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ATI Practice A&B Study Guide part 2 A nurse is reinforcing teaching with a client about prevention of stress injuries. Which of the following instructions should the nurse include? - "When lifting a heavy object, keep it close to your body." A nurse is caring for a client who is alert and in a long term care facility. Which of the following actions should the nurse take to protect the client's privacy? - Ask the client before discussing his condition when his family is present. A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? - Administer an analgesic 30 min before starting procedure A client who had a recent below the knee amputation says,"I don't know how i can continue to live my life without my leg." Which of the following responses should the nurse make? - "Tell me what concerns you have about your future." A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? - Donning a mask to measure the vital signs of a client who has pertussis A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? - Shred the paper in a secure container A nurse reinforcing teaching with am older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep? - Sleep patterns change with age A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? - Young adults should receive a dental assessment every 6 months A nurse is caring for a client who has a prescription for potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? - Beneficence (acting in the pts best interest) A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? - The client report urinary incontinence
A nurse in long term care facility is contributing to the plan of care for a client who is at risk for a pressure ulcer. Which of the following recommendations should the nurse include in the plan of care? - Perform a thorough skin inspection each day A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching? - a headache is a manifestation of carbon monoxide poisoning A nurse is assisting with a plan of care for a client who has a bacterial infection and is a persistent oral temperature of 38.9C (102F). Which of the following interventions should the nurse include in the plan of care to treat the fever? - Administer Acetaminophen A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age related changes? - Circulation becomes less efficient with age A nurse is caring for a client who has an NG tube and is receiving a continuous enternal feeding. Which of the following actions should the nurse take? - Hold the feeding for two consecutive gastric residuals greater than 250 ml A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? - Positive Chvostek's sign
- tap the clients facial nerve near the ear,If the clients facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels * A nurse is providing wound care for a group of clients. Which of the following should the nurse identify is healing by secondary intention? - A stage 3 pressure ulcer on the coccyx A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? - Attend an exercise class A nurse is assisting w/ the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client w/ communication? - Ask the client close ended questions A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection? - Drain urine from the tubing before ambulation
A nurse is reinforcing teaching w/ an older adult about oral hygiene. Which of the following instructions should the nurse in the teaching? - replace her toothbrush following illness A nurse is moving a client up in bed w/ the assistance of a second nurse. Which of the following actions should the nurse take? - Place feet apart w/ the foot nearest the head of the clients bed in front of the other foot A nurse is contributing to the plan of care for client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? - Compare the clients pedal pulses bilaterally every every 4 hr A nurse is palpating the pulse located on the top of the pts foot. Which of the following pulses should the nurse document that she is palpitating? - Dorsalis pedis A nurse is reinforcing teaching w/ a pt who is receiving PCA. Which of the following statements by the pt indicates an understanding of the teaching? - " I will not allow anyone to press the PCA button for me" A nurse is preparing to admin an eternal feeding to a client who has an NG tube place. Which of the following methods should the nurse use to verify correct placement of NG tube? - Check the pH of the gastric aspirate A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? - - Evacuate clients from the area
- Pull the lever on the fire alarm box
- Close the fire doors on the unit
- Use the fire extinguisher to put out the fire A nurse is reinforcing teaching about the use of crutches w/ a pt who has a fractured right tibia & fibula. Which of the following statements by the pt indicates an understanding of the teaching? - " I will be sure to keep the crutch tips dry. " A nurse is contributing to the plan of care for a pt who has a positive throat culture for steptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? - Ensure that the pt wears a surgical mask during transportation throughout the facility A charge nurse is reinforcing teaching w/ an assistive personnel (AP) about performing pulse ox. Which of the following info should the nurse include in the teaching - remove polish from the clients fingernail before applying the oximentry probe
