Fichas de aprendizaje ATI Fundamentals Practice A, B, & Final, ATI Fundamentals Review 2019 | Quizlet
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3/28/22, 6:44 PM
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ATI Fundamentals Practice A, B, & Final, ATI
Fundamentals Review 2019
Términos de la unidad (278)
A nurse is reviewing a client's
The dose
medication prescription, which
reads, "digoxin 0.25 by mouth
every day." Which of the
following components of the
prescription should the nurse
question?
A client who reports shortness
Observe the rate, depth, and character of the
of breath requests her nurse's
client's respirations.
help in changing positions.
After repositioning the client,
which of the following actions
should the nurse take next?
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A nurse is caring for a client
Lower the client to the floor and place a pad under
who, while sitting in a chair,
the client's head.
starts to experience a seizure.
Which of the following actions
should the nurse take?
A home health nurse is
Educating clients about the recommended
planning to provide health
immunization schedule for adults
promotion activities for a
group of clients in the
community. Which of the
following activities is an
example of the nurse
promoting primary
prevention?
A nurse is using the I-SBAR
Assessment
communication tool to provide
the client's provider with
information about the client.
The nurse should convey the
client's pain status in which
portion of the report?
A nurse is caring for a client
Edema at the infusion site
who is receiving IV therapy via
a peripheral catheter. The
nurse should identify that
which of the following findings
is an indication of infiltration?
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A nurse is providing discharge
3/28/22, 6:44 PM
Washing dishes
teaching to a client who is
recovering from lung cancer.
The provider instructed the
client that he could resume
lower-intensity activities of
daily living. Which of the
following activities should the
nurse recommend to the
client?
A nurse is caring for a client
Daily weight
who has acute renal failure.
Which of the following
assessments provides the most
accurate measure of the
client's fluid status?
A nurse is planning to assess
Inspection
the abdomen of a client who
reports feeling bloated for
several weeks. Which of the
following methods of
assessment should the nurse
use first?
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3/28/22, 6:44 PM
A nurse is explaining the use of
A client who has a prescription for a transfusion of
written consent forms to a
packed red blood cells
newly-licensed nurse. The
nurse should ensure that a
written consent form has been
signed by which of the
following clients?
A nurse in a long-term care
"It must be difficult to care for someone who is
facility is admitting a client
confined to bed."
who is incontinent and smells
strongly of urine. His partner,
who has been caring for him at
home, is embarrassed and
apologizes for the smell.
Which of the following
responses should the nurse
make?
A nurse in a provider's office is
Bounding pulse
assessing a client who has
heart failure. The client has
gained weight since her last
visit and her ankles are
edematous. Which of the
following findings by the nurse
is another clinical
manifestation of fluid volume
excess?
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A nurse is caring for a client
3/28/22, 6:44 PM
Cover the incision with a moist sterile dressing.
who is postoperative following
abdominal surgery. Which of
the following actions should
the nurse take first after
discovering that the client's
wound has eviscerated?
A nurse is teaching a client
"Bear weight on both of your legs."
who has lower extremity
weakness how to use a fourpoint crutch gait. Which of the
following instructions should
the nurse include in the
teaching?
A nurse in a provider's office is
Liver Damage
collecting information from an
older adult client who reports
that he has been taking
acetaminophen 500 mg/day
for severe joint pain. The nurse
should instruct the client that
large doses of acetaminophen
could cause which of the
following adverse effects?
A nurse is planning to
PC for after meals
document care provided for a
client. Which of the following
abbreviations should the nurse
use?
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A nurse is responding to a
A 10-month-old infant can pull up to a standing
parent's question about his
position.
3/28/22, 6:44 PM
infant's expected physical
development during the first
year of life. Which of the
following information should
the nurse include?
An assistive personnel (AP) is
The AP hangs the collection bag at the level of the
assisting a nurse with the care
bladder.
of a female client who has an
indwelling urinary catheter.
Which of the following actions
by the AP indicates a need for
further teaching?
A newly licensed nurse is
Consult the medication reference book available
preparing to administer
on the unit.
medications to a client. The
nurse notes that the provider
has prescribed a medication
that is unfamiliar to her. Which
of the following actions should
the nurse take?
A nurse is providing oral care
Place the client in a lateral position with the head
for a client who is unconscious.
turned to the side before beginning the procedure.
