droplet airborne contact protective environment - ANSWERSdroplet A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? Auscultate lung sounds Measure urine output Monitor blood pressure readings Monitor electrolyte levels - ANSWERSMeasure urine output A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? "Most people are happy when their children grow up and leave home" "You should be proud that your children are becoming independent" "Maybe you should consider why you are feeling useless" "People in middle adulthood often find satisfaction in nurturing and guiding young people" - ANSWERS"People in middle adulthood often find satisfaction in nurturing and guiding young people" A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (select all that apply) Check the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove Consider purchasing a generator for power backup Observe for signs of hypoxia Select synthetic clothing and bedding - ANSWERSCheck the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove Observe for signs of hypoxia A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? Use a resuscitation bag with 80% oxygen prior to the procedure Select a suction catheter that is half the size of the lumen Place the end of the suction catheter in water soluble lubricant Adjust the wall suction apparatus to a pressure of 170 mmHg - ANSWERSSelect a suction catheter that is half the size of the lumen A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. Which of the following actions should the nurse take? Instruct the family to refrain from pushing the button for the client while she is asleep Inform the client that because she is on PCA, vital signs will be taken every 8 hours Teach the client to avoid pushing the button until the pain is above 7 on a scale of 0 to 10 Increase the basal rate and shorten the lock out interval time if the client's pain level is too high - ANSWERSInstruct the family to refrain from pushing the button for the client while she is asleep A nurse is admitting a client who has been having frequent tonic clonic seizures. Which of the following actions should the nurse add to the client's plan of care? Wrap blankets around all 4 sides of the bed Apply restraints during seizure activity Place the client in a supine position during seizure activity Have a tongue depressor at the client's bedside - ANSWERSWrap blankets around all 4 sides of the bed A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manage intervene due to a violation of HIPPAA guidelines? A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse A nurse asks a nurse from another unit to assist with documentation for a client A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care A nurse discusses a client's status with the physical therapist who is caring for the client - ANSWERSA nurse asks a nurse from another unit to assist with documentation for a client A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficle infection. Which of the following information should the nurse include in the teaching? Assign the client to a room with a negative airflow system Use alcohol based hand sanitizer when leaving the client's room Clean contaminated surfaces in the client's room with a phenol solution Have family members wear a gown and gloves when visiting - ANSWERSHave family members wear a gown and gloves when visiting A nurse is preparing to administer 0.5 ml of oral single dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration Transfer the medication to a medicine cup Place the client in a semi fowler's position prior to medication administration Verify the dosage by measuring the liquid before administering it - ANSWERSGently shake the container of medication prior to administration A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high fowler's position Increase the client's intake of carbohydrates Massage reddened areas with unscented lotion Have the client use a trapeze bar when changing position - ANSWERSHave the client use a trapeze bar when changing position A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate? Ambulating a client who is postoperative Inserting an indwelling urinary catheter for a client Demonstrating the use of an incentive spirometer to a client Confirming that a client's pain has decreased after receiving an analgesic - ANSWERSAmbulating a client who is postoperative A nurse is an acute care facility preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include? Client flow sheet Acuity ratings Current medications Incident reports - ANSWERSCurrent medications A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" "I blame medical science for not curing me" "Where is my daughter at a time like this?" "Will I ever begin to fell in charge of my life again?" - ANSWERS"What could [Show Less]
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