ATI practice

A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take?

Tell the child they will feel discomfort during the catheter insertion

A nurse is caring for a client who has arteriovenous fistula Which of the following

findings should the nurse report?

Absence of a bruit

A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding

of the teaching?

"I will wear loose clothing around my ICD"

A nurse is caring for a client who is at 14 weeks gestation and reports feelings of

ambivalence about being pregnant. Which of the following responses should the nurse make?

"Describe your feelings to me about being pregnant"

A nurse is planning care for a client who has a prescription for a bowel- training program

following a spinal cord injury. Which of the following actions should the nurse include in

the plan of care?

Administer a rectal suppository 30 minutes prior to scheduled defecation times.

A nurse is caring for a client who is in active labor and requests pain management. Which

of the following actions should the nurse take?

Place the client in a warm shower.

a nurse in an emergency department is performing triage for multiple clients following a

disaster in the community. To which of the following types of injuries should the nurse

assign the highest priority?

Below-the knee amputation

a nurse manager is updating protocols for the use of belt restraints. Which of the

following guidelines should the nurse include?

Document the client's condition every 15 min

A nurse is teaching an in-service about nursing leadership. Which of the following

information should the nurse include about an effective leader?

Acts as an advocate for the nursing unit.

A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and

reports that she has been following her (unable to read) care. The nurse should identify which of

the following findings indicates a need to revise the client's plan of care.

Hba1c 10 %

A nurse in a provider's office is reviewing the laboratory results of a group of clients. The

nurse should identify that which of the following sexually transmitted infections is a nationally

notifiable infectious disease that should be reported to the state health department?

Chlamydia

A nurse is teaching a newly licensed nurse about therapeutic techniques to use when

leading a group on a mental health unit. Which of the following group facilitation techniques

should the nurse include in the teaching?

Use modeling to help the clients improve their interpersonal skills

A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include

in the plan of care?

Provide unleavened bread.

A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment

The client reports feeling less anxious.

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client's airway and initiating an IV , which of the following actions should the nurse do next.

Administer flumazenil to the client.

A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect?

Elevated temperature

A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?

Jitteriness

A nurse in a pediatric clinic is reviewing the laboratory test results of a school age

child. Which of the following findings should the nurse report to the provider?

WBC 14,000/mm3

A charge nurse is teaching a newly licensed nurse about clients designating a health care

proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of

the following information should the charge nurse include?

"The proxy can make treatment decisions if the client is under

anesthesia."

A nurse in the PACU is caring for a client who reports nausea. Which of the

following actions should the nurse take first?

Turn the client on their side.

A nurse is caring for a client who has a history of depression and is experiencing a

situational crisis. Which of the following actions should the nurse take first?

Confirm the client's perception of the event

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the

actions should the nurse take?

Document the client's condition every 15 minutes.

A nurse is caring for a client who has end-stage kidney disease. The client's adult

child asked about becoming a living donor for his father. Which of the following conditions in the child's medical history is a contraindication of this procedure?

hypertension

A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a staffing shortage. Which of the following client should the nurse delegate to the LPN?

A client who is postoperative following a bowel resection with an NG tube set to continuous suction.

A nurse is working on a surgical unit is developing a care plan for a client who has

paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Teach the client to shift his weight every 15 min while sitting

A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the

following pain-management (Unable to read) a safe option for the client?

Pudendal block

A nurse is caring for a client who has left homonymous hemianopsia. Which of

the following is an appropriate nursing intervention?

Place the bedside table on the right side of the bed.

A nurse is assessing a client who has major depressive disorder. Which of the

following findings should the nurse identify as the (Unable to read) (Most important?)

The client reports giving away personal items

A nurse is providing teaching about immunizations to a client who is pregnant. The

nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply)

Tetanus diphtheria and acellular pertussis vaccine

Inactivated influenza vaccine.

A nurse is providing discharge teaching for a group of clients. The nurse should

recommend a referral to a dietitian

A client who has gout and states, "I can continue to eat anchovies on my pizza."

A hospice nurse is visiting with the son of a client who has terminal cancer. The son

reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

"I can give you information about respite care if you are interested."

A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications

Methylprednisolone.

The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching?

"You can increase your dietary intake of folic acid by eating cereals and citrus fruits".

A community health nurse is assessing an adolescent who is pregnant. Which of

the following assessments is the nurse's priority?

Understanding of infant care.

A nurse manager is planning to teach staff about critical pathways. Which of the

following information should the nurse include?

(Unable to read) decrease health care costs.

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider?

Exhibit 1

Blood pressure: 102/56 mm Hg. Heart rate: 95/min

Respiratory rate: 18/min Temperature: 37.4C (99.3F)

Exhibit 2

Medication Administration Record

Clozapine 150 mg PO twice daily

Benztropine 0.5 mg PO twice daily as needed for tremors.

Exhibit 3

Nurse's notes:

Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in

the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of

breakfast and reports slightly nauseous.

they should report the sore throat.

A charge nurse is educating a group of unit nurses about delegating client tasks to

assistive personnel

"An RN evaluates the client needs to determine tasks to delegate"

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

FHR baseline 170/min

A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse's priority?

Ensure that the client has a referral for physical therapy

A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station?

A client who has depressive disorder and reports feeling hopeless.

A nurse is preparing to measure a temperature of an infant. Which of the following

action should the nurse take?

