question

to use the nursing process correctly, the nurse must first

answer

obtain information about the client

question

a 3 year old child has had multiple tooth extractions while under general anesthesia. the client returns from the post anesthesia care crying, but awake, from the recovery room. which approach is likely to be successful?

answer

examine mouth last

question

abdominal assessment order:

answer

inspection, auscultation, percussion, palpation

question

a nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the.

answer

involvement of the client in planning the change

question

while starting an IV for a client, the nurse notices that her gloved hands get spotted with blood. the client has not been diagnosed with any infection transmitted via the bloodstream. which of the following should the nurse do as soon as the task is completed

answer

remove the gloves carefully and follow with hand hygiene

question

a nurse's neighbor is scheduled for elective surgery. the neighbor's provider indicated that a moderate moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. which of the following is appropriate for the nurse to suggest?

answer

donating autologous blood before the surgery

question

an AP tells the nurse, "I am unable to find a large BP cuff for a client who is obese. Can I just use the regular cuff?" The nurse replies that using a regular cuff for an obese pt will result in a reading that is....

answer

high

question

an AP says to the nurse, "this client is incontinent of stool 3 or 4 times a day. i get angry, and i think the client is just doing it to get attention. i think we should put diapers on her." what is the appropriate response?

answer

it is very upsetting to see an adult client regress

question

a nurse is caring for a cline just diagnosed with type 1 diabetes mellitus. the client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. the nurse explains the importance of learning self care and appropriately adds which of the following statements?

answer

tell me what i can do to help you overcome your fear of giving yourself injections?

question

a client is admitted to the hospital in the terminal stage of cancer. the nurse enters the client's room to administer medications and finds the client crying. the appropriate action is to...

answer

sit and hold the client's hand

question

when initiating CPR, the nurse must confirm which of the following assessment findings prior to beginning chest compressions?

answer

absence of pulse

question

a client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. when assessing skin tutor, the nurse should...

answer

grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back

question

a nurse tells a client that the provider has prescribed IV fluids. the client appears to be upset about the IV catheter insertion, but says nothing to the nurse. which of the following is an appropriate nursing response?

answer

is there something about this procedure that concerns you?

question

a nurse is precepting a a newly licensed nurse who is preparing to help a client perform tracheostomy care. the nurse should intervene if the equipment the precept gathered included...

answer

COTTON BAWLS

question

a hospitalized client needs a chest x ray. the radiology department calls the nursing unit and says that they are sending a transporter for the client. when entering the client's room, the priority action is to

answer

check the client's identification bracelet

question

at the surgical scrub sink, a surgical nurse demonstrates the proper surgical hand washing technique by scrubbing...

answer

with her hands held higher than her elbows

question

a nurse on a rehabilitation unit is transferring a client from a bed to a chair. to avoid back injury, which of the following techniques should the nurse use?

answer

bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurses hands under the client's axillae

question

nurse has group of obese clients. to make them lose weight...

answer

attempt to develop the client's self motivation

question

client with appendicitis is learning coughing and deep breathing. prob didn't learn anything if...

answer

reports severe pain

question

grabby confused client...

answer

firmly tell the client to not grab

question

An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." which is an appropriate nursing response?

answer

"you seem worried. are you concerned someone may see you without your teeth?"

question

ATI TIP

answer

(when answering an ATI communication/responding question, you are correct in answering a response that recognizes and responds to the client's feelings)

question

While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

answer

count the apical pulse rate for I full min, and describe the rhythm in the chart

question

when admitting a client, the nurse records which information in the client's record first?

answer

assessment of the client (first step of nursing process)

question

ATI TIP #2

answer

(when asked a priority setting question: assessment, analysis, planning, intervention, evaluation)

question

A nurse is caring for a client who requires rectal temperature monitoring. available at the client's bedside is a thermometer with a long, slender tip. which of the following is the appropriate action for the nurse to take?

answer

obtain a thermometer with a short, blunt insertion end (long slender is for axillary or oral)

question

A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 minutes. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which is an appropriate nursing action?

answer

disconnect the machine, and measure the blood pressure manually every 15 min. (malfunctioning equipment is a safety risk, remove it)

question

A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the clients blood pressure?

answer

obtain the blood pressure under the same conditions each time

question

A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client's temp. is 102.6 F, her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority?

answer

elevated temp.

question

ATI TIP #3

answer

with this kind of priority question, use mallow's hierarchy of needs: sleep & food, security, love & belonging, self-esteem, self-actualization.

question

An older adult just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

answer

help the client write down the questions to ask the provider, so that the client doesn't forget

question

A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. the client's surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that..

answer

the signature on the preoperative consent form is the client's

question

A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, thick is the most important nursing action initially?

answer

evaluate pedal pulses (assessment of the reason for admission is first priority)

question

to use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should..

answer

place bed in high horizontal position

question

A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, the nurse should..

answer

ask the client why she has changed her mind

question

When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. The sounds become for distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a..

answer

pericardial friction rub

question

A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should..

answer

lock the wheels on the bed and stretcher

question

A postoperative client has been diagnosed with paralytic ileum. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be..

answer

absent. (paralytic ileum is an immobile bowel)

question

before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of..

answer

friction

question

which of the following should a group of comity health nurses plan as part of a primary prevention program for occupational pulmonary diseases?

answer

elimination of the exposure

question

A nurse is caring for a client diagnosed with a terminal illness. The client asks serval questions about the nurse's religious beliefs related to death and dying. An appropriate nursing response is to

answer

encourage the client to express his thought about death and dying

question

At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. the auscultate the aortic valve, the nurse should place the stethoscope at which location?

answer

second intercostal space to the right of the sternum

question

which of the following should the nurse do first when preparing to provide tracheostomy care?

answer

PREFORM HAND HYGIENE

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