Which of the following actions
should the nurse take?
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3/28/22, 6:44 PM
A nurse is planning to perform
Repeat each joint motion five times during each
passive range-of-motion
session.
exercises for a client. Which of
the following actions should
the nurse take?
A nurse is teaching a client
Cough deeply after each use.
who is postoperative how to
use a flow-oriented incentive
spirometer. Which of the
following instructions should
the nurse include?
A nurse is teaching a client
Have the client demonstrates the procedure.
how to self-administer insulin.
Which of the following actions
should the nurse take to
evaluate the client's
understanding of the process
within the pyschomotor
domain of learning?
A nurse is providing teaching
Gelatin
about food choices to a client
who has a prescription for a
clear liquid diet. Which of the
following selections by the
client indicates an
understanding of the
teaching?
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A nurse is performing a
3/28/22, 6:44 PM
Romberg test
neurological assessment for a
client. Which of the following
examinations should the nurse
use to check the client's
balance?
A nurse in a provider's office is
WBC 15,000 mm3
reviewing the laboratory
findings of a client who
reports chills and aching joints.
The nurse should identify
which of the following findings
as an indication that the client
has an infection?
A nurse is preparing to
Ventrogluteal
administer an intramuscular
injection to a young adult
client. Which of the following
injection sites is the safest for
this client?
A nurse is applying an ice bag
Fill the bag two-thirds full with ice.
to the ankle of a client
following a sports injury. Which
of the following actions should
the nurse take?
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A nurse is caring for a client
3/28/22, 6:44 PM
Impaired peristalsis of the intestines
who is 48 hr postoperative
following a small bowel
resection. The client reports
gas pains in the periumbilical
area. The nurse should plan
care based on which of the
following factors contributing
to this postoperative
complication?
A client is being discharged
Wear cotton clothing to avoid static electricity.
home with oxygen therapy via
a nasal cannula. Which of the
following instructions should
the nurse provide to the client
and family?
A nurse is planning to insert a
"I can see that this is upsetting you."
nasogastric tube for a client
after explaining the procedure.
The client states, "You are not
putting that hose down my
throat." Which of the following
statements should the nurse
make?
A nurse is preparing to
Position the client on his left side.
administer a cleansing enema
to a client. Which of the
following actions should the
nurse plan to take?
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A nurse on a surgical unit is
3/28/22, 6:44 PM
Airway
receiving a client who had
abdominal surgery from the
postanesthesia care unit.
Which of the following
assessments should the nurse
make first?
A nurse is caring for a client
Tie the restraint with a quick-release knot.
who has a prescription for a
vest restraint. Which of the
following actions should the
nurse take?
A nurse is cqaring for a client
Oil retention
who has a fecal impaction.
Before digital removal of the
mass, which of the following
types of enemas should the
nurse plan to administer to
soften the feces?
A nurse is providing education
People who practice Judaism stay with the body of
about cultural and religious
the deceased until burial.
traditions and rituals related to
death for the assistive
personnel on the unit. Which
of the following information
should the nurse include?
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A nurse is reviewing the
3/28/22, 6:44 PM
...
correct use of a fire
extinguisher with a
client. Which of the
following actions
should the nurse direct
the client to take first?
A nurse is preparing to provide
Place the client in Trendelenburg's position.
chest physiotherapy for a
client who has left lower lobe
atelectasis. Which of the
following actions should the
nurse plan to take?
A nurse is planning care for a
Provide a protein intake of 1.5 g/kg of body weight
client who is postoperative
per day.
and has a history of poor
nutritional intake. Which of the
following actions should the
nurse include in the plan of
care to promote wound
healing?
A nurse is caring for a client
Cold extremities
who has a terminal illness.
Which of the following findings
indicates that the client's death
is imminent?
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A nurse is caring for a client
3/28/22, 6:44 PM
Hemolytic
who is receiving a blood
transfusion. The client reports
flank pain and the nurse notes
reddish-brown urine in the
client's urinary catheter bag.
The nurse recognizes these
manifestations as which of the
following types of transfusion
reactions?
A nurse on a mental health unit
Loss
is preparing to terminate the
nurse-client relationship with a
client who no longer requires
care. Which of the following
concepts should the nurse and
client discuss in the
termination phase of the
relationship?