A nurse is reinforcing teaching w/ a pt about using guided imagery. Which of the following actions should the nurse take? - Direct the client to visualize tension leaving the body. A pt who has advanced cancer tells the nurse that he has a difficult time talking to anyone about illness. Which of the following actions should the nurse take to encourage therapeutic communication? - Let the pt know that he/she is available and willing to listen A nurse is reinforcing teaching about hospice care measures with the fam of a pt who is dying. Which of the following statements by a member of the clients family indicates an understanding of the teaching? - We will keep her room cool to help her breathe better A nurse is caring for a client who has metastatic cancer & practices Catholicism. The client asks the nurse to discuss the afterlife w/ her. Which of the following statements by the nurse assists in the meeting the clients spiritual needs? - " Tell me what the afterlife means to you." A nurse is speaking w/ a pt who has type 2 diabetes mellitus & a prescription for insulin. The pt verbalizes anger about having to take insulin. Which of the following responses should the nurse make? - "I see that you are angry. Lets sit down and talk." A nurse is caring for a Pt who is refusing medical treatment. Which of the following actions should the nurse take? - Document the clients refusal of the treatment A nurse is assisting w/ the admin of a pt who has active TB. Which of the following actions should the nurse plan to take? - Assign the pt to a negative pressure airflow room A nurse is caring for a female pt who has a urinary incontinence. Which of the following actions should the nurse take? - Apply moisture skin barrier to the Pts perineal area A nurse is caring for a Pt who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? - "When i look at myself in the mirror , I dont know if i can go on." A nurse caring for a Pt with CDIFF. Which of the following solutions should the nurse use to perform hand hygiene while caring for this Pt? - Mild Soap A nurse is explaining ethics & values to a newly licensed nurse. The nurse should explain that allowing a Pt to make a decision about treatment is an example of which of the following ethical principles? - Autonomy A nurse is reinforcing pre-op teaching w/ a pt who does not speak the same language as the nurse. Which of the following actions should the nurse take? - Provide handouts written in the clients primary language
A nurse is collecting data from a pt who is 2 days post op following a colostomy. Which of the following findings should the nurse report to the provider? - A purple colored stoma A nurse is reinforcing teaching with a pt who has insomnia. Which of the following statements by the pt indicates an understanding of the teaching? - " I should turn on the ceiling fan to block out unwanted noise." A nurse working in a community clinic is talking w/ an older adult pt who states that his life has no purpose. The nurse should ID that the Pt is in which of the following stages of Eriksons Theory of Psychosocial Development? - Ego Integrity vs. Despair A nurse is preparing to remove staples from the pts incision. Which of the following actions should the nurse take? - remove the staple from the skin after both sides are visible A nurse is caring for a pt who has been vomiting excessively & has diarrhea. Which of the following find should the nurse ID as an indication of fluid volume deficit? - Urine specific gravity 1. A nurse is providing oral hygiene for a pt who is unconscious. ID the sequence of the steps the nurse should take. - 1. Assess the Pts gag reflex
- position the pt on his side w/ his head turned to the side
- Place a towel under the Pts head w/ an emesis basin under his chin
- Separate the upper and lower teeth w/ an oral airway device
- Cleanse the Pts mouth using a toothbrush A nurse is caring for a pt who post op following a mastectomy. The Pt states, " I can barely look at myself in the mirror." The nurse should ID that the Pt is experiencing which of the following?
- Actual loss A nurse is caring for an older pt who has advanced rheumatoid arthritis but seldom requests pain meds. Which of the following actions should the nurse take? - Obsv. the Pt for nonverbal indications of pain A nurse is reinforcing teaching w/ a pt who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? - "I will place a gel pad directly above your pubic area before I place the probe." A nurse is caring for a pt who is scheduled for surgery the following day. During the night, the pt is unable to sleep & is restless. Which of the following statements should the nurse make? - "It must be difficult facing this type of surgery."
