ATI essential quiz – Flashcards
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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?
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"you should have a fecal occult blood test every year"
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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?
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Assis the client to an upright position
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A nurse is preparing to administer 0.5ml of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
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Gently shake the container of medication prior to administration
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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?
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"I'll check the wires and cables on my TV to make sure they are in good working order"
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a nurse is caring for a client who requires a 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?
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"I flushed what I urinated at 7:00am and have saved all urine since"
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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
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Acupuncture
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A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair
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1. ask the client if he can bear weight 2. position the chair on the left side of the bed 3. have the client sit and dangle his feet at the bedside 4. Use the stand-and-pivot technique to move the client to the chair
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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?
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Ask another nurse to observe the medication wastage -a second nurse must witness the disposal of any portion of a dose of a controlled substance
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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.
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1. Inject 10 units of air into the bottle of NPH insulin 2. Inject 5 units of air into the bottle of regular insulin 3. Withdraw the correct dose of regular insulin from the bottle 4. Withdraw the correct dose of NPH insulin from the bottle.
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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?
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Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration
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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?
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flush the tube with 15 mL of sterile water The nurse should flush the feeding tube with 15-30mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30-60 mL of sterile water following the administration of the last medication.
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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?
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Allow extra time for the client to respond to questions.
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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?
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The client holds the cane on the stronger side of her body -The client should hold the cane on the stronger side of her body to increase support and maintain alignment
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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?
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-pupil clarity -Visual fields -Visual acuity
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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?
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Place the client's arm in a dependent position
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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?
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Wrap monitoring cords with stockinette and tape them in place -Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a non latex barrier material, such as stockinette, and using non latex tape to secure them
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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?
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Tell the client to keep the head of the bed elevated at least 30 degree -The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula
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A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
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-Place the client in a room with negative-pressure airflow -Wear gloves when assisting the client with oral care -Use antimicrobial sanitizer for hand hygiene
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A nurse is talking with the 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?
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Role overload
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A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effect?
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Auscultate lung sounds -The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath
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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?
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-narrowed arterial lumen
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a nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?
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Airborne (smaller than 5 microns in diameter:varicella, tuberculosis, and measles)
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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?
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select a suction catheter that is half the size of the lumen