A nurse is caring for a client
Sit at the bedside while feeding the client.
who has bilateral casts on her
hands. Which of the following
actions should the nurse take
when assisting the client with
feeding?
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A nurse is caring for a client
3/28/22, 6:44 PM
Wear gloves when changing the client's gown.
who has Clostridium difficile
and is in contact isolation.
Which of the following actions
should the nurse take?
A nurse is planning care for a
-Provide oral hygiene frequently.
client who has a single-lumen
-Measure the amount of drainage from the NG
nasogastric (NG) tube for
tube every shift.
gastric decompression. Which
-Secure the NG tube to the client's gown.
of the following actions should
the nurse include in the plan of
care? (Select all that apply.)
A nurse is called away for an
Fidelity
emergency while conversing
with a client who is concerned
about his medical diagnosis.
The nurse returns to the client
promptly, as promised. Which
of the following ethical
principles is the nurse
demonstrating?
A nurse in the emergency
Tachycardia
department is caring for a
client who has abdominal
trauma. Which of the following
assessment findings should the
nurse identify as an indication
of hypovolemic shock?
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A nurse is reviewing the
3/28/22, 6:44 PM
Decreased calcium
laboratory values for a client
who has a positive Chvostek's
sign. Which of the following
laboratory findings should the
nurse expect?
An adolescent client in an
"Tell me more about how your friends discourage
outpatient mental health
you."
facility tells the nurse that it is
hard to follow his treatment
plans because his friends
discourage him. Which of the
following statements should
the nurse make?
A nurse is reviewing measures
When lifting an object, spread your feet apart to
to prevent back injuries with
provide a wide base of support.
assistive personnel (AP). Which
of the following instructions
should the nurse include?
A nurse on a telemetry unit is
"All of this equipment can be frightening."
caring for a client who had a
myocardial infarction. The
client states "All this equipment
is making me nervous." Which
of the following responses
should the nurse make?
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A nurse is caring for a client
3/28/22, 6:44 PM
"The pain is like a dull ache in my stomach."
who reports pain. When
documenting the quality of the
client's pain on an initial pain
assessment, the nurse should
record which of the following
client statements?
A client who is nonambulatory
evacuate the client
notifies the nurse that his trash
can is on fire. After the nurse
confirms the fire, which of the
following actions should the
nurse take next?
A nurse is completing an
Rapid heart rate
admission assessment for a
client who reports vomiting
and diarrhea for the past 3
days. Which of the following
findings should the nurse
expect?
A nurse has accepted a verbal
0.3 mg
prescription for three tenths 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 client's medical record?
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A nurse is preparing a heparin
3/28/22, 6:44 PM
8 mL/hr
solutionA nurse is preparing a
heparin infusion for a client
who was hospitalized with
deep-vein thrombosis. The
order reads: 25,000 units of
heparin in 250 mL of 0.9%
sodium chloride to infuse at
800 units/hr. At what rate
should the nurse set the
infusion pump? (Round the
answer to the nearest whole
number. Use a leading zero if it
applies. Do not use a trailing
zero.)
A nurse is caring for a client
Cleanse the wound from the center outward
who has a prescription for
wound irrigation. Which of the
following actions should the
nurse take?
The nurse is caring for a client
Skin blanching
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?
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3/28/22, 6:44 PM
A nurse is teaching a client
"When descending stairs, I will first shift my weight
whose left leg is in a cast
to my right leg."
about using crutches. Which of
the following statements
should the nurse identify as an
indication that the client
understands the teaching?
A nurse is caring for a client
Tell the client to keep the head of the bed elevated
who has an NG tube and is
at least 30 degrees
receiving intermittent feedings
through an open system.
Which of the following actions
should the nurse take first?
A nurse is reviewing a client's
Medication dose
medication prescription that
reads "digoxin 0.25 by mouth
everyday." Which of the
following components of the
prescription should the nurse
verify with the provider?
A nurse is caring for a client
"I will be sure to remove my hearing aid before
who has recently started using
taking a shower"
a behind-the-ear hearing aid.
Which of the following
statements should the nurse
identify as an indication that
the client understands the use
of this assistive device?
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A nurse enters a client's room
3/28/22, 6:44 PM
"Client found lying on floor"
and finds her on the floor. The
client's roommate reports that
the client was trying to get out
of bed and fell over the side
rail onto the floor. Which of
the following statements
should the nurse document
about this incident?
