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ATI Fundamentals Practice A
Terms in this set (59)
A nurse is evaluating a client's use of a cane. What action should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of her body.
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 hr. What action 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. What action 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.
Rationale: this will close the epiglottis over the trachea and prevent the tube from passing into the trachea.
A nurse is reviewing a client's fluid and electrolyte status. What findings should the nurse report to the provider?
Potassium 5.4 mEq/L
Rationale: This value is above the expected reference range of 3.5 to 5 mEq/L. This client is at risk for dysrhythmias.
What is the reference range for sodium?
136 to 145 mEq/L
What is the reference range for creatinine?
Women: 0.5 to 1.1 mg/dL
Men: 0.6 to 1.3 mg/dL
What is the reference range for BUN?
10 to 20 mg/dL
A nurse is providing discharge instructions to a client who will be using a walker. What client statement indicates an understanding of the teaching?
"I will hire someone to trim the tree that hangs low over the stairs of my front porch"
Rationale: Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. What tasks should the nurse assign to an AP?
- Assist the client with a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive med.
- Use a communication board to ask what the client wants for lunch.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. What action should the nurse take?
Reassure the client that this is an expected response to grief.
Rationale: During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. What type of dressing should the nurse use?
Rationale: Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.
A nurse is administering an otic medication to an older adult client. What action should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the trigs of the client's ear.
Rationale: Pressing gently on the tragus of the ear will help the medication get into the inner ear.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. What action should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
Rationale: The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. What 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.
Rationale: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.
A nurse is planning strategies to manage time effectively for client care. What strategies should the nurse implement?
Use the planning step of the nursing process to prioritize client care delivery.
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