A nurse is caring for a client who is prescribed iv fluids. while inserting the iv catheter

ATI Nurse Logic: Knowledge and Clinical JudgementA nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newlylicensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor?

While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left

A nurse is providing discharge education to the parents of a preschooler who is prescribedacetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that hasbeen prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to

A nurse is collecting data on a recently admitted client. Which of the following techniques should the

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'mgoing to have the surgery. Everybody has to die sometime." Which of the following responses by thenurse is appropriate?

A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribedciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many

A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clientswho are tactile learners. Which of the following activities should be included as a learning strategy in the

A nurse is collecting data about a client’s respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A: Vesicular (Vesicular sounds are soft and low-pitched)

A nurse employs a thorough, systematic method for obtaining OBJECTIVE data about a client. Which of the following methods should the nurse us to collect this information? A: Physical Examination (Physical findings are objective and the nurse should collect this information in a systematic way.

A nurse is assisting a provider with performing thoracentesis to remove pleural fluid. How should the nurse position the client? A: Leaning forward over a pillow.

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A: “Raise your index finger if you need to pause during the insertion.”

A nurse is performing a mental-status exam for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client’s ability to think abstractly? A: Discuss the meaning of a common proverb. (Evaluates clients ability to think abstractly.)

A nurse is presenting an in-service session about nutrition. Which of the following simple sugars should the nurse identify as the carb found in milk? A: LACTOSE (Sugar found in milk)

A nurse is assisting with teaching a newly licensed nurse about pain management in clients age of 65 and older. Which of the following pieces of information should the nurse include? A: Clients who are 65 or older are reluctant to report pain. (Might not want to bother or anger caregivers and might believe that pain is expected.)

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicate she is experiencing psychological distress? A: “I keep having nightmares about my upcoming surgeries.”

A nurse is assisting with the admission of a client to the medical unit and asks if he has advance directives. The client states “I have a document with me that names someone who can make health care decisions for me if i am not able.” The nurse should identify that the client is referring to which of the following documents?A: Durable Power of Attorney Document (names a

surrogate who can make health decisions or the client if the client is unable to do so)

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? A: During the admission process. (Nurse should initiate discharge planning as soon as the client is admitted to the facility.

A nurse discovers that a client received the wrong medication. Which of the following should the nurse take first? A: Collect data from the client. (For any side effects from either receiving the wrong medication or not receiving the prescribed medication”

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A: Exert pressure on the bony prominences when holding the eyelids open.

A nurse is measuring the blood pressure for several clients. Which of the following results is within the expected reference range for blood pressure? A: 116/70 mmHg

A nurse is assisting a client who has dysphagia at mealtime. Which following actions should the nurse take? A: Advise the client to tuck his chin downward.

A nurse is collecting data from a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A: Increased blood pressure.

A nurse is reinforcing teaching with a Group of unit nurses about the experiences of clients who are having surgery. Which phase of care begins with transferring the client to the surgical suite table and ends with the transfer tp PACU? A: Intraoperative

A nurse is examining a client’s thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A: “Turn your head back and swallow.”

A nurse is instructing an assistive personnel AP about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

A: Provide more water feedings. (Nurse should provide more fluids by adding free water.)

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A: Insert the tip of the tubing 8cm (3)

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for the evaluation? A: Sitting

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?A: Clean the drain site from the center outward.

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A: Test for the presence of the client’s GAG REFLEX.

A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about this procedure before. Which of the following actions should the nurse take? A: Stop reinforcing the teaching and check with the surgeon about informed consent.

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? A: Sodium 123 mEq/L

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular sized cuff for a client who is obese? Which of the following explanations should the nurse give the AP? A: “Using a cuff that is too small will result in an inaccurately high reading.”

A nurse is reviewing the lab results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant (VRE). Which of the following types of precautions should the nurse initiate? A: CONTACT

A nurse in a long-term care facility is feeding a client. Which of the following observations should the nurse identify as an indication that the client requires an evaluation for dysphagia? A: Pocketing food.

A nurse is reinforcing teaching about crutch use with a client who has had knee surgery. Which of the following instructions should the nurse include? A: “Hold both crutches with a hand when you sit down in a chair.”

A nurse is assisting with the admission of a client to a facility. the client wears eyeglasses and has a hearing aid. Which of the following actions should the nurse take before beginning the interview process. A: Make sure the device is functioning

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A: Avoid beverages that contain caffeine.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A: Face the client when speaking

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?A: Soak the inner cannula of the tracheostomy tube in normal saline.

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A: Hyperglycemia

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire healthcare associated infections (HAI’s). Which of the following routes of infection should the manager identify as an iatrogenic HAI? A: Infection acquired from a diagnostic procedure

A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A: GRIMACING

A nurse is monitoring a client’s laboratory results. Which of the following results should the nurse report to the provider? A: Potassium 3 mEq/L

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

amount of medication in the vial. Which of the following actions should the nurse take? A: Have another nurse witness the disposal of the medication.

