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Nursing Fundamentals ATI Practice A
Terms in this set (57)
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of the body
Proceeding with Ambulation:
1. the patient stands with weight evenly distributed between the feet and the cane
2. The cane is held on the patients stronger side and is advanced 4-12in (10-30cm)
3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane
4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane
5. The weaker leg is moved forward until even with the stronger leg along with advancement of the cane
pg 1078 (Taylor)
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
Check the IV tubing for obstruction.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the esophagus
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 meq/L
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
"I will hire someone to trim the tree that hangs low over the stairs of my front porch"
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to the UAP? Select all that apply
-Assist the client with a partial bed bath
-Measure the client's BP after the nurse administers an antihypertensive medication
-Use a communication board to ask what the client wants for lunch
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response to grief.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which type of dressing should the nurse use?
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the tragus of the client's ear.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Make sure the client wears a mask when outside her room if there is construction in the area.
A nurse is auscultating the anterior chest of a client who was newly admitted to a medical surgical unit. liste to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds
Normal breath sounds
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
use the planning step of the nursing process to prioritize client care delivery
A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
Make sure two fingers can fit under the sleeves.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
"Is your pain sharp or dull?"
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
administer the medication into the abdomenthe client should pinch or spread the skin at the injection site, at least 2 in from the umbilicus, and administer the medication into the subcutaneous tissue
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
Obtain the pronouncement of death from the provider .
Remove tubes and indwelling lines .
Wash the client's body .
Ask the client's family members if they would like to view the body .
Place a name tag on the body
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Use tracheostomy covers when outdoors
A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the needle at a 45 degree angle.
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
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
use a bed exit alarm system
A nurse is assessing an older adult clients risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs? Select all that apply
A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complimentary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which therapy?
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?
"We will apply oxygen through a tube in your nose."
A nurse is performing a skin assessment of a client who expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
A mole with assymetrical appearance
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Regulate oxygen via nasal cannula at a flow rate no more than 6l/min
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
the client uses nonacetone nail polish remover
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?
I am relying on support from our family during this time"
nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?
Let's talk about how the change in your hob status will affect you.
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has tuberculosis in a room with negative-pressure airflow.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
compare the clients home medications with the providers prescriptions
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
d. Stand close to the cabinet when lifting it.
A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
Notify the nursing manager
A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care?
Situation, Background, Assessment, and Recommendation (SBAR)
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
place the clients arm in a dependent position because the veins will dilate due to gravity
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
Nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?
Use the complete name of the medication magnesium sulfate.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which action should the nurse take first?
check the client for injuries
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints.
A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
The family member washed out the feeding bag with warm water once every 24 hours.
A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?
Administer pain medication 45 min before changing the client's dressing
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement?
wear a gown when caring for the client
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 the nurse identify as an indication that the treatment was successful?
decrease in heart rate
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
ask another nurse to observe the medication wastage
A client has a sodium level of 125 mEq/L. Which finding should the nurse expect?
Nurse is preparing an education program for staff about advocacy. What information should the nurse include?
Advocacy ensures clients' safety, health, and rights.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
"I am available to talk if you should change your mind."
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
a. "I can concentrate best in the morning."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate response by the nurse?
"It indicates the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
b) ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
"It might help me to listen to music while I'm lying in bed."
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