A nurse is contributing to the plan of care for a Pt who is dying. which of the following interventions should the nurse recommend the Pts family's in the plan of care? ( select all that apply ) - - Keep the family updated about the Pts status
- Encourage the family to comb the Pts hair
- Tell the Pts family what to expect as the Pts death nears A nurse is caring for four Pts. For which of the following Pts should the nurse use the therapeutic communication technique of silence? - A Pt who has just experience a death of a child A nurse is caring for an older Pt & is concerned that the Pt may have a fecal impaction. Which of the following is the most important question for the nurse to ask? - "Have you had had small liquid stools?" A nurse in a long term care facility is collecting admission data from a Pt who uses hearing aid. Which of the following actions should the nurse take? - Choose a private room for the interview A nurse is checking a Pts muscle strength. Which of the following techniques should the nurse use? - The Pt shrugs her shoulders while the nurse applies firm pressure over the mid-line of the shoulders A nurse is checking a Pt for a pulse deficit after detecting an irregular HR. Which of the following actions should the nurse take? - Count the pts radial & apical pulse simultaneously w/ another nurse A nurse caring for a Pt who has dyspnea caused by a respiratory infection. The nurse should assist the Pt into which of the following positions? - Orhtopneic A nurse is assisting w/ the care of a Pt who has a prescription for IV therapy. The Pt tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? - Seafood A nurse is caring for a Pt who has limited mobility. Which of the following actions should the nurse take to maintain the Pts skin integrity? - Use warm water when bathing the Pt A nurse is caring for a Pt who has chronic pain. The nurse recommend s that the Pt concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? - Guided Imagery A nurse is caring for a Pt who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take? - measure the Pts gastric before each feeding
B. Calculate the client's pulse for 30 seconds and multiply by 2. C. Assist the client to a side-lying position. D. Auscultate the area of the client's chest over the Erb's point. - A. Count the client's radial and apical pulses simultaneously with another nurse. (The nurse should have another nurse count the radial pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates.) A nurse is preparing to obtain a clients vital signs. Which of the following actions should the nurse take when washing their hands? A. Rinse their forearms with running water before applying soap. B. Hold their hands above elbow level while washing and rinsing. C. Generate a lather by rubbing their hands together vigorously for 5 seconds. D. Turn off the faucet with a clean paper towel after drying hands. - D. Turn off the faucet with a clean paper towel after drying hands. (If the nurse's hands are wet or the paper towel is wet when they turn off the faucet, they increase the risk of transferring micro-organisms from the faucet back to their hands.) A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A. A piston syringe. B. Barrier ointment. C. Chilled irrigation solution. D. Sterile cotton balls. - A. A piston syringe (The nurse should use an irrigation or piston syringe with an angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to flush exudate and debris from the wound. A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions. A. Orthopneic.
B. Dorsal recumbent. C. Sims' D. Prone. - A. Orthopneic. (The nurse should assist the client into the orthopedic position by having the client sit upright either in bed or in a chair and lean forward. This position allows maximal chest expansion and facilitates breathing). A nurse in reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? A. Use pictures of different food groups to help the client plan a daily menu. B. Ask the client what they already know about meal planning. C. Give the client a brochure with sample menus for all meals. D. Involve the family in the discussion of the client's meal plan. - B. Ask the client what they already know about meal planning. (The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. Then, the nurse can plan education to meet the client's needs). A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter. - D. Attach a humidifier to the base of the flow meter. (The nurse should attach a humidifier at the base of the flow meter to moisten the air for the client. This action will prevent dying mucous membranes when the client is receiving oxygen at a rate greater than 4 L/min). A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?"
-Administer a prophylactic dose of antibiotics prior to discharge. - -Wash hands after removing gloves. (The nurse should perform hand hygiene after removing gloves to prevent the transmission of micro-organisms from one setting or client to another). -Use antimicrobial hand gel after refilling a client's water pitcher (The nurse should perform hand hygiene after touching a client's supplies to prevent the transmission of micro-organisms). -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. (The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of micro-organisms from one client to another). A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? A. BUN 18 mg/dL. B. A thready pulse. C. Hemoglobin 15 g/dL. D. Prominent neck veins. - B. A thready pulse. ( A client who has fluid volume deficit will have thready peripheral pulses). A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? A. Administration of an enema. B. Performance of a paracentesis. C. Insertion of an indwelling urinary catheter. D. Placement of an NG tube. - B. Performance of a paracentesis. (The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis). A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? A. Ego integrity vs. despair B. Generativity vs. self-absorption
C. Identity vs. role confusion D. Intimacy vs. isolation - A. Ego integrity vs. despair (The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. Supporting the client's ego integrity will help the client cope with the challenges of aging). A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A. Art therapy. B. Tai chi. C. Guided imagery. D. Biofeedback. - C. Guided imagery. (Guided imagery is a technique that can produce physical changes in the body, such as decreasing pain levels, by concentrating on a visualization of a pleasurable memory). A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? A. "I know that I can change my advance directives if I need to in the future." B. "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney." C. "My family can overrule the decisions made by my health care surrogate." D. "Advance directive from one state are valid in any other state." - A. "I know that I can change my advance directives if I need to in the future." (The client can change their advance directives at their discretion). A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone."
