ATI Concept Level 1 EXAM A

ATI Concept Level 1 EXAM A A nurse manager is developing a facility policy about the use of a fax machine to communicate information from a client's electronic medical record (EMR). What should the nurse include in the policy? Use a coversheet when sending a fax from the health care unit A nurse is caring for a client who is 2 days post operative following an above the knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. What should the nurse do to treat the patient neuropathic pain? Administer a beta-blocking medication to the client. A nurse is assessing a client who has fibromyalgia. What treatment modality prescription should the nurse expect for the clients mixed pain? Pregabalin PO twice daily A nurse is planning a menu for a client who practices Seventh-Day Adventism. What food selection should the nurse take? Scrambled-eggs A nurse is providing teaching to a client who has chronic-fatigue syndrome, what should the nurse say? Take NSAIDs for body aches and pains. A nurse is using therapeutic communication to attempt de-escalation with a client who is yelling at staff members. What statement should the nurse make? Tell me what is causing your anger at this moment. A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. What actions should the nurse manager take the promote interoperability. Recommend a single coding system for each department to use. A nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting (CINV) during her previous round of treatment. What intervention should the nurse include in the patient's plan of care? Administer ondansetron to the client prior to chemotherapy administration. A nurse is teaching a client about strategies to prevent constipation. What instructions should the nurse include? "Perform moderate exercises daily" "Add more whole grains to you diet" "Increase your fluid intake" A nurse is documenting an assessment in a client's electronic health record who an assistive personnel (AP) asks to enter the morning blood glucose for the client. What actions should the nurse take? Request that the AP use another computer to enter the data. A nurse is performing a focused assessment on a client who has chronic pain die to fibromyalgia. What should the nurse ask to assess the quality of the client's pain? Can you describe what your pain feels like? A nurse is preparing to leave the room of a client who is on isolation precautions. What action should the nurse take when removing a tied surgical mask? Remove the mask by securely holding the ties and moving it away from the face. A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. What finding should the nurse identify as a need for administration of a PRN pain medication? Rapid breathing. A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. What action should the nurse take? Have the patient lie supine A nurse is preparing a client for an elective vaginal hysterectomy when the client states, "My doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already singed that consent form" What response should the nurse make? You have the right to refuse this and any other procedure, even after you have signed the consent form. A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. What information should the nurse plan to include? An adult client may be in a mechanical restraint for up to 4 hours. A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In what order should the nurse take action? 1.Assist the client to an upright position 2.Aspirate 5mL of gastric content 3.Test the pH of gastric aspirate 4.Measure gastric residual volume 5. Flush the NG tube with 30 mL of water. A nurse is planning a community health program about substance use disorders. What information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? A healthy woman of any age should consume no more than 7 drinks in a week. A nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion. What actions should the nurse take? Document the client's status every 15 min. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80 mg/0.8 mL. How many mL should the nurse administer? 1.2 mL A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. What action should the nurse take to provide emotional support to the parent? Inform the parent that anger is a natural response when dealing with loss. A nurse is preparing to document care in a client's medical record. In adherence with the Joint Commission National Patient Safety Goals regarding communication errors, what entries should the nurse make? "Client medicated with morphine 5 mg IM for pain" A nurse is preparing to administer a medication via intermittent IV bolus to a client who is receiving a continuous infusion via an infusion pump. The client's IV fluid solution is incompatible with the bolus, What action should the nurse take first? Stop the continuous IV infusion. A nurse on the medical-surgical unit is caring for a group of clients. The nurse should identify that what type of pain is classified as neuropathic? Spinal nerve pain, postherpetic neuralgia pain, phantom limb pain. A nurse on a pediatric unit is admitting an infant who has pertussis, what isolation precautions should the nurse initiate? Droplet A nurse is preparing to collect a stool specimen from a client who has had diarrhea for 3 days, with fever and abdominal cramping. When reviewing the client's recent medication administration record, the nurse should recognize that treatment with what medication increases the clients risk of developing a Clostridium difficile infection? Ciproflaxin. A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. What statement should the nurse include in the teaching? "Websites ending in '.gov' are reliable sites for obtaining health information from government agencies. A nurse is caring for a client who has Clostridium difficile infection and is incontinent of stool following long-term antibiotic therapy. What action should the nurse make? Wear a gown when providing care for the client. A charge nurse is teaching a group of newly licensed nurses how to prevent errors during administration of blood transfusions. What actions should the nurse include? Use a new blood administration tubing set for each blood bag infused A nurse is preparing to admit a client to the hospital. What action should the nurse take first? Determine the need for an interpreter A nurse is providing teaching to the parent of a 6-year-old girl about preventing UTIs. What statement by the parent indicates an understanding of the teaching. "I will increase her intake of foods high in fiber" A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. What actions should the nurse plan to take? Gradually lengthen the time between the client's scheduled voids. A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is accompanied by his 16 year-old mother and his maternal grandfather. What action should the nurse take when assisting with informed consent? Witness consent obtained from the infant's mother. A nurse is provider's office is counseling a client who reports insomnia. What statements should the nurse make to include the client's preferences into a sleep promotion plan? "Sleep in the location of your home where you feel you rest best" A nurse is providing dietary teaching to a client who has diarrhea. What instructions should the nurse include? "Increase your intake if potassium-rich foods when you are experiencing diarrhea" A nurse is teaching sleep hygiene to a client who has insomnia. What statement should the nurse make? Exercise in the morning after arising A nurse is caring for an older adult who has a leg wound following a fall on the stairs. The nurse should identify what factors as an expected, age-related change in older adults that can impair wound healing? Elastin fiber separation and thicken A nurse is preparing to administer three medications to a client who has an NG tube: A levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule. What action should the nurse take? Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water. A nurse is preparing to administer morphine 5 mg IM from a 10 mg/mL viral to help manage a client's acute pain. What action should the nurse plan to take after administering a controlled substance? Have a second nurse witness and initial the disposal of the remaining medication. A nurse in an orthopedic clinic is documenting data about several clients. What actions should the nurse take to comply with the regulations of HIPAA? Lock or log off computers whenever he leaves the area A nurse is caring for a 2-year old toddler who is immediately postoperative. What pain scale should the nurse use to assess the toddler's pain level? FLACC scale A nurse is caring for a 47-year old female client who has urinary incontinence. What action should the nurse take first? Obtain a specimen from the client for culture A nurse is reviewing a client's new prescriptions that were just documented in the client's medical record by the provider. What abbreviation should the nurse classify with the provider? Enoxaparin 40 mg SQ QD A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. What statement by the client indicates an understanding of the teaching? "I should use a warm paraffin dip for my hands and feet." A nurse is providing discharge teaching about nutrition management to a client who has COPD. What instruction should the nurse include in the teaching? Have a high-calorie protein drink between meals A nurse is caring for an older adult client who has osteoarthritis and plans to go to an assisted living facility due to decreased mobility. What actions should the nurse take when acting in the role of client advocate. Research facilities for the client that best meet her specific needs. A nurse on a medical-surgical unit is caring for a group of clients. What clients should the nurse monitor for the development of reflex urinary incontinence. A client who has a T12 spinal cord injury. A nurse is teaching a client who is postpartum about preventing injury when using a car seat for her newborn. What instructions should the nurse include? Install the car seat so that it is facing the rear of the vehicle. A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. What online sources should the nurse select to research this infant care issue? Cumulative index to Nursing and Allied Health Literature (CINAHL) A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the nurse how to prevent further reactions. What responses should the nurse make? "Wash your child's exposed clothing with hot water and detergent" A nurse is preparing to contact a client's provider regarding the need for a prescription for pain medications. When using the SBAR communication tool, the nurse should provide what information in the assessment portion of the tool? "The client is in audible distress and rates her pain as an 8 own a scare from 0-10." A nurse is asked by a provider to perform an invasive procedure for which he has not received training. What action should the nurse take to ensure that it is within his legal scope of practice to perform this procedure? Check the state's nurse practice act before performing the procedure. A nurse is caring for a client who has dysphagia following a stroke. What action should the nurse take to facilitate safe swallowing and decrease the risk of aspiration. Delay the client's meal-time if he is fatigued. A newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. What responses should the charge nurse make? "The state board of nursing can provide this information" A home health nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. What statements should the nurse make? "Have your child rest with his head elevated after meals" A nurse is admitting a client who has pulmonary tuberculosis. What transmission-based precautions should the nurse initiate? Airborne A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent GI cancers. What image indicates a food or beverage the nurse should encourage the client to include liberally in his diet. Fruits A nurse is developing a plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty, what interventions should the nurse include? Place grab bars by the toilet. A nurse is assessing the spiritual wellbeing an development of a preschooler. The nurse asks the preschooler, "Why is it wrong to kick your baby sister?" What responses should the nurse expect? "It's wrong because my dad said I can't kick her" A nurse is assessing a preschooler who has a UTI. What findings should the nurse expect? Abdominal pain A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. What plan should the nurse recommend as part of tertiary prevention? Start a needle-exchange program A hospice nurse is planning care for a client who has terminal cancer. The client tells the nurse that she practices the Hindu religion. What interventions should the nurse include in the plan of care to support the client's cultural beliefs? Allow time for a family member to perform a ritual bath after the client dies. A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify which ethnic groups in the community is at greatest risk for developing hypertension? African Americans A nurse in a long term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, what actions should the nurse take? Compare a list of the clients current medications with the ones he will take in LTC A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/ hr? 125mL/hr A nurse is caring for a client who has cancer and is planning discharge to home with hospice care. What statement by the client indicates that he is experiencing spiritual distress? "I wish God had not allowed this cancer to invade my body" A nurse is reviewing the medication administration record of a client who is 2 days post operative following abdominal surgery. The nurse should identify that what medications can result in delayed wound healing? Prednisone A nurse in a community health clinic is screening a 10-yr old girl for scoliosis. What instructions should the nurse give the child for this examination. Bend forward at the waist and let your arms hang down. A charge nurse is educating