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ATI Theory Questions Exam 3
Terms in this set (60)
A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make?
A. It takes time to get over the loss of a loved one
B. You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling.
C. Why don't you try something to take your mind off your troubles, like watching a funny movie
D. I might not share your exact situation, but I do know what people go through when they deal with loss
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vitals and notes an elevation in BP and <3 rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS).
A. Exhaustion stage
B. Resistance stage
C. Alarm reaction
D. Recovery reaction
A nurse is caring for a client who has left-side hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem?
A. Role conflict
B. Role overload
C. Role ambiguity
D. Role strain
B, C, E
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply)
A. Suggest coping skills for the client to use in this situation
B. Allow the client to provide input in the treatment plan
C. Assist the client with time management, and address the client's priorities
D. Provide extensive instructions on the client's treatment regimen
E. Encourage the client in the expression of feelings and concerns.
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?
A. Prescribing taks unilaterally
B. Delegating care to one member
C. Speaking to the primary client privately
D. Convening a family meeting
B, D, E
A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply)
A. Talk to the interpreter about the family while family is in room
B. Ask family one question at a time
C. Look at interpreter when asking the family questions
D. Use lay terms if possible
E. Do not interrupt the interpreter and the family as they talk
A nurse is caring for a patient who shares the nurse's religious background. Which of the following information should the nurse anticipate?
A. Members of the same religion share similar feelings about their religion
B. A shared religious background generates mutual regard for one another
C. The same religious beliefs can influence individuals differently
D. The nurse and client should discuss differences and commonalities in their beliefs
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take?
A. Contact the hospital's spiritual services
B. Ask him what is making him cry
C. Provide quiet times for these moments
D. Turn on the television for a distraction
A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements made by the nurse indicates culturally appropriate care to the client?
A. I will make sure the menu includes kosher options
B. I will discuss the daily schedule with the client to make sure the client will have time for prayer
C. I will make sure to use direct eye contact when speaking with this client
D. I will make sure daily communion is available for this client
A nurse is caring for a client who is a Jehovah's witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that the blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make?
A. I believe in this case you should really make an exception and accept the blood transfusion
B. I know your family would approve of your decision to have a blood transfusion
C. Why does your religion mandate that you cannot receive any blood transfusions
D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADL's. Which of the following rationales for self- care should the nurse communicate to the family?
A. Allowing the client to function independently will strengthen her muscles and promote healing
B. The client needs to be given privacy at times for self- reflecting and organizing her life.
C. The client's sense of loss can be lessened through retaining control of certain areas of her life
D. Performing ADLs is required prior to discharge from an acute care facility
A nurse is caring for a client who has Stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kubler- Ross' model, which stage of grief is the client experiencing?
A, D, E
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief, and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply)
A. Would you like me to contact the chaplain to come speak with you?
B. You will feel better soon. You have been expecting this for a while now.
C. Let's talk about your children and how they are going to react.
D. You know, it is quite normal to feel anger toward your husband at this time
E. Tell me more about how you are feeling
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion?
A. Regular breathing patterns
B. Warm extremities
C. Increased urine output
D. Decreased muscle tone
C, D, E
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements made by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply)
A. I will remove the dentures from the body
B. I will make sure the body is lying completely flat
C. I will apply fresh linens and place a clean gown on the body
D. I will remove all equipment from the bedside
E. I will dim the lights in the room
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine?
A. presence of associated manifestations
B. location of the pain
C. pain quality
D. Aggravating and relieving factors
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain?
A. Ask the client what precipitates the pain
B. Question the client about location of the pain
C. Offer the client a pain scale to measure his pain
D. Use open-ended questions to identify the client's pain sensations.
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?
A. client who has a broken femur and reports hip pain
B. client who has incisional pain 72 hours following pacemaker insertion
C. client who has food poisoning and reports abdominal cramping
D. client who has episodic back pain following a fall 2 years ago
C, D, E
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of medication. Which of the following effects should the nurse anticipate? (Select all that apply)
A. urinary incontinence
D. orthostatic hypotension
A nurse is caring for a patient who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
A. I will wait to use this device until it's absolutely necessary
B. I'll be careful about pushing the button too much so I don't get an overdose
C. I should tell the nurse if the pain doesn't stop while I am using this device
D. I will ask my adult child to push the dose button when I am sleeping
A nurse is caring for a patient scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take?
