RN Fundamentals ATI: Fundamentals for Nursing REVIEW MODULE EDITION 9.0 Questions and Answers With Detailed Scenario, Explanations and Rationale.

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ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises p... ose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX style questions, such as multiple choice and multiple select items, providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales. NCLEX® CONNECTIONS To prepare for the NCLEX, it is important to understand how the content in this Review Module is connected to the NCLEX test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, www.ncsbn.org. When reviewing content in this Review Module, regularly ask yourself, “How does this content fit into the test plan, and what types of questions related to this content should I expect?” To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline. These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are: ● Safe and Effective Care Environment ◯ Management of Care ◯ Safety and Infection Control ● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity ◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation An NCLEX Connection might, for example, alert you that content within a unit is related to: ● Basic Care and Comfort ◯ Assistive Devices ■ Assess client use of assistive devices a nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) a. Home health care B. rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities e. Oncology centers 2. a nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply.) a. Preferred provider organization (PPO) B. medicare C. long term care insurance D. exclusive provider organization (ePO) e. medicaid 3. a nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits B. ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. educating acute care nurses on postoperative complications related to obesity 4. a nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. monitoring evidence based practice for clients who have a specific diagnosis B. ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining if medications are safe for administration to clients 5. a nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) a. intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation e. Home health care PRACTICE Active Learning Scenario a nurse on a medical surgical unit is acquainting a group of nurses with the Quality and Safety education for Nurses (QSeN) initiative. Use the ati active learning template: Basic Concept to complete this item. RELATED CONTENT: list the six QSeN competencies, along with a brief description of each. a nurse is caring for a group of clients on a medical surgical unit. for which of the following client care needs should the nurse initiate a referral for a social worker? (select all that apply.) a. a client who has terminal cancer requests hospice care in her home. B. a client asks about community resources available for older adults. C. a client states that she wants her child baptized before surgery. D. a client requests an electric wheelchair for use after discharge. e. a client states that he does not understand how to use a nebulizer. 2. a goal for a client who has difficulty with self feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? a. social worker B. Certified nursing assistant C. registered dietitian D. occupational therapist 3. a client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication’s effects? (select all that apply.) a. provider B. Certified nursing assistant C. pharmacist D. registered nurse e. respiratory therapist 4. a client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? a. social worker B. Certified nursing assistant C. occupational therapist D. speech language pathologist 5. a nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical surgical unit. When she gives examples of the types of tasks certified nursing assistants (Cnas) may perform, which of the following client activities should she include? (select all that apply.) a. Bathing B. ambulating C. Toileting D. Determining pain level e. measuring vital signs PRACTICE Active Learning Scenario a nurse is teaching a group of newly licensed nurses about the various nursing roles they can aspire to after they achieve mastery in basic nursing skills. Use the aTI active learning Template: Basic Concept to complete this item. RELATED CONTENT: Describe at least five types of advance practice nursing roles, including a brief description of their primary responsibilities. a nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. the nurse understands that this client’s choice is an example of which of the following ethical principles? a. Fidelity b. autonomy c. Justice D. nonmaleficence 2. a nurse offers pain medication to a client who is postoperative prior to ambulation. the nurse understands that this aspect of care delivery is an example of which of the following ethical principles? a. Fidelity b. autonomy c. Justice D. beneficence 3. a nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? a. Fidelity b. autonomy c. Justice D. nonmaleficence 4. a nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. the nurse understands that this action is an example of which of the following ethical principles? a. Fidelity b. autonomy c. Justice D. nonmaleficence 5. a nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? a. a nurse on a medical surgical unit demonstrates signs of chemical impairment. b. a nurse overhears another nurse telling an older adult client that if he doesn’t stay in bed, she will have to apply restraints. c. a family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. a client who is terminally ill hesitates to name her spouse on her durable power of attorney form. PRACTICE Active Learning Scenario a nurse is teaching a group of nursing students about the process of resolving ethical dilemmas. Use the ati active