A and B ATI - A_and_B_ATI PDF

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A_and_B_ATI...

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A nurse is planning to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? Use a clock pattern to describe food on the client's plate. Describing the location of food using clock pattern allows client to have greater independence during meals. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? Allow extra time for the client to respond to questions. Older adults often process information at slower rate than younger clients - allow extra time to allow client to ask questions and absorb information A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select ALL that apply. Place the client in a room with negative-pressure airflow - airborne precautions Wear gloves when assisting the client with oral care - standard precautions. Use antimicrobial sanitizer for hand hygiene - wash hands with soap & water when visibly soiled. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 10 units of air into the bottle of NPH insulin. Inject 5 units of air into the bottle of regular insulin. Withdraw the correct dose of regular insulin from the bottle. Withdraw the correct dose of NPH insulin from the bottle. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? Rapid heart rate Tachycardia indicates fluid-volume deficit - expected Urine specific gravity would be > 1.030 Hypotension A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? Auscultate lung sounds. ABCs - monitor for fluid-volume excess Moist crackles in lungs, dyspnea, SOB

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? "I can concentrate best in the morning." verbalizing best time for him to learn. 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? Contact precautions Major wound infections require contact precautions - admit client to private room. Caregivers should wear gown & gloves during direct contact. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? Initiate an enteral feeding through a gastrostomy tube. Initiate feedings through nasoenteric, gastrostomy, and jejunostomy tubes. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Cleanse the wound from the center outward. Prevent introduction of micro-organisms from the outer skin surface. 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 report which of the following client statements? "The pain is like a dull ache in my stomach." Describing quality of pain A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? Use progressive relaxation techniques at bedtime. promotes sleep by decreasing stress & reducing muscle tension. A nurse is caring for a client who is postoperative and 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. 1st - Assess A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water. Flush with 15-30 mL of sterile water before administration and between each medication. Flush feeding tube with 30-60 mL of sterile water following administration of last medication. 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?" Review life & question its meaning. 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 performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? Have the client stand with her arms at her side and her feet together. Roberg's test helps identify alterations in balance. Observe for swaying & loss of balance. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly. Weight-bearing exercises are essential for maintaining bone mass. Walking engages older adult clients in preventive & therapeutic strategy. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring family members wear gowns & gloves to prevent transmission of C. diff spores. A nurse is talking with a 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? Role overload. Refers to having more responsibilities within a role than one person can perform. 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 can on the stronger side of her body. Should be parallel to client's greater trochanter. Advance cane 15-30 cm - 6-12 inches - at a time. Move weaker leg forward with cane to divide body weight between cane & stronger leg. 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? Withhold the blood transfusion. Principle of autonomy = right to refuse treatment 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 caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? Skin blanching. Skin blanching, edema, & coolness at IV site indicate infiltration. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A client who has an IV infusion pump receives an additional 250 mL of IV fluid. IV pump malfunction - assist in compiling information for risk management to prevent further similar incidents. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A nurse asks a nurse from another unit to assist with her documentation. Only HC professionals directly caring for client may access the client's medical information 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. Taking sips as NG tube passes oropharynx will close epiglottis over trachea & prevent tube's passage into trachea. A nurse is preparing a heparin infusion for a client who has hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of

0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? 8 mL/hr 250mL 800 units -------- X ----------- = 8 mL/hr 25,000 units 1 hr 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. Calculate fluid used for irrigation & subtract it from client's total urinary output. A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? Select ALL that apply. Pupil clarity - cataracts create halos around lights = cannot see items in path clearly Visual fields - might not see objects outside central vision & trip over them or bump into them & fall Visual acuity - might not see objects in path & trip over them or bump into them & fall NOTE: Lacrimal apparatus = impaired ability to produce tears Bulbar conjuctivae = infection in eye; does not impair vision A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? Narrowed arterial lumen. Arterial bruits - blowing sound from blood flowing thru occluded or narrowed arteries. 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? Tell the client to keep the head of the bed elevated at least 30 degrees. ABCs - prevent aspiration of enteral formula; prevent reflux of formula backward into esophagus A nurse has accepted a verbal prescription for three 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 medication record? 0.3 mg zero precedes decimal. No zero after decimal point unless whole number follows zero.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? Situation, background, assessment, and recommendation (SBAR) A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? Ask the client if he can bear weight. - Assess 1st Position the chair on the left side of the bed. - stronger side Have the client sit and dangle his feet at the bedside. - prevent dizziness. Use the stand-and-pivot technique to move the client to the chair. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? "Are you able to help with your hygiene care?" Risk of injury due to overestimation of client's ability to help with hygiene care. 1st Assess 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? Stand close to the cabinet when lifting it. Close to center of gravity & decreases back strain from horizontal reaching. A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? Fried Egg Not part of mechanical soft diet. Poached or scrambled eggs are acceptable replacement. 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. Anger stage of psychosocial adaptation to illness. Support client & ensure him that this is expected reaction to cancer diagnosis. A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this." Coping strategy - talking with others in family & supporting each other. Family using social supports to assist them throughout grief process. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Use the complete name of the medication magnesium sulfate." Write complete medication name when documenting medications to avoid any misinterpretation for morphine sulfate. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? Acupuncture Contraindicated for any skin infection to prevent open portal on skin's surface = increase risk for further infection A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? Airborne Varicella spreads via droplet nuclei smaller than 5 microns in diameter. Also droplet = tuberculosis & measles A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? "I'll check the wires and cables on my TV to make sure they are in good working order." Oxygen is highly flammable gas. Electrical equipment in room with oxygen needs to be functioning properly so it does not create electrical sparks. 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. Ensure medication is mixed. Medication is pre-packaged into "single-dose" - do NOT transfer Client should be in high-Fowler's position A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries. Assess first

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? Erythema on pressure points Requires prompt relief of pressure & additional measures to protect skin from further breakdown. 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? Have the client use a trapeze bar when changing position. Assist in repositioning & transferring - avoids friction & shearing that result from sliding up & down in bed. A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? Remove the stockings at least once per shift. Check circulation & skin integrity. A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Wrap monitoring cords with stockinette and tape then in place. Monitoring devices & cords contain latex. Prevent contact with cords & devices with client's skin by covering them with nonlatex barrier material - like stockinette, & using nonlatex tape to secure them. 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? Select a suction catheter that is half the size of the lumen. Prevent hypoxemia & trauma to mucosa. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? "They indicate the form of treatment a client is willing to accept in the event of a serious illness." Client directs treatment in event of terminal illness. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. One option is a fecal occult blood test annually. A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? Semi-Fowler's or high-Fowler's allows for maximum expansion of the lungs. 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 client's arm in a dependent position. Veins will dilate due to gravity. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? Assist the client to an upright position. Use the least invasive intervention. Facilitate maximal chest expansion - improves gas exchange & prevents pressure on diaphragm from abdominal organs. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? The dose Dose is not complete, number 0.25 should be followed by unit of measure to clarify amount. A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? Calf swelling Swelling, redness, & tenderness in calf muscle are manifestations of thrombophlebitis. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I flushed what I urinated at 7:00 am and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. 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. Second nurse must witness disposal of any portion of a dose of a controlled substance. 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. Which of the following actions should the nurse take first? Check the IV tubing for obstruction. 1st - Assess Check tubing for obstruction - might be able to facilitate flow of fluid through tubing. - could re-establish infusion rate 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?" Ask whether pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps d...