D. "You should cover your mouth with a tissue when you cough." - D. "You should cover your mouth with a tissue when you cough." (Pneumonia is spread by droplets. Covering the mouth with a tissue when coughing is an effective method of containing secretions to avoid spreading the infection). A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? A. "Keep your feet close together." B. "Tighten your stomach muscles." C. "Straighten your knees." D. "Bend at your waist." - B. "Tighten your stomach muscles." (The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back). A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider? A. A purple-colored stoma. B. Protrusion of the stoma. C. A small amount of bleeding from the stoma. D. Intestinal gas in the pouch. - A. A purple-colored stoma. (The stoma should be reddish-pink and moist. A purple-colored stoma is an indication of poor circulation and the nurse should report this finding to the provider immediately). A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports incisional pain as 7 on a scale of 0-10. B. The client reports increased nausea and chills. C. The client has an oral temperature of 38.5° (101.3° F). D. The client has tenderness and warmth in their calf. - D. The client has tenderness and warmth in their calf. (When using the airway, breathing, circulation approach to client care,
the nurse should determine that the priority finding to report is tenderness and warmth in the client's calf, which can indicate the presence of a thrombus. If it moves from the vein to the heart, brain or lungs, it can cause life-threatening complications). A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? (The audio clip contains a conversation of two nurses, "I heard that a dog attacked Mr. Jones'...") A. Inform the nurses that the neighbor's dog did NOT cause the wound. B. Tell the nurses to change the topic of conversation. C. Complete an incident report upon returning to the unit. D. Report the nurses' conversation to the client's provider. - B. Tell the nurses to change the topic of conversation. (The nurse has the responsibility to protect the client's right to confidentiality and should intervene on the client's behalf. A breach of client confidentiality can result in liability for those involved). A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? A. "Stand with your feet together and your arms at your sides." B. "After I place the turning fork, tell me when you no longer hear the sound." C. "I'm going to stroke the lateral side of the bottom of your foot." D. "Touch each fingertip as quickly as possible with your thumb." - A. "Stand with your feet together and your arms at your sides." (The Romberg test measures stability with and without the eyes closed. The nurse should instruct the client to stand with their feet together and their arms at their sides). A nurse is contributing to the plan of care for a client who is dying. Which of the following intervention should the nurse recommend to include the client's family in the plan of care? ( Select all that apply. )
- Keep the family updated about the client's status.
- Suggest that family members return home at night to allow the client to rest.
A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance)
- Place a towel under the client's head with an emesis basin under their chin.
- Assess the client's gag reflex.
- Cleanse the client's mouth using a toothbrush.
- Separate the client's upper and lower teeth with an oral airway device. -Position the client on their side with their head turned to the side. - 1- Assess the client's gag reflex. (The nurse should first assess the client's gag reflex to determine risk for aspiration) 2- Position the client on their side with their head turned to the side. (Turning the client on their side allows secretions to drain from the mouth). 3- -Place a towel under the client's head with an emesis basin under their chin.(Using a towel and emesis basin helps protect bed linens). 4- Separate the client's upper and lower teeth with an oral airway device. (An oral airway device allows safe access to the client's mouth). 5- Cleanse the client's mouth using a toothbrush (Finally, the client's mouth can be cleansed with a toothbrush or swabs). A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take? A. Measure the client's gastric residual before each feeding. B. Change the bag and tubing every 24 hours. C. Document intake and output. D. Flush the tubing with 30 mL of water after each feeding. - A. Measure the client's gastric residual before each feeding. (When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take). A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? A. Sit beside the client.
B. Speak slowly and loudly. C. Dim the lights in the client's room. D. Choose a private room for the interview. - D. Choose a private room for the interview. (The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying). A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which the following entities? A. An insurance agency offering a life insurance policy. B. A family member who requests the client's diagnosis. C. A physical therapist who is involved in the client's care. D. An employer completing a pre-employment screening. - D. An employer completing a preemployment screening. (According to HIPPA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care). A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include? A. "This dressing keeps the wound bed dry." B. "This dressing allows the wound bed to breathe." C. "This dressing requires a secondary dressing." D. This dressing requires paper tape to secure." - B. "This dressing allows the wound bed to breathe." (A transparent dressing is applied to allow oxygen to pass through the dressing. This is referred to as "breathing" and promotes healing of the wound.) A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure? A. Fluid Overload
