ATI RN Fundamentals online practice 2019 B with NGN

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? - answer The caregiver insists on remaining in the room A middle adult client tells the nurse "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? - answer "People in middle adulthood often find satisfaction in untiring and guiding young people." A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? - answer Initiate an enteral feeding through a gastrostomy tube A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? Round to nearest whole number - answer 8 ml/hr 800 units/hr x 250ml /25,000 units A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following client statements? - answer The pain is like a full ache in my stomach A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? - answer I flushed what I urinated at 7:00 am and have saved all urine since A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? - answer Rapid heart rate A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - answer When descending stairs, I will shift my weight to my right leg. A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? - answer Current medications A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? - answer Arrange food in a consistent pattern on the clients plate A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? - answer Walking briskly A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? - answer -check the cord routinely for frays or tearing is correct -consider purchasing a generator for power backup -observe for signs of hypoxia A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? - answer A client who has asthma A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? - answer Spect a suction catheter that is half the size of the lumen A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? - answer Instruct the family to refrain from pushing the button for the client while she is asleep. A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? - answer N95 A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? - answer I can take echinacea to improve my immune system A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? - answer The newly licensed nurse places the cap of the bottle of sterile salon solution on the sterile field. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? - answer Withhold the blood transfusion A nurse on a medical unit is preparing to discharge a client to home. Which of the following should the nurse take as part of the medication reconciliation process? - answer Compare prescriptions with medications the client received while at the facility A charge nurse is discussing the responsibility of nurses caring for clients who have a C-diff infection. Which of the following information should the nurse include in the teaching? - answer Have family members wear a gown and gloves when visiting. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? - answer Ambulating a client who is postoperative A nurse is calculating a clients fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the clients intake and output record as 120 malodorous fluid? - answer 8 oz of ice chips A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the BP? - answer 120 mm Hg A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility? - answer Witness the clients signature on the consent form. A nurse in a surgical suite notes documentation on a clients medical record that he has a latex allergy. In preparation for the clients procedure, which of the following precautions should the nurse take? - answer Wrap monitoring cords with stockinette and tape them in place. A nurse manager is overseeing the care on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? - answer A nurse asks a nurse from another unit to assist with documentation for a client A nurse has Accepted a verbal prescription for 3/10 of a milligram of levothyroxine IV stat for a client who has myxedema coma how should the nurse transcribe the dosage of this medication in the clients medical record? - answer 0.3 mg A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? - answer A client who smokes one pack of cigarettes each day A nurse is reviewing a clients medication prescription that reads, Digoxin 0.25 by mouth every day. Which of the following components of the prescription should the nurse verify with the provider? - answer Medication dose A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? - answer what could I have done to deserve this illness? A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? - answer Flush the tube with 15 mL of Sterile water A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures? - answer Apply and ankle - foot orthotic device to the clients feet A client who is non-ambulatory notifies the nurse that his trashcan is on fire. After the nurse confirms the presence of the fire, which of the following action should the nurse take next? - answer Evacuate the client A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessment should the nurse identify as the priority? - answer Auscultate lung sounds A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psycho motor approach to learning? - answer Practice sessions A nurse is giving change - of - shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? - answer Breath sounds A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? - answer Assess the client for orthostatic hypotension A nurse is caring for a client who has a prescription for five units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure - answer 1.) inject 10 units of air into NPH 2.)inject 5 units of air into regular 3.)withdraw the correct amount of regular insulin 4.)withdraw the correct dose of NPH insulin A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse Identify as indicating infiltration? - answer Skin blanching A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? - answer You should have a fecal occult blood test every year A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? - answer Tell the client to keep the head of the bed elevated at least 30° A nurse is preparing to administer 0.5 ML of oral single dose liquid medication to a client. Which of the following actions should the nurse take? - answer Gently shake the container of medication prior to administration A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? - answer Maintain a consistent time to wake up each day A nurse is caring for a group of clients on a medical surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity(telling the truth)? - answer A client who is una