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pn ati fundamentals
A nurse working in a hospital overhears the following conversation between two other nurses on the
elevator. Which of the following actions should the nurse take? - Tell the nurses that this conversation is
not appropriate
A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing
following surgery. The client's religion prohibits eating meat on particular days. Which of the following
actions should the nurse take? - Ask the dietitian to recommend alternative food choices for the client
A nurse is collecting data from a client who requires bed rest and reports abdominal discomfort. The
nurse notes abdominal distention. Which of the following conditions should the nurse identify as an
adverse effect of bed rest? - Constipation
A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which
of the following findings is the priority for the nurse to report to the provider? - The client has redness
and warmth in his calf
A nurse is contributing to the plan of care for four clients. Four which of the following clients should the
nurse initiate airborne precautions? - A client who has measles
A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to
immobility. Which of the following actions should the nurse recommend to the include in the plan? -
Support the client's feet with foot boots
A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions
should the nurse use when feeding the client? - Instruct the client to tilt her head forward while eating
A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic
communication technique of silence? - A client who has just experienced the death of his child
A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off her
right leg. Which of the following is the proper crutch gait for the client? - Three-point
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A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction.
Which of the following is the most important question for the nurse to ask? - Have you had small liquid
stools?
A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the
following findings should the nurse report to the provider? - A purple-colored stoma
A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following
findings should the nurse identify as an indication of fluid volume deficit? - Urine specific gravity 1.045
A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions should
the nurse take to maintain the client's confidentiality while providing care? - Provide information to
another nurse at change of shift
A nurse is preparing to obtain a client's vital signs. When washing her hands, which of the following
actions should the nurse take? - Turn off the faucet with a clean paper towel after drying hands
A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the
priority action for the nurse to take? - Measure the client's gastric residual before each feeding
A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following
instructions should the nurse give the partner about turning the client in bed? - Tighten your stomach
muscles
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the
nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the
attention tot he charge nurse prior to the initiation of the therapy? - latex
A Nurse is preparing a client for a Romberg test. Which of the following statements should the nurse
make? - Stand with your feet together and your arms at your sides
A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the
following findings is the priority? - The client's output was 60 mL for the past 3 hours
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A nurse is caring for a client who has breast cancer and expresses fear about the future. Which of the
following responses should the nurse make? - You seem really afraid. let's talk more about your feelings
A nurse is contributing to the plan for care for a client who practices Islam. Which of the following
questions should the nurse ask the client to clarify her religious preferences? - Do you consume pork
products?
A nurse is assisting with the admission of an adult client to the medical-surgical unit. Which of the
following findings should the nurse identify as an indication that the client is malnourished? - Pale, scaly
skin
A nurse is preparing to document information about a client's lower legs, which are swollen with 6mm
edema. Which of the following information should the nurse document? - 3+ pitting edema
A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of
diabetes mellitus. Which of the following actions should the nurse take first? - Ask the client what he
already knows about meal planning
A nurse is checking a client's muscle strength. Which of the following techniques should the nurse use? -
The client shrugs he shoulders while the nurse applies firm pressure over the midline of the shoulders
A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the
following instructions should the nurse include? - You should cleanse your eye from the inner to the
outer edge prior to putting in the drops
A nurse is documenting client care in a client's electronic health record. Which of the following
statements should the nurse include in the documentation? - The client became short of breath when
ambulating
A nurse is administering an intramuscular (IM) injection to an adult client. Which of the following actions
should the nurse take? - Identify the landmarks for the ventrogluteal site before cleaning the skin