ATI CBC Level 2 Study Guide– Nursing
Assessment | Complete Guide With Verified
CorrectAnswers
A community health nurse is teaching a group of older adult clients about interventions to prevent
pneumonia. Which of the following instructions should the nurse include in the teaching?
- ANSWER-
Wash your hands when you return home from running errands
A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the
following findings should the nurse identify as a risk factor for developing cholecystitis?
- ANSWER-
Client is taking atorvastatin
A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain.
The client has a heart rate of 66/min and a respiratory rate of 9/min. Which of the following
medications should the nurse anticipate the provider willscribe
pre for the client?
- ANSWER-
Naloxone
A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux.
Which of the following information should the nurse include in the teaching?
- ANSWER-Plan to
finish eating at least 3 hr before bedtime
A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings
should the nurse expect? - ANSWER-Circumoral tingling
A nurse is leading a small group discussion in an acute care mental health facility when one client
suddenly begins to experience a panic attack. Which of the following actions should the nurse
- take?
ANSWER-Remain with the client until manifestationsside sub
A nurse in an emergency department is assessing a client who reports severe constipation. The nurse
should identify which of the following findings as an indication that the client might have- a small
bowel obstruction?- ANSWER-Visible peristaltic waves in the upper abdomen
A nurse is reviewing the urinalysis results of a client who has completed
-day
a 14
course of
ciprofloxacin to treat pyelonephritis. Which of the following values should indicate to the nurse that
the client has a continuing infection?
- ANSWER-Positive leukocyte esterase
, A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right
kidney. Which of the following findings should the nurse instruct the client to report to the provider?
-
ANSWER-Painful urination
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following
findings is a priority to report to the provider?
- ANSWER-Hemoglobin 7.6 mg/dL
A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2
50mm Hg, and HCO3- 25 mEq/L after experiencing an airway obstruction. Which of the following
interventions is the nurse's priority for this client?
- ANSWER-Apply oxygen therapy to the client
A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse
expect?- ANSWER-Exophthalmos
A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for
a hearing aid. Which of the following client statements indicates an understanding of the teaching?
-
ANSWER-"I will make sure the hearing aid is off befo
re inserting it in my ear"
A nurse is assessing a client who has an ulcer due to peripheral vascular disease. Which of the
following findings should the nurse identify as an indication that the client has a venous ulcer rather
than an arterial ulcer?
- ANSWER-Discoloration and edema of the right ankle
A nurse is providing home care instructions to a client who had a-arm
shortplaster cast applied for a
wrist fracture. Which of the following instructions should the nurse include?
- ANSWER-Elevate the
wrist above heart level
A nurse is providing discharge planning for a client who has gestational diabetes. Which of the
following interventions should the nurse identify as the priority?
- ANSWER-Determine the client's
knowledge regarding gestational diabetes
A school nurse is assessing a school
-age child who has erythema infectiosum (fifth disease). Which of
the following manifestations should the nurse expect?
- ANSWER-Facial eruption
A nurse is teaching about foot care with a group of older adults who have type 1 diabetes mellitus.
Which of the following information should the nurse include in the teaching?
- ANSWER-Trim
toenails straight across to prevent ingrown toenails
Assessment | Complete Guide With Verified
CorrectAnswers
A community health nurse is teaching a group of older adult clients about interventions to prevent
pneumonia. Which of the following instructions should the nurse include in the teaching?
- ANSWER-
Wash your hands when you return home from running errands
A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the
following findings should the nurse identify as a risk factor for developing cholecystitis?
- ANSWER-
Client is taking atorvastatin
A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain.
The client has a heart rate of 66/min and a respiratory rate of 9/min. Which of the following
medications should the nurse anticipate the provider willscribe
pre for the client?
- ANSWER-
Naloxone
A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux.
Which of the following information should the nurse include in the teaching?
- ANSWER-Plan to
finish eating at least 3 hr before bedtime
A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings
should the nurse expect? - ANSWER-Circumoral tingling
A nurse is leading a small group discussion in an acute care mental health facility when one client
suddenly begins to experience a panic attack. Which of the following actions should the nurse
- take?
ANSWER-Remain with the client until manifestationsside sub
A nurse in an emergency department is assessing a client who reports severe constipation. The nurse
should identify which of the following findings as an indication that the client might have- a small
bowel obstruction?- ANSWER-Visible peristaltic waves in the upper abdomen
A nurse is reviewing the urinalysis results of a client who has completed
-day
a 14
course of
ciprofloxacin to treat pyelonephritis. Which of the following values should indicate to the nurse that
the client has a continuing infection?
- ANSWER-Positive leukocyte esterase
, A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right
kidney. Which of the following findings should the nurse instruct the client to report to the provider?
-
ANSWER-Painful urination
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following
findings is a priority to report to the provider?
- ANSWER-Hemoglobin 7.6 mg/dL
A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2
50mm Hg, and HCO3- 25 mEq/L after experiencing an airway obstruction. Which of the following
interventions is the nurse's priority for this client?
- ANSWER-Apply oxygen therapy to the client
A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse
expect?- ANSWER-Exophthalmos
A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for
a hearing aid. Which of the following client statements indicates an understanding of the teaching?
-
ANSWER-"I will make sure the hearing aid is off befo
re inserting it in my ear"
A nurse is assessing a client who has an ulcer due to peripheral vascular disease. Which of the
following findings should the nurse identify as an indication that the client has a venous ulcer rather
than an arterial ulcer?
- ANSWER-Discoloration and edema of the right ankle
A nurse is providing home care instructions to a client who had a-arm
shortplaster cast applied for a
wrist fracture. Which of the following instructions should the nurse include?
- ANSWER-Elevate the
wrist above heart level
A nurse is providing discharge planning for a client who has gestational diabetes. Which of the
following interventions should the nurse identify as the priority?
- ANSWER-Determine the client's
knowledge regarding gestational diabetes
A school nurse is assessing a school
-age child who has erythema infectiosum (fifth disease). Which of
the following manifestations should the nurse expect?
- ANSWER-Facial eruption
A nurse is teaching about foot care with a group of older adults who have type 1 diabetes mellitus.
Which of the following information should the nurse include in the teaching?
- ANSWER-Trim
toenails straight across to prevent ingrown toenails