A. offer information on a relaxation technique and ask the client f he is interested in trying it
B. request a social worker to see the client and discuss medication
C. attempt to use biofeedback techniques with the client
D. tell the client many people feel the same way before surgery and to think of something else
A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients?
A, C, E
A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (Select all that apply)
A. Art therapy
D. Therapeutic touch
A, C, D
A nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (Select all that apply)
A. guided imagery
B. massage therapy
D. music therapy
E. therapeutic touch
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention?
A. tell the client the goal of the therapy is to promote healing
B. ask whether the client is comfortable with using prayer
C. encourage the client to participate actively for best results
D. Instruct the client to relax during therapy
B, D, E
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply)
A. increase volume of your voice
B. make sure only one person speaks at a time
C. avoid discouraging the client by saying that you don't understand him
D. allow plenty of time for the client to respond
E. use brief sentences with simple words
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement?
A. immediately complete a thorough assessment
B. put the client in a room with a client who has a hearing loss
C. provide a private room and limit stimulation
D. speak at a higher volume to the client, and encourage ambulation
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that applY)
A. weber test showing lateralization on the right ear
B. light reflex at 10 o'clock in the left ear
C. indications of obstruction in the left ear canal
D. rinne test showing less time for air and bone conduction
E. rinne test showing air conduction less than bone conduction in the left ear
A nurse is caring for a patient who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to further risk for ototoxicty? (select all that apply)
A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understand the instructions?
A. i use a damp cloth to clean the outside part of my hearing aids
B. i clean the ear molds of my hearing aids with rubbing alcohol
C. i keep the volume of my hearing aids turned up so i can hear better
D. i take the batteries out of my hearing aids when i take them off at night
A nurse on a medical surgical unit has received change- of- shift report and will care for 4 clients. which of the following client's needs should the nurse assign to an AP?
A. feeding a client who was admitted 24 hr ago with aspiration pneumonia
B. reinforcing teaching with a client who is learning to walk with a quad cane
C. reapplying a condom catheter for a client who has urinary incontinence
D. applying a sterile dressing to a pressure ulcer.
A nurse manger of a medical-surgical floor unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client?
A. charge nurse
C. Practical Nurse (PN)
D. Assistive personnel (AP)
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply)
A. the roommate ambulates independently
B. the client ambulates with his slippers over his antiembolic stockings
C. the client uses a front-wheeled walker when ambulating
D. the client had pain meds 30 mins ago
E. the client i s allergic to codeine
F. the client ate 50% of his breakfast this morning
An RN is making assignments for a practical nurse (PN) Which of the following assignments should the PN question?
A. assisting a client who is 24-hr postoperative to use a incentive spirometer
B. collecting a clean-catch specimen from a client who has a wound infection
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. teaching a client who has asthma to use metered- dose inhaler
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. (Select all that apply)
A. right client
B. right supervision and evaluation
C. right direction and communication
D. right time
E. right circumstances
A nurse is caring for a pt. who is 1 day post-op following a total knee arthroplasty. The pt. states his pain is a 10. After reviewing the clients medication administration record, which of the following medications should the nurse administer?
A. meperidine 75mg IM
B. fentanyl 50mcg/hr transdermal
C. morphine 2mg IV
D. oxycodone 10mg PO
A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A. I can open the capsule with the beads in it and sprinkle them on my oatmeal
B. If i am having difficulty swallowing, I will add the liquid medication to a batch of pudding.
C. I can crush the pills with the coating on them
D. I will eat 2 crackers with the pain pills
A nurse is preparing to inject heparin sub-cut for a client who is post-op. Which of the following actions should the nurse take?
A. use a 22-gauge needle
B. select a site on the clients abdomen
C. spread the skin with the thumb and index finger
D. observe for bleb formation to confirm proper placement
A nurse is teaching a client to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include?
A. flush tube before and after each medication
B.mix medications with your enteral feeding
C. push tablets through the tube slowly
D. mix all the crushed medications prior to dissolving in water
A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands proper techniques?
A. i will straighten my ear canal by pulling my ear down and back
B. i will gently apply pressure with my finger to the front part of my ear after putting in the drops
C.i will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in
D. after the drops are in, I will place a cotton ball all the way into my ear canal
A nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the groups understands how to implement medication therapy? (Select all that apply)
A. i will observe for side effects
B. i will monitor for therapeutic effects
C. i will prescribe the appropriate dose
D. i will change the dose if adverse effects occur
E. i will refuse to give a medication if i believe it is unsafe
A nurse is preparing to administer digoxin to a client who states, "I do not want to take that medication. I do not want one more pill." Which of the following responses should the nurse make?