learning template: basic concept to complete this item. UNDERLYING PRINCIPLES: Define the ethical decision making process. NURSING INTERVENTIONS: list the steps of making an ethical decision. a nurse observes an assistive personnel (ap) reprimanding a client for not using the urinal properly. the ap tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the ap committing? a. assault b. battery C. False imprisonment D. invasion of privacy 2. a nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. the nurse believes that this is not in the client’s best interest, so she prepares to administer a pRn sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? a. assault b. False imprisonment C. negligence D. breach of confidentiality 3. a nurse in a surgeon’s office is providing preoperative teaching for a client who is scheduled for surgery the following week. the client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? a.“i’d rather have my brother make decisions for me, but i know it has to be my wife.” b. “i know they won’t go ahead with the surgery unless i prepare these forms.” C.“i plan to write that i don’t want them to keep me on a breathing machine.” D.“i will get my regular doctor to approve my plan before i hand it in at the hospital.” 4. a nurse is caring for a client who is about to undergo an elective surgical procedure. the nurse should take which of the following actions regarding informed consent? (select all that apply.) a. Make sure the surgeon obtained the client’s consent. b. Witness the client’s signature on the consent form. C. explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. e. tell the client about alternatives to having the surgery. 5. a nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? a. alert the american nurses association. b. Fill out an incident report. C. Report the observations to the nurse manager on the unit. D. Leave the nurse alone to sleep. PRACTICE Active Learning Scenario a nurse is teaching a group of nursing students about avoiding liability for negligence. Use the ati active Learning template: basic Concept to complete this item. UNDERLYING PRINCIPLES: List the five elements necessary to prove negligence. NURSING INTERVENTIONS: List at least four ways nurses can avoid liability for negligence a nurse is preparing information for change of shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift B. Blood pressure from the previous day c. Bone scan scheduled for today D. medication routine from the medication administration record 2. a nurse is discussing the hIPaa Privacy rule with nurses during new employee orientation. Which of the following information should the nurse include? (Select all that apply.) a. a single electronic records password is provided for nurses on the same unit. B. family members should provide a code prior to receiving client health information. c. communication of client information can occur at the nurses’ station. D. a client can request a copy of her medical record. e. a nurse may photocopy a client’s medical record for transfer to another facility. 3. a nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client’s record? (Select all that apply.) a. cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. c. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. e. Wait until the end of the shift to document. 4. a nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). a. medication error B. needlesticks c. conflict with provider and nursing staff D. omission of prescription e. complaint from a client’s family member 5. a nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) a. repeat the details of the prescription back to the provider. B. have another nurse listen to the telephone prescription. c. obtain the provider’s signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. e. tell the charge nurse that the provider has prescribed morphine by telephone a nurse on a medical surgical unit has received change of shift report and will care for four clients. Which of the following client’s needs should the nurse assign to an assistive personnel (ap)? a. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. reinforcing teaching with a client who is learning to walk using a quad cane C. reapplying a condom catheter for a client who has urinary incontinence D. applying a sterile dressing to a pressure ulcer 2. a nurse manager of a medical surgical unit is assigning care responsibilities for the oncoming shift. a client is awaiting transfer back to the unit from the paCu following thoracic surgery. to which of the following staff members should the nurse assign this client? a. Charge nurse B. rn C. practical nurse (pn) D. assistive personnel (ap) 3. a nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an ap. Which of the following information should the nurse share with the ap? (Select all that apply.) a. the roommate ambulates independently. B. the client ambulates with his slippers on over his antiembolic stockings. C. the client uses a front wheeled walker when ambulating. D. the client had pain medication 30 min ago. e. the client is allergic to codeine. F. the client ate 50% of his breakfast this morning. 4. an rn is making assignments for a practical nurse (pn) at the beginning of the shift. Which of the following assignments should the pn question? a. assisting a client who is 24 hr postoperative to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who has a wound infection C. providing nasopharyngeal suctioning for a client who has pneumonia D. teaching a client who has asthma to use a metered dose inhaler 5. a nurse is preparing an in service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply.) a. right client B. right supervision and evaluation C. right direction and communication D. right time e. right circumstances PRACTICE Active Learning Scenario a nurse manager is reviewing the responsibilities of delegation with a group of nurses on a medical unit. use the ati active learning template: Basic Concept to complete this item. NURSING INTERVENTIONS: list at least five tasks the delegating nurse must perform when supervising and evaluating a delegatee. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. c. change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain. 2. A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. she states, “The client said his leg pain was back, so i checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PrN for pain, so i decided he needs it. i asked the unit nurse to observe me preparing and administering it. i checked with the client 40 minutes later, and he said his pain is going away.” The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning c. intervention D. evaluation 3. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply.) A. respiratory rate is 22/min with even, unlabored respirations. B. The client’s partner states, “He said he hurts after walking about 10 minutes.” c. Pain rating is 3 on a scale of 0 to 10 D. skin is pink, warm, and dry. e. The assistive personnel reports the client walked with a limp. 4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain. B. inserting a nasogastric (Ng) tube to relieve gastric distention. c. showing a client how to use progressive muscle relaxation. D. Performing a daily bath after the evening meal. e. repositioning a client every 2 hr to reduce pressure ulcer risk. 5. A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A.“i will determine the most important client problems that we should address.” B. “i will review the past medical history on the client’s record to get more information.” c.“i will go carry out the new prescriptions from the provider.” D.“i will ask the client if his nausea has resolved.” A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. orient the client to his room. B. conduct a client care conference. c. review medical prescriptions. d. develop a plan of care. 2. A nurse is admitting a client who has acute cholecystitis to a medical surgical unit. Which of the following actions are essential steps of the admission procedure? (select all that apply.) A. explain the roles of other care delivery staff. B. Begin discharge planning. c. Provide information about advance directives. d. document the client’s wishes about organ donation. e. introduce the client to his roommate. 3. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (select all that apply.) A. ensure that the client has possession of his valuables. B. confirm that the rehabilitation center has a room available at the time of transfer. c. Assess how the client tolerates the transfer. d. give a verbal transfer report via telephone. e. complete a transfer form for the receiving facility. 4. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (select all that apply.) A. Advance directives status B. follow up care c. instructions for diet and medications d. most recent vital sign data e. contact information for the home health care agency 5. As part of the admission process, a nurse at a long term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client’s family? A. Body mass index B. Usual times for meals and snacks c. favorite foods d. Any difficulty swallowing PRACTICE Active Learning Scenario A nurse is reviewing with a group of newly licensed nurses the essential components of an admission assessment. Use the ATi Active Learning Template: Basic concept to complete this item. NURSING INTERVENTIONS: List at least three aspects of the health history the nurse must gather and document, as well as at least three aspects of the psychosocial evaluation the nurse must gather and document. When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6 ft away from the client’s bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. c. place a mask on the client to limit the spread of micro organisms into the surgical wound. d. Keep a box of facial tissues nearby for the client to use during the dressing change. 2. a nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? a. The flap closest to the body B. The right side flap c. The left side flap d. The flap farthest from the body 3. a nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) a. a bottle containing a sterile solution B. The edge of the sterile drape at the base of the field c. The inner wrapping of an item on the sterile field d. an irrigation syringe on the sterile field e. One gloved hand with the other gloved hand 4. a nurse is reviewing hand hygiene techniques with a group of assistive personnel (ap). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) a. apply 3 to 5 ml of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. c. rinse the hands with hot water. d. use a clean paper towel to turn off hand faucets. e. allow the hands to air dry after washing. 5. a nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) a. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. c. The procedure is delayed 1 hr because the provider receives an emergency call. d. The nurse turns to speak to someone who enters through the door behind the nurse. e. The client’s hand brushes against the outer edge of the sterile field. A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SArS). the nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities c. ensuring proper medical treatment D. Identifying endemic disease e. Monitoring for common source outbreaks 2. A nurse is caring for a client who presents with linear clusters of fluid containing vesicles with some crustings. the nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. ringworm c. Systemic lupus erythematosus D. Herpes zoster 3. A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. the client is experiencing which of the following stages of infection? A. Prodromal B. Incubation c. convalescence D. Illness 4. A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. the nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. fever B. Malaise c. edema D. Pain or tenderness e. Increase in pulse and respiratory rate 5. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. c. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. e. Wear a gown when performing care that might result in contamination from secretions. PRACTICE Active Learning Scenario A nurse educator is teaching a module on the chain of infection during nursing orientation to a group of newly licensed nurses. Use the AtI Active learning template: Basic concept to complete this item. RELATED CONTENT: list the six links in the chain of infection that must be present for an infection to occur. a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) a. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client’s call light is within reach. D. Provide the client with nonskid footwear. e. Complete a fall risk assessment. 2. a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a.“i will place the client on his side.” B. “i will go to the nurses’ station for assistance.” C.“i will administer his medications.” D.“i will prepare to insert an airway.” 3. a nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority? a. extinguish the fire. B. activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. 4. a nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority? a. Complete a fall risk assessment. B. educate the client and family about fall risks. C. eliminate safety hazards from the client’s environment. D. Make sure the client uses assistive aids in his possession. 5. a charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent falls, which of the following clients should the nurse assign to the room closest to the nurses’ station? a. a middle adult who is postoperative following a laparoscopic cholecystectomy B. a middle adult who requires telemetry for a possible myocardial infarction C. a young adult who is postoperative following an open reduction internal fixation of the ankle D. an older adult who is postoperative following a below the knee amputation PRACTICE Active Learning Scenario a nurse educator is addressing the safe use of seclusion and restraints with a group of newly licensed nurses. What information should the nurse include? Use the ati active learning template: Basic Concept to complete this item. NURSING INTERVENTIONS: Describe at least six nursing responsibilities when caring for a client in either seclusion or restraints. a nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) a. family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. a “No Smoking” sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. e. a fire extinguisher should be readily available in the home. 2. a nurse educator is presenting a module on basic first aid for newly licensed home health nurses. the nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? a. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea 3. a nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? a.“I will set my water heater at 130° f.” B. “once my baby can sit up, he should be safe in the bathtub.” C.“I will place my baby on his stomach to sleep.” D.“once my infant starts to push up, I will remove the mobile from over the crib.” 4. a home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? a. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. the lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body. 5. a home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) a. most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products. D. Healthy individuals usually recover from the illness in a few weeks. e. Handling raw and fresh food separately can prevent food poisoning. PRACTICE Active Learning Scenario a nurse educator is teaching a module on the basic principles of creating a home safety plan during nursing orientation to a group of newly appointed home health nurses. Use the atI active Learning template: Basic Concept to complete this item. NURSING INTERVENTIONS: List four key elements that a home safety plan should include A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. supine B. semi Fowler’s c. semi prone D. Trendelenburg 2. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse’s priority at this time? A. obtain a walker for the client to use to transfer back to bed. B. call for additional staff to assist with the transfer. c. Use a transfer belt and assist the client back into bed. D. Determine the client’s ability to help with the transfer. 3. A nurse is completing discharge instructions for a client who has coPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. lie on her back with her head and shoulders on a pillow. B. lie flat on her stomach with her head to one side. c. sit on the side of her bed and rest her arms over pillows on top of her bedside table. D. lie on her side with her weight on her hip and shoulder with her arm flexed in front of her. 4. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (select all that apply.) A. request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. c. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles. 5. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (select all that apply.) A.“my line of gravity should fall outside my base of support.” B. “The lower my center of gravity, the more stability i have.” c.“To broaden my base of support, i should spread my feet apart.” D.“When i lift an object, i should hold it as close to my body as possible.” E. “When pulling an object, i should move my front foot forward.” . a nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? a. a client who received crush injuries to the chest and abdomen and is expected to die B. a client who has a 4 inch laceration to the head c. a client who has partial thickness and full thickness burns to his face, neck, and chest d. a client who has a fractured fibula and tibia 2. a nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) a. Open doors to client rooms. B. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. draw shades and close drapes. e. instruct ambulatory clients in the hallways to return to their rooms. 3. an occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. c. Brush the chemical off the skin and clothing. d. leave the clothing in place until emergency personnel arrive. 4. a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? a. “i will get the caller off the phone as soon as possible so i can alert the staff.” B. “i will begin evacuating clients using the elevators.” c.“i will not ask any questions and just let the caller talk.” d.“i will listen for background noises.” 5. a nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) a. a client who is dehydrated and receiving iV fluid and electrolytes B. a client who has a nasogastric tube to treat a small bowel obstruction c. a client who is scheduled for elective surgery d. a client who has chronic hypertension and blood pressure 135/85 mm Hg e. a client who has acute appendicitis and is scheduled for an appendectomy PRACTICE Active Learning Scenario a nurse educator is teaching a module on biological pathogens during orientation to a group of newly hired nurses. What information should the nurse educator include? use the ati active learning template: Basic concept to complete this item. RELATED CONTENT: list four manifestations and the recommended treatment for anthrax, botulism, pneumonic plague, and tularemia. a nurse is caring for a 20 year old client who is sexually active and has come to the college health clinic for a first time checkup. Which of the following interventions should the nurse perform first to determine the client’s need for health promotion and disease prevention? a. measure vital signs. B. encourage Hiv screening. C. determine risk factors. d. instruct the client to use condoms. 2. a nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (select all that apply.) a. Help the client see the benefits of her actions. B. identify the client’s support systems. C. suggest and recommend community resources. d. devise and set goals for the client. e. teach stress management strategies. 3. a nurse in a health clinic is caring for a 21 year old client who reports a sore throat. the client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? a. testicular examination B. Blood glucose C. Fecal occult blood d. Prostate specific antigen 4. a nurse is talking with a client who recently attended a cholesterol screening event and a heart healthy nutrition presentation at a neighborhood center. the client’s total cholesterol was 248 mg/dl. after seeing the provider, the client started taking medication to lower his cholesterol level. the client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? a. Cholesterol screening B. nutrition presentation C. medication therapy d. Cardiac rehabilitation 5. a nurse at a provider’s office is talking about routine screenings with a 45 year old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? a.“so i don’t need the colon cancer procedure for another 2 or 3 years.” B. “For now, i should continue to have a mammogram each year.” C.“Because the doctor just did a Pap smear, i’ll come back next year for another one.” d.“i had my blood glucose test last year, so i won’t need it again till next year.” PRACTICE Active Learning Scenario a nurse is caring for a client in a spinal cord injury rehabilitation center following head and neck injuries sustained while riding a bicycle. the client had surgery during the acute phase of treatment to relieve intracranial pressure and to stabilize his cervical spine. now, the client and his partner are learning essential self management strategies. Use the ati active learning template: Basic Concept to complete this item. RELATED CONTENT: list each of the three levels of prevention with an example of each level from this client’s history or from what this client might have done to prevent this injury and its life altering consequences. a nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. the client is able to discuss the appropriate technique. B. the client is able to demonstrate the appropriate technique. C. the client states that he understands. d. the client is able to write the steps on a piece of paper. 2. a nurse in a provider’s office is collecting data from the mother of a 12 month old infant. the client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. learning has occurred in which of the following domains? a. Cognitive B. affective C. Psychomotor d. Kinesthetic 3. a nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a.“i don’t want my spouse to see my incision.” B. “Will you give me pain medicine after the surgery?” C.“Can you tell me about how long the surgery will take?” d.“My roommate listens to everything i say.” 4. a nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. identify goals the nurse and the client agree are reasonable. d. determine what the client knows about stress incontinence. 5. a nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart healthy diet. the client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client’s learning? a. encourage the client to ask questions. B. ask the client to explain how to select or prepare meals. C. encourage the client to fill out an evaluation form. d. ask the client if she has resources for further instruction on this topic. PRACTICE Active Learning Scenario a nurse is preparing a presentation at a community center for a group of parents who want to learn how to prevent childhood obesity. use the ati active learning template: Basic Concept to complete this item. RELATED CONTENT list at least three factors the nurse should consider when incorporating ways to enhance learning. list at least three barriers the nurse might encounter among the attendees. a nurse is talking with the parents of a 6 month old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (select all that apply.) a. rolls from back to front B. Bears weight on legs C. Walks holding onto furniture D. sits unsupported e. sits down from a standing position 2. a nurse is cautioning the mother of an 8 month old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? a.