Place the tip of the thermometer under the center of the infant's

axilla.

A nurse is planning care for a client who has bipolar disorder and is experiencing

mania. Which of the following interventions should the nurse include in the plan?

Encourage the client to take frequent rest periods

A nurse is admitting medications to a group of clients. Which of the following

occurrences requires the completion of an incident report?

A client receives his antibiotics 2hr late

A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her

newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

"Of course, I will heat that up for you."

a nurse is preparing an in-service for a group of nurses about malpractice issues in

nursing. Which of the following examples should the nurse include in the teaching?

Administering potassium via IV bolus

a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

Establish a toileting schedule for the client

The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives?

thrombophlebitis

A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, "It's hard not to listen to the voices." Which of the following questions should the nurse ask the client?

"What are the voices telling you?"

A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

Applying elbow immobilizers of an infant receiving cleft lip injury

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances?

Respiratory alkalosis

A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of

the following

Inject air into the NPH insulin vial.

Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?

"We should establish our roles in the initial session."

A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella

rooster. Which of the following information should the nurse include?

Children who have varicella are contagious until vesicles are crusted

A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following requires intervention by the staff nurse?

Waits 2 minutes between suctions

A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?

Use three pronged grounded plugs.

A nurse is providing care for a group of clients. Which of the following client's should the nurse identify as having the highest risk for developing a pressure injury?

A client who has dementia and is incontinent of urine and feces

A nurse is teaching a client who has glaucoma and a new prescription for timolol

eyedrops. Which of the following statements indicates an understanding of the teaching?

"I will place pressure on the corner of my eye after using he eye drops"

A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

Swelling of the face

A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make

"I can give you information about making end of life decisions"

A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

protect the IV bag from exposure to light.

A nurse is caring for a client who is experiencing mild anxiety. Which of the

following findings should the nurse expect?

Heightened perceptual field

A nurse is reviewing the laboratory report of a client who has been having lithium

carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

Administer the medication.

A nurse is providing teaching to an older adult client about methods to promote

nighttime sleep. Which of the following instructions should the nurse include?

Eat a light snack before bedtime

A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?

Pregabalin

nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take?

Report continuous bubbling in the water seal chamber.

A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects?

Urinary retention.

A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states "I don't know what to do. Everything has been happening so quickly." Which of the following by the nurse is therapeutic?

"Can you talk about what happens with your partner at home?"

A nurse is providing dietary teaching to a guardian of a preschooler who has a new

diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will put my child on a gluten-free diet".

A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

Prime IV tubing with 0.9% sodium chloride

A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate?

0.9% normal saline.

A nurse is teaching who has chronic pain about avoiding constipation from

opioid medications. Which of the following should the nurse include in the teaching?

Increase exercise activity

A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching?

"Drink 2 liters of warm water per day".

A nurse is receiving change-of-shift report for a group of clients. Which of the

following clients should the nurse plan to assess first?

A client who has a hip fracture and a new onset of tachypnea

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

Consume food high in bran fiber

A nurse is caring for a 1-day-old newborns who has jaundice and is receiving

phototherapy. Which of the following actions should the nurse take?

Ensure that the newborn wears a diaper.

a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"I will intervene if there is conflict between a client and his provider"

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Evaluate the client's ability to help with repositioning

A nurse is orientation a newly licensed nurse who is caring for a client who is

receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV?

"It allows preset pressure delivered during spontaneous ventilation."

A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding?

Weak femoral pulses

a nurse is auscultating for crackles on a client who has pneumonia. Which of the

following anterior chest wall locations should the nurse auscultate?

C upper quadrant??

A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include?

A statement that participants can leave the study at will.

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

Excessive sweating

A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?

The client develops hiccups.

A nurse is preparing discharge information for a client who has type 2 diabetes

mellitus. Which of the following resources should the nurse provide to the client?

Food exchange lists for meal planning from the American Diabetes Association

A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?

"You should push the button before physical activity to allow

maximum pain control."

A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin?

Glargine insulin.

A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of

the following should the toddler participate?

Playing with a large plastic truck.

A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should

the nurse take?

Monitor the rate of the client's feedings

A nurse in an emergency department is caring for a client who received a dose of penicillinand is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse's priority?

Administer oxygen

A nurse is caring for a client who has Raynaud's disease. Which of the following

actions should the nurse take?

Provide information about stress management.

A nurse is reviewing the medical history of a client who has angina. Which of the

following findings in the client's medical history should identify as a risk factor for angina?

Magnesium hydroxide 30 ml PO.

A nurse overhears two assistive personnel (AP) discussing care for a client while in

the elevator. Which of the following actions should the nurse take?

Report the incident to the AP's charge nurse.

A nurse is planning care for a client who is receiving hemodialysis. Which of the

following actions should the nurse include in the plan of care?

Check the vascular access site for bleeding after dialysis

A nurse in the emergency department is caring for a client who reports intimate

partner violence. Which of the following interventions is the nurse's priority?

Determine if the client has any injuries

A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

Maternal hypoglycemia

A nurse is assessing a school-age child who has a urinary tract infection. Which of

the following findings should the nurse expect?

Enuresis.

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

A client who is 1 day postoperative following a vertebroplasty

A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number)

6 ml

A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching?

"This test should be performed after your baby is 24 hours old."

A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching?

"I should avoid eating popcorn and fresh pineapple"