ATI – Flashcard
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Discussing changes in a client's plan of care with his friend who is a nurse on another unit
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While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take?
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Cover the area with a transparent wound barrier.
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A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to administer per dose?
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2.5 tsp
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A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion?
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Obtaining the client's level of oxygen saturation
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A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate?
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Tell me more about your concerns."
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A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many tablets should the nurse administer with each dose?
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2.5 tablets.
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A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching?
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I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities."
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A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter?
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Supine
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A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program?
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Prepare a healthy meal to serve at the end of class.
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A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries?
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Twisting at the waist and shoulders
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A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions?
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Away from the body
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A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill?
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Chlorine (bleach)
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A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication?
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Hyperglycemia
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A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status?
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Deep reddish-colored tongue
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A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication?
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Urinary retention
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A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching?
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q.d.
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A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin?
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Pallor
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A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider?
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Dimpling of the tissue in the upper outer quadrant
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A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills?
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Living wills detail treatment wishes of the client in the event of terminal illness.
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A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actionsw should the nurse take in an attempt to prevent diarrhea after subsequent feedings?
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Reduce the rate of the feedings.
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A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)?
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A written prescription from the provider
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A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops?
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Warm refrigerated drops to room temperature prior to instillation.
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A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy?
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What part of your mother's care concerns you?"
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A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy?
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0.75 mEq/L
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A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication?
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Headache
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A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching?
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I will use my cromolyn inhaler before using my albuterol inhaler."
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A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement?
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A client who is recovering from a cardiac catheterization
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A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?
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1.5 ml
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A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness?
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Dark urine
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A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information?
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Assigning staff members on each shift the same password for accessing medical records
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A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following?
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Advocacy
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A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions?
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A client who has rubella
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A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia?
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NG tube to suction
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A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority?
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Slurred speech
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A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention?
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Abdominal distension
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A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective?
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Toast with peanut butter
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A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication?
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WBC 2,800/mm3
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A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate?
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Assist the client to a side-lying position
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A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate?
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25 to 35 lb
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A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis?