A nurse on a medical unit is
Compare prescriptions with medications the client
preparing to discharge a client
received while at the facility.
to home. Which of the
following actions should the
nurse take as part of the
medication reconciliation
process.
A nurse is caring for a client
Witness the client's signature on the consent form.
who requires an informed
consent for a surgical
procedure. Which of the
following actions is the nurse's
responsibility?
A nurse is planning an
"You should receive a pneumococcal immunization
educational program for a
every 10 years."
group of older adults at a
senior living center. Which of
the following
recommendations should the
nurse include?
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A nurse is caring for a client
3/28/22, 6:44 PM
Withhold the blood transfusion
who is refusing a blood
transfusion for religious
reasons. The client's partner
wants the client to have the
blood transfusion. Which of
the following actions should
the nurse take?
A nurse is admitting a client
Droplet
who has rubella. Which of the
following types of
transmission-based
precautions should the nurse
initiate?
A middle adult client tells the
"People in middle adulthood often find satisfaction
nurse, "I feel so useless now
in nurturing and guiding young people."
that my children do not need
me anymore." which of the
following responses should
the nurse make?
A nurse is providing discharge
Check the cord routinely for frays or tearing
teaching to a client who has a
Consider purchasing a generator for power backup
new prescription for a home
Observe for signs of hypoxia
oxygen concentrator. Which of
the following instructions
should the nurse provide to
the client and his family?
(Select all that apply)
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The nurse is caring for a client
Instruct the family to refrain from pushing the
who is receiving pain
button for the client while she is asleep.
3/28/22, 6:44 PM
medication through a patientcontrolled analgesia (PCA)
pump. Which of the following
actions should the nurse take?
A nurse is admitting a client
Wrap blankets around all four sides of the bed
who has been having frequent
tonic-clonic seizures. Which of
the following actions should
the nurse add to the client's
plan of care?
A nurse manager is overseeing
A nurse asks a nurse from another unit to assist with
the care activities on a unit. For
documentation for a client
which of the following
situations should the nurse
manager intervene due to a
violation of HIPAA guidelines?
A nurse is caring for a client
Have the client use a trapeze bar when changing
who has limited mobility in his
position.
lower extremities. Which of the
following actions should the
nurse take to prevent skin
breakdown?
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a nurse is preparing to
3/28/22, 6:44 PM
Ambulating a client who is postoperative
delegate client care tasks to
an assistive personnel (ap).
which of the following tasks
should the nurse delegate?
a nurse in an acute care facility
current medications
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?
A nurse is caring for a client
"What could I have done to deserve this illness?"
who has terminal liver cancer.
Which of the following
statements should the nurse
identify as an indication that
the client is experiencing
spiritual distress?
A nurse is calculating a client's
8 oz of ice chips
fluid intake over the past 8
hour. Which of the following
items should the nurse plan to
document on the client's intake
and output record as 120ml of
fluid?
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A nurse is planning teaching
3/28/22, 6:44 PM
practice sessions
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 psychomotor approach to
learning?
a nurse is preparing to obtain
add 30 mm Hg
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 blood pressure
a nurse is caring for a client
we can talk about advanced directives brochures
who has a terminal diagnosis
and whos health is declining.
Advanced directives.
A nurse is reviewing practice
Initiate an enteral feeding through a gastrostomy
guidelines with a group of
tube.
newly licensed nurses. Which
of the following interventions
should the nurse include that is
within the RN scope of
practice?
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a nurse is assessing a client
3/28/22, 6:44 PM
distended neck veins
who received an IV fluid bolus
for dehydration. Which of the
following findings should the
nurse identify as an indication
of fluid volume excess?
A nurse in a surgical suite
Wrap monitoring cords with stockinette and tape
notes documentation on a
them in place.
client's medical record that he
has a latex allergy. In
preparation for the client's
procedure, which of the
following precautions should
the nurse take?
A home health nurse who has
A client who has asthma.
attended a training session for
the therapeutic use of
aromatherapy with essential oil
is planning to use this modality
with some of her clients. For
which of the following clients
should the nurse consult the
provider before using this
complementary therapy?
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A nurse is planning care for a
3/28/22, 6:44 PM
N95 respirator
client who has tuberculosis.