A. your physician prescribed it for you, so you really should take it
B. Well, let's just get it over quickly then
C. Okay, i will just give you other medications
D. tell me your concerns about taking this medication
A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indiction that the newly hired nurse understands medication error prevention?
A. taking all medications out of the unit-dose wrappers before entering the clients room
B. checking with the provider when single dose requires administration of multiple tablets
C. Administering a medication, then looking up the usual dosage range
D. relying on another nurse to clarify a medication prescription
A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? (Select all that apply)
A nurse prepares an injection of morphine to administer to a client in pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take?
A. offer to assist the client who needs the bedpan
B. administer injection the other nurse prepared
C. prepare another syringe and administer the injection
D. tell the client who needs the bedpan she will have to wait for her nurse.
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 ml/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply)
A.i feel lightheaded
B. i feel as though my heart is racing
C. i feel a little short of breath
D. the nurse technician told me my BP was 150/90
E. i think my ankles are less swollen
A, D, E
A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply)
A. the temp. around the IV site is cooler
B. the rate of the infusion increases
C. the skin at IV site is red
D. The IV dressing is damp
E. the tissue around the venipuncture site is swollen
During a new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of preventive strategies?
A. i will leave the IV catheter in place after the client completes the course of IV antibiotics
B. as long as i am working with the same client, i can use the same IV catheter for my second insertion attempt.
C. if my client needs to use the restroom, it would be safer to disconnect his IV infusion as long as i clean the injection port thoroughly with an antiseptic swab
D. i will replace any IV catheter when suspect contamination during insertion
A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and not feeling well. The nurse notes warmth, edema, induration, and red streaking on client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?
A. obtain a specimen for culture
B. apply warm compresses
C. administer analgesics
D. discontinue the infusion
A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure.?
A. i will thread the needle all the way into the vein until the hub rests against the insertion site after i see a flashback of blood
B. i will insert the needle into the clients skin at an angle of 10 to 30 degrees with the bevel up
C. i will apply pressure approx. 1.2 inches below the insertion site prior to removing the needle
D. I will choose a vein in the antecubital fossa for IV insertion due to size and easily accessible location
A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make?
A. you will need to get a rubella immunization if you haven't had one prior to pregnancy
B. you can safely take over-the-counter medications
C. you should avoid any vitamin preparations containing iron
D. your provider can prescribe medication for nausea if you need it
A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommended to minimize in the entry of medication into breast milk?
A. drink 8 oz milk with each dose of medication
B. use medications that have an extended half-life
C. take each dose right after breastfeeding
D. pump breast milk and freeze it prior to feeding to the newborn
To promote adherence with medication self-administration, a nurse is making recommendations for an older client. Which of the following instructions should the nurse include? (Select all that apply)
A. adjust dosages according to daily weight
B. place pills in daily pill holders
C. ask for liquid forms if the client has difficulty swallowing pills
D. ask a relative to assist periodically
E. request child-resistant caps on medication containers
A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply)
A. increased gastric acid production
B. lower BP
C. higher body water content
D. increased absorption of topical medications
E. increased gastric emptying time
A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications foe various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity?
A. increasing the metabolism of the medications over time
B. increasing the protein-binding response
C. increasing medications' transit time through the intestines
D. decreasing the excretion of medications
A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs) (Select all that applY)
A. orthostatic hypotension
C. acute dystonia
D. decreased level of consciousness
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? (select all that apply)
A.get up and change positions slowly
B. avoid eating aged cheese and smoked meat
C. report any usual bruising or bleeding to doctor immediately
D. eat the same amount of foods that contain vitamin K everyday
A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply)
A. take sips of water frequently
B. wear sunglasses when outdoors
C. use a soft toothbrush when brushing teeth
D. take the medication with an antacid
E. urinate prior to taking the medication
A nurse is an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurses priority?
A. teaching the client about the purpose of the medication
B. documenting clients anxiety level
C. identifying the client's medication allergies
A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects?
A. decreased therapeutic effects of cimetidine
B. increased risk of imipramine toxicity
C. decreased risk of adverse effects of cimetidine
D. increased therapeutic effects of imipramine
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