ATI CBC 3 - Exam A
A nurse is providing family education for a client who wishes to conceive...the nurse
should identify that ovulation is expected to occur on which of the following calendar
dates? - D-the 19th.
The nurse should teach the client that ovulation is expected to occur 13-15 days after
day one of her menses.
A nurse in an acute care mental health facility is planning care for a client who has
bipolar disorder and who is experiencing acute mania. What action should the nurse
take? - Provide the client with finger foods to eat.
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the
infant exhibits a sudden onset of cyanosis and is hyperpneic. What action should the
nurse take? - Place the infant in a knee-chest position.
This maximizes the oxygenation status of the infant during hypercyanotic episodes
A nurse is providing discharge teaching to a client following gastric bypass surgery for
management of obesity. What is a client statement that indicates understanding of the
teaching? - "I will remain in a reclining position for 30 minutes after I eat"
Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining
in a reclining position slows gastric emptying and minimizes the risk of dumping
syndrome.
A nurse is teaching a client who has genital herpes simplex virus. What statement
should the nurse include in the teaching about this STI? - "You should cleanse the
lesions with a saline solution twice each day."
This helps to prevent secondary bacterial infections.
A nurse is caring for a client who has a terminal illness and is approaching death. Which
of the following actions should the nurse take? - Apply a thin coating of lip balm to the
client's lips.
A client who is dying can experience dehydration. Applying lip balm to the client's lips
promotes comfort.
A nurse in an emergency department is assessing a client who was in a motor-vehicle
crash. The client has a BAC of 0.18% and states, "I would never drink and drive." This
is demonstrating use of which defense mechanism? - Denial
Client refuses to acknowledge the reality of a situation.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is
experiencing moderate placental abruption. What should the nurse do? - Insert a large-
bore IV catheter.
, A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid
volume and blood replacement might be necessary to correct defects in coagulation.
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of
the following interventions should the nurse plan to include? - Palpate for changes in the
muscle of the affected extremity.
The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or
swelling. These manifestations indicate enlargement of the tumor.
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum
hemorrhage. What actions should the nurse take immediately? - Massage the client's
fundus
The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots
and promotes contractions.
An intensive care nurse is providing education about organ and tissue donation to the
parent of an adolescent who has died following a motor-vehicle crash. Which of the
following responses by the parent indicates an understanding of the teaching? - "No one
will notice the organs were donated if we have an open casket at the funeral".
The nurse should reassure the parents that organ transplantation does not change the
appearance of the body.
A nurse in an emergency department is creating a plan o care for a client who reports a
recent sexual assault. What intervention should the nurse include? - Explain to the client
the reason each procedure is conducted.
It is important to explain the reason each assessment procedure is conducted and why
b/c a client who reports a recent sexual assault is extremely vulnerable.
A community health nurse is assessing an older adult client. Which of the following
situations should the nurse identify as a possible indication of undue influence? - The
client's niece moves into her home to provide care.
Undue influence can occur when an older adult moves into someone's home, or when
someone moves into their home to provide better care for the client.
A nurse is preparing to administer immunizations to a 2 mo. old infant at a well-child
visit. What immunization should the nurse plan to administer? - Haemophilus influenzae
type b
This vaccine is administered in a series of 3-4 doses starting at 2 mo. of age
A nurse is discussing palliative care with the family of a client who is terminally ill. Which
of the following information should the nurse include? - Palliative care includes a variety
of therapies.
Palliative care includes a holistic approach using a variety of therapies to improve the
client's level of comfort.
A nurse is providing family education for a client who wishes to conceive...the nurse
should identify that ovulation is expected to occur on which of the following calendar
dates? - D-the 19th.
The nurse should teach the client that ovulation is expected to occur 13-15 days after
day one of her menses.
A nurse in an acute care mental health facility is planning care for a client who has
bipolar disorder and who is experiencing acute mania. What action should the nurse
take? - Provide the client with finger foods to eat.
A nurse is caring for an infant who has Tetralogy of Fallot. The nurse notes that the
infant exhibits a sudden onset of cyanosis and is hyperpneic. What action should the
nurse take? - Place the infant in a knee-chest position.
This maximizes the oxygenation status of the infant during hypercyanotic episodes
A nurse is providing discharge teaching to a client following gastric bypass surgery for
management of obesity. What is a client statement that indicates understanding of the
teaching? - "I will remain in a reclining position for 30 minutes after I eat"
Following gastric bypass surgery, clients are at risk for dumping syndrome. Remaining
in a reclining position slows gastric emptying and minimizes the risk of dumping
syndrome.
A nurse is teaching a client who has genital herpes simplex virus. What statement
should the nurse include in the teaching about this STI? - "You should cleanse the
lesions with a saline solution twice each day."
This helps to prevent secondary bacterial infections.
A nurse is caring for a client who has a terminal illness and is approaching death. Which
of the following actions should the nurse take? - Apply a thin coating of lip balm to the
client's lips.
A client who is dying can experience dehydration. Applying lip balm to the client's lips
promotes comfort.
A nurse in an emergency department is assessing a client who was in a motor-vehicle
crash. The client has a BAC of 0.18% and states, "I would never drink and drive." This
is demonstrating use of which defense mechanism? - Denial
Client refuses to acknowledge the reality of a situation.
A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is
experiencing moderate placental abruption. What should the nurse do? - Insert a large-
bore IV catheter.
, A 16-18 gauge IV catheter is to be inserted into the client's brachial artery because fluid
volume and blood replacement might be necessary to correct defects in coagulation.
A nurse is planning care for a client who has a benign chondroma of the tibia. Which of
the following interventions should the nurse plan to include? - Palpate for changes in the
muscle of the affected extremity.
The nurse should palpate to monitor for changes such as muscle spasm, atrophy, or
swelling. These manifestations indicate enlargement of the tumor.
A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum
hemorrhage. What actions should the nurse take immediately? - Massage the client's
fundus
The greatest risk to the client is hemorrhage. Massaging the client's fundus expels clots
and promotes contractions.
An intensive care nurse is providing education about organ and tissue donation to the
parent of an adolescent who has died following a motor-vehicle crash. Which of the
following responses by the parent indicates an understanding of the teaching? - "No one
will notice the organs were donated if we have an open casket at the funeral".
The nurse should reassure the parents that organ transplantation does not change the
appearance of the body.
A nurse in an emergency department is creating a plan o care for a client who reports a
recent sexual assault. What intervention should the nurse include? - Explain to the client
the reason each procedure is conducted.
It is important to explain the reason each assessment procedure is conducted and why
b/c a client who reports a recent sexual assault is extremely vulnerable.
A community health nurse is assessing an older adult client. Which of the following
situations should the nurse identify as a possible indication of undue influence? - The
client's niece moves into her home to provide care.
Undue influence can occur when an older adult moves into someone's home, or when
someone moves into their home to provide better care for the client.
A nurse is preparing to administer immunizations to a 2 mo. old infant at a well-child
visit. What immunization should the nurse plan to administer? - Haemophilus influenzae
type b
This vaccine is administered in a series of 3-4 doses starting at 2 mo. of age
A nurse is discussing palliative care with the family of a client who is terminally ill. Which
of the following information should the nurse include? - Palliative care includes a variety
of therapies.
Palliative care includes a holistic approach using a variety of therapies to improve the
client's level of comfort.