The nurse should use which of
the following pieces of
personal protective equipment
when providing care for the
client?
A nurse is caring for a client
3) Inject 10 units of air into the bottle of NPH
who has a prescription for 5
insulin1) Inject 5 units of air into the bottle of
units of regular insulin and 10
regular insulin4) Withdraw the correct dose of
units of NPH insulin to mix
regular insulin from the bottle2) Withdraw the
together and administer
correct dose of NPH insulin from the bottle
subcutaneously. Determine the
correct order of steps for this
procedure. (Move the steps
into the box on the right,
placing them in the order of
performance. Use all the
steps.)
A charge nurse is observing a
The newly licensed nurse places the cap of a bottle
newly licensed nurse prepare
of sterile saline solution on the sterile field.
a sterile field for a dressing
change. Which of the
following actions by the newly
licensed nurse requires
intervention by the charge
nurse?
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3/28/22, 6:44 PM
A nurse in a clinic is caring for
"You should have a fecal occult blood test every
a middle adult client who
year."
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?
A nurse is discussing the use of
"I can take echinacea to improve my immune
herbal supplements for health
system."
promotion with a client. Which
of the following client
statements indicates an
understanding of herbal
supplement use?
indwelling urinary catheter
a nurse is giving a change of
bladder scan
breath sounds
shift report about a client
admitted earlier who has
pneumonia
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a home health nurse is
3/28/22, 6:44 PM
the caregiver insists on remaining in the room
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
A nurse is performing a
Narrowed arterial lumen
peripheral vascular assessment
for a client. When placing the
bell of the stethoscope on the
client's neck, she hears the
following sound. This sound
indicates which of the
following?
ethical principle of veracity
nurse tells client she has cancer
a community health nurse is
a client who smokes one pack of cigarettes each
checking BP for a group of
day
clients at a community health
screening. which of the
following clients is at an
increased risk for
hypertension?
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a nurse has just inserted an NG
3/28/22, 6:44 PM
an x-ray
tube for a client. Which of the
dollowing findings should the
nurse expect to confirm
correct tube placement?
A nurse is performing a
Have the client stand with her arms at her side and
Romberg's test during the
her feet together.
physical assessment of a client.
Which of the following
techniques should the nurse
use?
A nurse is teaching an older
Walking briskly
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?
a nurse is caring for a client
apply an ankle-foot orthotic device to the client's
who has decreased mobility.
feet
which of the following actions
should the nurse take to
decrease the client's risk of
developing plantar flexion
contractures?
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A nurse is preparing to
3/28/22, 6:44 PM
Flush the tube with 15 mL of sterile water.
administer multiple
medications to a client who
has an enteral feeding tube.
Which of the following actions
should the nurse plan to take?
A nurse is preparing to transfer
Assess the client for orthostatic hypotension.
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?
A nurse is administering an otic
Press gently on the tragus of the client's ear.
medication to an older adult
client. Which of the following
actions should the nurse take
to ensure that the medication
reaches the inner ear?
A nurse is providing care to
A client who has an IV infusion pump receives an
four clients. Which of the
additional 250 mL of IV fluid.
following situations requires
the nurse to complete an
incident report?
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A nurse is caring for a client
Reassure the client that this is an expected
who is expressing anger over
response to grief.
3/28/22, 6:44 PM
his diagnosis of colorectal
cancer. Which of the following
actions should the nurse take?
A nurse is lifting a bedside
Stand close to the cabinet when lifting it.
cabinet to move it closer to a
client who is sitting in a chair.
To prevent self-injury, which of
the following actions should
the nurse take when lifting this
object?
A nurse is reviewing a client's
Potassium 5.4 mEq/L
fluid and electrolyte status.
Which of the following findings
should the nurse report to the
provider?
A nurse is evaluating a client's
The client holds the cane on the stronger side of
use of a cane. Which of the
her body.
following actions should the
nurse identify as an indication
of correct use?
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A nurse is assisting a client
3/28/22, 6:44 PM
Semi-Fowler's
who is postoperative with the
use of an incentive spirometer.
Into which of the following
positions should the nurse
place the client?
A charge nurse is discussing
Have family members wear a gown and gloves
the responsibility of nurses
when visiting.
caring for clients who have a
Clostridium difficile infection.
Which of the following
information should the nurse
include in the teaching?
