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2025
A community health nurse is caring for a group of families. The nurse should
identify that which of thefollowing families is experiencing a maturational loss?
a. A family whose only child recently died due to cancer.
b. A family whose head of household lost her job.
c. A family whose house was destroyed in a fire.
d. A family whose oldest child is moving away for college
Rationale: Flashcardmachine: Maturational loss- experienced as a result of natural
developmental processes.
E.g. The first child may experience a loss of status when her sibling is born. Also,
happens when sendingchildren off to kindergarten or college.
A nurse on a medical-surgical unit is dividing care for four clients. The nurse
should identify which of thefollowing situations as an ethical dilemma?
a. A client who has a new colostomy refuses to take instructions from the ostomy
therapist because she“doesn't like him.”
b. A surgeon who removed the wrong kidney during a surgical procedure refuses
to take responsibility forher actions.
c. The family of a client who has a terminal illness as the provider not to tell
the client the diagnosis.
d. A client who has Crohn's disease reports that his prescription drug plan will not
pay for his medications.Rationale: ATI FUNDA pg. 11 it involves between two moral
imperatives; answer will have a profound effect on the situation and the client.
A nurse is caring for a client who has chronic back pain and asked about
receiving acupuncture for relief.Which of the following findings should the nurse
identify as a contraindication to receiving this shipment?
, a. Obesity
b. Hypertension
c. Migraines
d. Cellulitis
◗ Rationale: Google: You can’t have acupuncture in a very swollen area e.g.
Cellulitis; and it’s a risk forinfection
◗ Rationale: Contraindicated in people who have bleeding disorders and skin
infections. Fundamentals pg694
A nurse is auscultating a client's abdomen. The nurse hears a blowing sound over
the aorta. The nurse shouldidentify this sound as which of the following?
a. Gallop
b. Bruit
c. Thrill
d. Murmur
Rationale: Bruit- turbulent blood flow within the aorta.
2013 - Folder 1
,1-39
1. A nurse is providing teaching to a client who has a new med prescription.
Which of the followingmanifestations of a mild allergic reaction should the
nurse include?
a. Ptosis
b. Hematuria
c. Urticaria
d. Nausea
2. A nurse is providing teaching to a client who has diabetes mellitus about
performing a capillary bloodglucose test. Which of hte following instructions should
the nurse include in the teaching?
a. Don sterile gloves prior to puncturing the site
b. Puncture site after cleansing and before antiseptic dries.
c. Gently squeeze the puncture site until a large droplet of blood forms
d. Hold the finger to puncture above the level of the heart
3. A nurse is providing teaching to a client about reducing the adverse effects of
immobility. Which of thefollowing statements by the client indicates an
understanding of the teaching?
a. I will perform ankle and knee exercises every hour- ROM is needed to
prevent contractures .
b. I will hold my breath when rising from a sitting position
c. I will remove my antiembolic stockings while I am in bed
d. I will have my partner help me change positions every 4 hours
4. A nurse is monitoring a client who is receiving continuous IV fluid therapy via a
peripheral vein in the leftforearm. Which of the following findings indicates that the
client has developed phelbitis at the IV site?
a. Erythema along the path of the vein
b. Pitting edema at the insertion site- infiltration since water is probably displaced.
, c. Coolness of the client’s left forearm - infiltration
d. Pallor of the client’s left forearm
5. A nurse is planning care for a client who reports insomnia. Which of the following
actions should the nurseperform shortly before bedtime?
a. Provide a late supper
b. Offer a wet washcloth for the client to wash her face
c. Perform range of motion excercise
d. Prepare a hot cocoa or tea for the client
6. A nurse is providing teaching to a newly licensed nurse about the care of a client
who has MRSA. Which ofthe following statements by the newly licensed nurse
indicates an understanding of teaching?
a. I will place the client in a private room
b. I will tell the client’s visitors to wear a mask when they are within 3 feet of the
client
c. I will remove my gown after leaving the client’s room
d. I will wear an N95 respirator mask when caring for the client
7. A nurse is teaching a client who requires maximal support about how to use a two
wheeled walker. Which ofthe following actions by the client indicates an
understanding of teaching.
a. The client moves the walker ahead 25.4cm with each step
b. The client picks up the walker with each step
c. The client stands with her elbow slightly while holding the walker
d. The client stoops slightly forward when moving the walker
8. A nurse in a provider’s office is caring for a client who states “I always have trouble
sleeping”. Which of thefollowing actions should the nurse take first?