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside so she can take it at a later time. Which of the following responses should the nurse provide? A: “Call me when you are ready, and I will return with the medication.”

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit help relieve pain. Which of the following responses should the nurse make? A: “It modulates the transmission of the pain impulse.”

A nurse is assisting with the care of a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect an injury to which of the following areas of the brain? A: Cerebellum

A nurse is reinforcing teaching with a client who has hypertension and is starting medication therapy for treatment. The provider has a recommend that, because of these new medications, the client should increase her intake of potassium. Which of the following foods should the nurse remind the client to include in her diet? A: Bananas

A nurse is preparing to collect data about the function of a client’s trigeminal nerve or cranial nerve (CN) V. Which of the following items should the nurse gather for the test? A: Cotton wisps

A nurse in a provider’s office is reinforcing teaching with a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? A: Black beans, Whole-grain bread

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A: Pull back the suction catheter by 1cm (0) if the client starts coughing

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A: Request a prescription for an isotonic enteral nutrition formula

A nurse is caring for a client who has a terminal illness, the client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A: Ask why the client is refusing the medication

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin assisting discharge planning? A: Upon admission to the care facility.

A nurse is reinforcing teaching with a preschooler about how to use a metered-dose inhaler. Which of the following methods should the nurse use during this instructional session? A: A simple demonstration of inhaler use

A nurse on a med-surgical unit is caring for a client. Which of the following actions should the nurse perform first when using the nursing process? A: Obtain client information

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A: Elevate the client’s head of the bed 45 degrees before the feeding.

A nurse is beginning her shift and reviewing the medication administration records (MARS) for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A: Call the provider to clarify the dosage

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. Which of the following actions should the nurse take? A: Encourage the client to express his thoughts about death and dying.

A nurse is helping a client perform range of motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform? A: Touching his chin to his chest

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A: Sit and hold the client’s hand

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings is the nurse’s priority to report to the surgeon immediately? A: Warm, tender area on the right calf. (Risk for thrombus formation/this is life-threatening postoperative complication)

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson’s developmental task for which of the following age groups? A: Pre-schoolers

While drawing blood for a lab test from a client, a nurse observes a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A: Carefully remove the gloves and follow with hand hygiene

A nurse is reinforcing teaching about bladder retracing in for a client who has urinary incontinence. Which of the following instructions should the nurse include? A: Try to block the urge to urinate until the next scheduled time

A nurse is collecting data about a clients spiritual wellbeing. Which of the following questions should the nurse ask? A: “What is your source of strength and hope?”

A nurse is reinforcing teaching with a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint? A: Antagonistic (responsible for the movement of the knee joint by contracting while other muscles relax)

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? A: Plasma volume expanders

A nurse is preparing to irrigate a client’s wound. Which of the following actions should the nurse take? A: Warm the irrigating solutions to 37C (98)

A nurse is caring for a client who has (MRSA) infection. A diet assistant asks the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instructions should the nurse give the diet assistant?

A: Don gloves when entering the room, and use of hand sanitizer when exiting

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A: Inspect both breasts simultaneously

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at bedside. Which of the following actions should the nurse take first? A: Lower the client to the floor

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A: EGGS

A nurse is reinforcing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include in the teaching? A: Include 2 cups of veggies in your daily diet.

A nurse is administering an IM injection to a 5-month old infant. Which of the following injection sites should the nurse use? A: Vastus Lateralis

A nurse is working with the facility’s language interpreter to explain a wound- care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when explaining the procedure to the client? A: Ensure the interpreter and the client speak the same dialect

A nurse is collecting data from a client who requires hygiene care. Which of the following pieces of information is the nurse’s priority to determine before preparing to bathe the client? A: How much the client can assist with bathing

A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A: Fowler’s

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A: Remove the IV catheter

A: Start chest compressions

A nurse is collecting data from a client who has mixed aphasia. Which of the following strategies should the nurse use to help facilitate with this client? A: Ask simple, short questions

A nurse in a provider’s office is caring for a client who has blepharitis. Which of the following actions should the nurse take first? A: Inspect the eye for drainage or redness

A nurse in a clinic is caring for a client who has retuned for a follow up visit after treatment of a laceration on her upper arm. Which of the following actions should the nurse perform when removing the sutures that the client received at her last visit. A: Clip the suture as close to the skin as possible

A nurse delegates the collection of a client’s temperature to an AP. The nurse notes that the AP obtained the client’s auxiliary temperature however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A: Right communication

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A: Remove the restraints at least every 2 hours