A nurse is preparing to
Ask another nurse to observe the medication
administer an injection of an
wastage.
opioid medication to a client.
The nurse draws out 1 mL of
the medication from a 2 mL
vial. Which of the following
actions should the nurse take?
A nurse is performing a
Narrowed arterial lumen
peripheral vascular assessment
for a client. When placing the
(Bruit)
bell of the stethoscope on the
client's neck, she hears the
following sound. This sound
indicates which of the
following? (Click on the audio
button to listen to the clip.)
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A nurse is using an open
Subtract the amount of irrigant used from the
irrigation technique to irrigate
client's urine output.
3/28/22, 6:44 PM
a client's indwelling urinary
catheter. Which of the
following actions should the
nurse take?
A nurse is assessing an older
B) Pupil clarity
adult client's risk for falls.
D) Visual fields
Which of the following
E) Visual acuity
assessments should the nurse
use to identify the client's
safety needs? (Select all that
apply.)
A nurse is caring for a client
Skin blanching
receiving fluid through a
peripheral IV catheter. Which
of the following findings at the
IV site should the nurse
identify as infiltration?
A nurse is preparing to
Gently shake the container of medication prior to
administer 0.5 mL of oral
administration.
single-dose liquid medication
to a client. Which of the
following actions should the
nurse take?
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A nurse is administering IV
3/28/22, 6:44 PM
Auscultate lung sounds.
fluid to an older adult client.
The nurse should perform
which priority assessment to
monitor for adverse effects?
A nurse is planning care to
Use a clock pattern to describe food on the client's
improve self-feeding for a
plate.
client who has vision loss.
Which of the following
interventions should the nurse
include in the plan of care?
A nurse is assessing an adult
Erythema on pressure points
client who has been immobile
for the past 3 weeks. The nurse
should identify that which of
the following findings requires
further intervention?
A nurse is reviewing protocol
Select a suction catheter that is half the size of the
in preparation for suctioning
lumen.
secretions from a client who
has a new tracheostomy.
Which of the following actions
should the nurse plan to take?
A nurse is admitting a client
Airborne
who has varicella. Which of the
following types of transmission
precautions should the nurse
initiate?
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A nurse is caring for a client
3/28/22, 6:44 PM
Use progressive relaxation techniques at bedtime.
who is reporting difficulty
falling asleep. Which of the
following measures should the
nurse recommend?
A nurse is responding to a call
Check the client for injuries.
light and finds a client lying on
the bathroom floor. Which of
the following actions should
the nurse take first?
A nurse is caring for a client
Eggs
who has had his diet
prescription changed to a
mechanical soft diet. Which of
the following food items
should the nurse remove from
the client's breakfast tray?
A nurse in a long-term care
"Are you able to help with your hygiene care?"
facility is planning to perform
hygiene care for a new
resident. Which of the
following assessment
questions is the nurse's priority
before beginning this
procedure?
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A nurse is giving discharge
"I'll check the wires and cables on my TV to make
instructions to a client who will
sure they are in good working order."
require oxygen therapy at
home. Which of the following
statements should the nurse
identify as an indication that
the client understands how to
manage this therapy at home?
A nurse is assessing a client
Calf swelling
who has been on bed rest for
the past month. Which of the
following findings should the
nurse identify as an indication
that the client has developed
thrombophlebitis?
A nurse is completing an
Rapid heart rate
admission assessment for a
client who reports vomiting
and diarrhea for the past 3
days. Which of the following
assessment findings should the
nurse expect?
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A nurse is planning an
Allow extra time for the client to respond to
education session for an older
questions.
3/28/22, 6:44 PM
adult client who has just
learned that she has type 2
diabetes mellitus. Which of the
following strategies should the
nurse plan to use with this
client?
A nurse is admitting a client
Contact precautions
who has an abdominal wound
with a large amount of
purulent drainage. Which of
the following types of
transmission precautions
should the nurse initiate?
A nurse manager is overseeing
A nurse asks a nurse from another unit to assist with
the care on a unit. Which of
her documentation.
the following situations should
the nurse manager identify as
a violation of HIPAA
guidelines?
A nurse is caring for a client
"I flushed what I urinated at 7:00 a.m. and have
who requires a 24-hr urine
saved all urine since."
collection. Which of the
following statements by the
client indicates an
understanding of the
teaching?
