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ATI PRACTICE A QUIZ 1020 ALREADY
PASSED
A NURSE IS PROVIDING HYGIENE CARE FOR A CLIENT WHO IS IMMOBILE WHICH
OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE? (Select all that Apply)
A: Check for personal items when changing the bed linens
B: Place a Clean Gown on the strongest arm first
C: Keep the bath water temperature between 43.3 C (110F) and 46.1 C (115F)
D: Shave the client's hair in the direction of the hair growth
E: Wash the client's extremities from proximal to distal โโA, C, D
A nurse is planning care for an older adult who is at risk for developing pressure ulcers. which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
A: Use a transfer device to lift the client up in the bed
B: Apply cornstarch to keep sensitive skin areas dry
C: Massage the skin over the client's bony prominences
D: Elevate the head of the bed no more than 45* โโA
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feeding via a gastrostomy tube due to an inability to swallow. Which of the following is a priority action by the nurse?
A: observe the client's respiratory status
B: Elevate the head of the client's bed 30* to 45*
C: Monitor intake and output every 8 hours
D: Check residual volume every 4 to 6 hours โโB
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?
A; obtain the client's consent
B: Witness the Client's signature
C: Explain the risks and benefits of the procedure
D: Explain the procedure to the client if they do not understand โโB
A nurse is attending a social event when another guest coughs weakly once, gasps his throat with his hands, and cannot talk. Which of the following actions should the nurse should take?
A: observe the client before taking further action
B: perform the heimlich maneuver
A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
A: wraps the blood pressure cuff snugly around the clients arm
B: Places the client's arm above the level of the clients heart
C: Checks the instrument gauge to ensure the reading starts at zero
D: Centers the cuff bladder over the client's brachial artery โโB
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
A: Wait 30 mins and return to measure the oral temperature
B: Provide the client a sip of warm water, wait 5 mins, and measure the temperature
C: Document that the nurse was unable to measure the client's temperature
D; Proceed to measure the oral temperature โโA
A nurse is caring for several clients who are at various developmental stages. the nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?
A: autonomy vs shame and doubt
B: generatively vs stagnation
C: identity vs role diffusion
D: integrity vs despair โโD
a nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?
A: I will begin 48 hrs before the client's discharge
B: I will begin once the client's discharge order is written
C: I will begin upon the client's admission to the facility
D: I will begin once the client's insurance company approves the discharge coverage โโC
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions
A: Excessive thirst and urination
B: Shakiness and diaphoresis
C: Fever and chills
D: Hypertension and crackles โโB
B: HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form
C: A clients address would be an example of personally identifiable information
D: HIPAA is a federal law, not a state law. โโA
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?
A: Planning
B: Evaluation
C: Assessment
D: Implementation โโC
A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, " Why do I need that? I am drinking plenty of fluids."Which of the following responses should the nurse provide?
A; It is quicker to administer medications intravenously in the hospital
B: Clients over the age of 65 must have a saline lock according to facility policy
C: We administer all medications intravenously to clients in this unit.
D: Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours โโD
A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
A: assess the apical pulse for a full minute
B: assess the apical pulse with a doppler device
C: assess the pedal pulses for a full minute
D: assess the pedal pulses with a doppler device โโA
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse is 100/min, respiratory rate is 24/min, BP 132/76 mmHg, and temperature is 36.8 *C (98.2 *F). which of the following actions should the nurse perform?
A: complete a neurological check
B: administer the prescribed PRN antihypertensive medication
C: increase the client's fluid intake
D: Hold the clients evening dose of digoxin โโA
A; more difficulty seeing due to a greater sensitivity to glare
B: decreased cough reflex
C: decreased bladder capacity
D: decreased systolic blood pressure
E: dehydration of the intervertebral discs โโA, B, C, E
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?
A: battery
B: assault
C: Malpractice
D: Abuse โโC
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
A: use a stiff toothbrush to clean the client's teeth
B: use the thumb and index finger to keep the client's mouth open
C: turn the client on his side before starting oral care
D: Apply Petroleum jelly to the client's lips after oral care โโC
A nurse is preparing to perform hang hygiene. Which of the following actions should the nurse take?
A: adjust the temperature to feel hot
B: Apply 4 to 5 ml of liquid soap to the hands
C: hold the hands higher than the elbows
D: rub hands and arm to dry โโB
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiologic changes? (SELECT ALL THAT APPLY)
A: Decrease gastric motility
B: decreased skin elasticity
C: increased pain threshold
D: Increased metabolic rate
E: Increased cardiac output โโA, B C
The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment the nurse notes that the client flinches when she
A: There were no injuries sustained
B: AN incident report was completed
C: an incident report was forwarded to risk management
D: the provider was notified โโD
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin?
A: reposition the client every 3 hours
B: Massage bony prominences to promote circulation
C: provide the client with a diet high in protein
D: Apply cornstarch to keep the skin dry โโC
A nurse is assisting with transferring a client from the bed to a wheelchair. which of the following actions should the nurse take?
A: place the wheelchair at a 90* angle to the bed
B: Lock the wheels of the bed and the wheelchair
C: Acquire the help of several people to lift the client
D: Elevate the bed to a position of comfort for the nurse โโB
A nurse is caring for a client who requires droplet precautions. which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?
A: gloves
B: goggles
C: Gown
D: Mask โโD
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?
A: lordosis
B: Ankylosis
C: Kyphosis
D: Scoliosis โโC
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?
A: logging out of the computer before leaving a terminal
B: sharing computer passwords with coworkers
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. which of the following actions should the nurse take to address the client's safety needs.
A; call the family and ask them to stay with the client
B: move the client to a room closer to the nurse's station
C: apply wrist and leg restraints to the client
D: administer medication to sedate the client โโB
A nurse is removing Personal Protective Equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse removes first?
A: Gown
B: Gloves
C: Face Shield
D: Mask โโB
A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
A: An adolescent who has a cervical fracture and is in a halo brace
B: A young adult who has a femur fracture and is in skeletal balanced suspension traction
C: A middle adult who has a fractured radius and an arm cast
D: an older adult who has a hip fracture and is in Buck's Traction โโD
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
A: Testing Visual Acuity
B: Observing For Facial Symmetry
C: Eliciting the gag reflex
D: Checking the pupillary response to light โโD