A nurse on a ped-unit is caring for a child who is 4 years old. To help with communication and play activities for this client, the nurse should consider which of the following characteristics of Piaget’s pre-operational period? A: ANIMISM

A nurse is caring for a client who has MRSA. Which of the following precautions should the nurse implement? A: Apply a gown when in the client’s room

A nurse on a med-surg unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique? A: The nurse washes with her hands held higher than her elbows

A nurse is collecting data during a neurological examination of a client. When asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A: Cranial nerve XII

A nurse is performing an otoscopic exam of a client’s right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A: Document this as an expected finding

A nurse is caring for a group of client’s who are receiving oxygen therapy. Which of the following client’s should the nurse plan to see first? A: A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is reinforcing teaching about crutches for a client who has a fracture of the right foot. Which of the following instructions should the nurse give to the client? A: “Keep the rubber crutch tips securely in place.”

A nurse is collecting data about a client who is unconscious. Family members are present and answer the nurse’s questions about the client’s medical history. The nurse should document this information as which of the following types of data? A: Secondary source data

A nurse is caring for a client who requires a Chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A: identify the client using 2 identifiers.

A nurse is reinforcing teaching with a client about how to obtain a capillary finger stick blood sample. Which of the following actions by the client requires the nurse to intervene? A: Elevates the finger above heart level

A nurse is reviewing lab results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as an indication of which of the following conditions? A: Leukopenia

A nurse on a med-surg unit observes smoke billowing from a client’s room. Which of the following actions should the nurse take first? A: Evacuate the client from the room

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide? A: “Tell me what I can do to help you overcome your fear of giving yourself injections.”

A: Reduced level of consciousness

A nurse rate’s a client’s biceps reflex at 2+. Which of the following characteristics should the nurse document about the client’s reflexes? A: Average

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client’s body? A: LUNGS (Percussion creates a vibration)

By asking a client to explain the statement, “A bird in the hand is worth 2 in the bush”, the nurse is evaluating the client’s ability in which of the following intellectual functions? A: Abstract reasoning

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at meal time?A: offer the client tart or sour foods first

A nurse is contributing to the plan of care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A: Renew the prescription for restraints within 24 hours

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A: Perform hand hygiene

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states they no longer want to have the surgery. Which of the following actions should the nurse take? A: notify the provider about the client’s decision

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A: AIRBORNE

A nurse in a providers office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client’s sleeping difficulties? A: “I often have a cup of coffee with my desert before going to bed.”

A nurse on a med-surg unit is admitting a client. Which of the following pieces of information should the nurse document in the client’s record first?

A: Data collection for the client

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A: Pull the NG tube back slightly

A nurse in a provider’s office is measuring an adult client and notes a decrease in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A: Osteoporosis (Loss of height)

A nurse in a provider’s clinic is taking a client’s age, height, weight, and vital signs, the nurse should identify this action as part of which of the following complements of the nursing process? A: Data collection

A nurse is supervising a newly licensed nurse who is suctioning a client’s tracheostomy. The nurse should identify that which of the following actions by the new nurse indicates an understanding of the procedure? A: Administering high flow oxygen prior to the procedure

A home health nurse is visiting the home of a caregiver who says he is “exhausted” from working part time in addition to caring for his mother who is an older adult and has severe dementia. Which of the following options should the nurse suggest to the caregiver? A: RESPITE CARE

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids and assist with which of the following functions? A: Regulation of acid-base balance

A nurse is planning to administer pain meds to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first? A: Use the pain scale to determine the client’s pain level

A nurse is reinforcing teaching about body mechanics with an AP. Which of the following should the nurse include? A: “Sit with your back supported”, “Keep your knees at hip level.”, “use an ergonomically designed computer keyboard.”

A nurse is reinforcing teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?

A: “I will make sure to replace my punch around 4 hours after i eat.”

During completion of a health history, a client exports having chest pain intermittently for the past week. Which of the following questions is the nurse’s priority? A: “Can you tell me what the pain felt like and show me exactly where it was?”

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. Which of the following actions should the nurse take? A: Apply pressure to the bridge of the nose after instillation of the medication.

A nurse is reinforcing teaching for a client who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include? A: Do not use any materials containing oil or alcohol when using oxygen.

A nurse on a med surg unit is caring for a client who has a seizure disorder. Which of the following items is the nurse’s priority to keep near the client at all times? A: Suction equipment

A nurse is reinforcing teaching about heat therapy with a client who has low back pain. Which of the following statements by the client indicates understanding of the teaching? A: “i need to place a towel between the heating pad and my skin.”

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A: The signature on the proper active consent for is the client’s

A nurse is reviewing lab data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A: Sodium 150 mEq/L

A nurse is obtaining the BP of a clients lower extremity. Which of the following actions should the nurse take? A: Place the bladder of the cuff over the posterior aspect of the thigh