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A nurse is preparing a heparin
3/28/22, 6:44 PM
8 mL/hr
infusion for a client who was
hospitalized with deep-vein
thrombosis. The order reads:
25,000 units of heparin in 250
mL of 0.9% sodium chloride to
infuse at 800 units/hr. At what
rate should the nurse set the
infusion pump? (Round the
answer to the nearest whole
number. Use a leading zero if it
applies. Do not use a trailing
zero.)
A nurse is caring for a client
Have the client take sips of water to promote
who requires an NG tube for
insertion of the NG tube into the esophagus.
stomach decompression.
Which of the following actions
should the nurse take when
inserting the NG tube?
A nurse is caring for a client
Determine the reasons why the client is refusing to
who is postoperative and
use the incentive spirometer.
refuses to use an incentive
spirometer following major
abdominal surgery. Which of
the following is the nurse's
priority action?
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A nurse is planning to insert a
3/28/22, 6:44 PM
Place the client's arm in a dependent position.
peripheral IV catheter for an
older adult client. Which of the
following actions should the
nurse plan to take?
A nurse manager is preparing
"Use the complete name of the medication
to review medication
magnesium sulfate."
documentation with a group of
newly licensed nurses. Which
of the following statements
should the nurse manager plan
to include in the teaching?
A nurse is caring for a client
Remove the stockings at least once per shift.
who requires bed rest and has
a prescription for antiembolic
stockings. Which of the
following actions should the
nurse take?
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A nurse is talking with the
3/28/22, 6:44 PM
Role overload
partner of an older adult male
client who has dementia. The
client's partner expresses
frustration about finding time
to manage household
responsibilities while caring for
his partner. The nurse should
identify that he is going
through which of the following
types of role-performance
stress?
A nurse is preparing to transfer
1) Ask the client if he can bear weight
a client who has right-sided
3) Position the chair on the left side of the bed
weakness from the bed to a
4) Have the client sit and dangle his feet at the
chair. In what order should the
bedside
nurse take the following
2) Use the stand-and-pivot technique to move the
actions to assist the client?
client to the chair
(Move the steps into the box
on the right, placing them in
the order of performance. Use
all the steps.)
A nurse is preparing a change-
Situation, background, assessment, and
of-shift report. Which of the
recommendation (SBAR)
following tools or documents
should the nurse use to
communicate continuity of
care?
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A nurse is assessing a client's
3/28/22, 6:44 PM
"I can concentrate best in the morning."
readiness to learn about insulin
administration. Which of the
following statements should
the nurse identify as an
indication that the client is
ready to learn?
A nurse is caring for a client
Acupuncture
who has herpes zoster and
asks the nurse about the use
of complementary and
alternative therapies for pain
control. The nurse should
inform the client that his
condition is a contraindication
for which of the following
therapies?
A nurse is caring for a client
Assist the client to an upright position.
who is having difficulty
breathing. The client is lying in
bed with a nasal cannula
delivering oxygen. Which of
the following interventions
should the nurse take first?
A nurse is caring for a client
A) Place the client in a room with negative-pressure
who has tuberculosis. Which of
airflow.
the following actions should
B) Wear gloves when assisting the client with oral
the nurse take? (Select all that
care.
apply.)
E) Use antimicrobial sanitizer for hand hygiene.
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A nurse is caring for a client
"They indicate the form of treatment a client is
who asks about the purpose of
willing to accept in the event of a serious illness."
advance directives. Which of
the following statements
should the nurse make?
A nurse is caring for a client
"This is a difficult time, but we are helping each
who is terminally ill. Which of
other through this."
the following statements
should the nurse identify as an
indication that the client's
family member is coping
effectively with the situation?
A nurse at an extended-care
"When the client moves, he should move the cane
facility is instructing a class of
forward first."
AP's about the use of assistive
devices during ambulation.
Which of the following should
the nurse give the AP's about
the clients' use of a cane?
A nurse is admitting a client
A room with air exhaust directly to the outdoor
who has active TB to a room
environment
on a medical-surgical unit.
Which of the following room
assignments should the nurse
make for this client?
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A nurse is assessing a client
3/28/22, 6:44 PM
Hyperglycemia
who is receiving TPN. Which of
the following findings should
the nurse recognize as a
complication to this therapy?
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