unit staff about the cultural aspects of client care following death. What statement by an assistive personnel indicates an understanding of the teaching? "The body of a client who practices Islam is washed and wrapped in a cloth following death." A nurse is beginning nutrition counseling with a client who has a BMI of 34.2. What question should the nurse ask first to address the client's excessive nutrition and obesity.? "Are you ready to make a lifelong commitment to a healthier lifestyle?" A nurse is preparing to extinguish a small fire in a client's room. What action should the nurse take when using the fire extinguisher? Slide the pin on top of the fire extinguisher straight out. A nurse is providing teaching about nutrition management to the parent of an 18-month old toddler who has phenylketonuria. What foods should the nurse recommend? Baked potato A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission Nation Patient Safety Goals regarding blood administration, what actions should the nurse plan to take? Verify the client and blood component using the two-person process. A nurse is creating a plan of care for a client who is nonambulatory and has bladder and bowel incontinence. What interventions should the nurse include to prevent skin break down? Offer the client a glass of water every 2 hours when repositioning. A nurse is planning care for a client who has bacterial meningitis caused by Haemophilus influenza. What of the following infection control interventions should the nurse include in the plan? Place a mask on the client during transport out of the room. A nurse is talking with a client who has major depressive disorder. The client states: "Nobody cares if I'm around or not". What response should the nurse make? "It sounds as though you're feeling hopeless" A nurse in a long term care facility is performing a fall risk assessment on a newly admitted client using the Timed UP and Go (TUG) test. The client reports using a tripod cane for ambulation. What action should the nurse take when using this test? Observe the client ambulating a distance of 3 m (10 feet) during the TUG test. A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk of thromboembolic events. What following actions should the nurse take? Pull up a small amount to skin using the thumb and forefinger of the non-dominant hand. A nurse is planning care for a client who has an indwelling urinary catheter. What interventions should the nurse include in the plan to prevent the development of a catheter-associated urinary tract infection (CAUTI). Secure the catheter tubing to the client's leg. A nurse in a long-term care facility discovers a small fire a client's trash can. After moving the client to safety, which of the following actions should the nurse take next? Pull the alarm to notify emergency services. A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. What action should the nurse plan to take? Ensure the client and the interpreter are combative A nurse is teaching about advance directives with an older adult client who has a terminal illness. What statement should the nurse make? "You're advance directives can designate a friend to make your health care decisions." A nurse is caring for a child who has celiac disease. What item should the nurse remove from the child's meal tray? Oatmeal with raisins. A nurse enters a client's room and finds the client lying on the floor. The client states that on the way to the bathroom her, "knee locked", causing her to fall. What action should the nurse take first? Check the client for injuries A nurse is developing a plan of care for a client who has urinary incontinence. What actions should the nurse include? Apply a moisture barrier cream to the client's skin A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, what statements by the parent indicates an understanding of the teaching? "I can give her watermelon pieces after I remove the seeds" A nurse is planning meals for a client who practices judaism and reports that she strictly adheres to orthodox dietary laws. The nurse should recognize that what dietary practices applies to the client's beliefs? The client is permitted to eat fish that have scales. A nurse in a provider's office is caring for a male client who just turned 50 years old. The client has no significant health problems or family history of health problems. What preventive health screening should the nurse recommend? Initial screening colonoscopy Digital rectal examination Monthly testicular self examination Annual skin examination A nurse is providing change-of-shift report about a group of clients to the oncoming nurse at the end of the shift. What statement should the nurse include? "The client has been very tearful since finding out he has diabetes mellitus. A community health nurse is developing a brochure about the use of smokeless tobacco. What information should the nurse plan to include? Smokeless tobacco provides a higher dose of nicotine than cigarettes. A nurse is preparing to administer an immunization via IM injection into an adult client's deltoid muscle. What actions should the nurse take? Select a 1-inch needle for the injection. A nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric surgery. What dietary recommendations should the nurse take? Eat foods that are high in protein. A nurse is teaching a young adult female about health screening for breast cancer. What statements by the client indicates an understanding of breast self-examination (BSE)? I should expect to feel a firm ridge along the bottom curve of each breast. A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. What action should the nurse plan to take first? Determine the level of health equity among groups in the community. A nurse is talking with a client who reports difficulty adjusting to the death of her partner. What response by the nurse demonstrates the therapeutic communication techniques of reflecting? "What do you think would help you cope with your loss?" A nurse is planning care to prevent a catcher-related blood stream infection for a client who is receiving IV fluid therapy. What interventions should the nurse include in the plan? Perform hand hygiene before toughing the IV tubing. A nurse is preparing to administer enoxaparin subcutaneously to a client who is postoperative following orthopedic surgery. The nurse should plan to administer this medication in what location? B love handle A nurse is developing a plan of care for an older adult client who is at risk of falling. What fall prevention measures should the nurse include in the plan? Ask the client to demonstrate how to use a call light. A nurse is planning care for a newly-admitted school-age child who has rubeola. What isolation precautions should the nurse plan to initiate? Airborne A charge nurse is observing a newly licensed nurse prepare medications for a client. What actions by the newly licensed nurse adheres to safe medication administration practices? The nurse compares the medication label with the client's medication administration record.