“My baby loved to play with his crib gym, but I took it away from him.” B. “I just bought a soft mattress so my baby will sleep better.” C.“My baby really likes sleeping on the fluffy pillow we just got for him.” D.“I put the baby’s car seat out of the way on the table after I put him in it.” 3. a nurse is reviewing car seat safety with the parents of a 1 month old infant. When reviewing car seat use, which of the following instructions should the nurse include? a. Use a car seat that has a three point harness system. B. Position the car seat so that the infant is rear facing. C. secure the car seat in the front passenger seat of the vehicle. D. Convert to a booster seat after 12 months. 4. a nurse is assessing from a 2 week old newborn during a routine checkup. Which of the following findings should the nurse expect? a. sleeps 14 to 16 hr each day B. Posterior fontanel closed C. Pincer grasp present D. Hands remain in a closed position e. Current weight same as birth weight 5. the mother of a 7 month old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? (select all that apply.) a.“It might be good to add bananas, as they can help with loose stools.” B. “Let’s make a list of the foods he is eating so we can spot any problems.” C.“Did the changes begin after you started one particular food?” D.“Has he been vomiting since he started these new foods?” e. “Most babies react with a little indigestion when you start new foods.” PRACTICE Active Learning Scenario a nurse is explaining to the parents of a 4 month old infant what infant milestones to expect during the first year of life, and how to foster infant development. Use the atI active Learning template: Growth and Development to complete this item. COGNITIVE DEVELOPMENT ● name the developmental stage Piaget has identified for the first two years of life. ● Identify three essential components that comprise this stage. AGE APPROPRIATE ACTIVITIES: Identify at least two toys and two activities the nurse should suggest that the parents provide for their infant. a nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident prevention strategies should the nurse include? (select all that apply.) a. store toxic agents in locked cabinets. B. Keep toilet seats up. C. Turn pot handles toward the back of the stove. d. Place safety gates across stairways. e. Make sure balloons are fully inflated. 2. a nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (select all that apply.) a. Building models B. Working with clay C. Filling and emptying containers d. Playing with blocks e. looking at books 3. a nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? a. establish consistent boundaries for the toddler. B. Place the toddler in a room with the door closed. C. Inform the toddler how you feel when he misbehaves. . d. Use favorite snacks to reward the toddler. 4. a mother tells the nurse that her 2 year old toddler has temper tantrums and says “no” every time the mother tries to help her get dressed. The nurse should recognize, the toddler is manifesting which of the following stages of development? a. Trying to increase her independence B. developing a sense of trust C. establishing a new identity d. attempting to master a skill 5. a nurse is reviewing nutritional guidelines with the parents of a 2 year old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? a.“I should keep feeding my son whole milk until he is 3 years old.” B. “It’s okay for me to give my son a cup of apple juice with each meal.” C.“I’ll give my son about 2 tablespoons of each food at mealtimes.” d.“My son loves popcorn, and I know it is better for him than sweets.” PRACTICE Active Learning Scenario a nurse is explaining to the parents of a 14 month old toddler what physical and cognitive development they can expect from now until their child is 3 years old. Use the aTI active learning Template: Growth and development to complete this item. PHYSICAL DEVELOPMENT: Identify at least four gross or fine motor skills the parents can expect at specific ages. COGNITIVE DEVELOPMENT: describe at least three parameters the parents can expect to observe during the toddler stage. a nurse is talking with the parent of a 4 year old child who states that his child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? a. offer the child a large snack before bedtime. B. allow the child to watch an extra 30 min of tV in the evening. c. have the child take an afternoon nap. D. Increase physical activity before bedtime. 2. a nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (select all that apply.) a. assembling puzzles B. Pulling wheeled toys c. Using musical toys D. Playing with puppets e. coloring with crayons 3. a nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child’s cooperation in taking medications? (select all that apply.) a. reassure the child an injection will not hurt. B. Mix oral medications in a large glass of milk. c. offer the child choices when possible. D. have the parents bring in a favorite toy from home. e. engage the child in pretend play with a toy medical kit. 4. a nurse is reviewing the centers for Disease control and Prevention’s (cDc) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? (select all that apply.) a. Haemophilus influenzae type B B. Varicella c. Polio D. hepatitis a e. seasonal influenza 5. a nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? a.“My son mimics my husband getting dressed.” B. “My son has temper tantrums every time we tell him to do something he doesn’t want to do.” c.“I think my son truly believes that his toys have personalities and talk to him.” D.“I feel bad when I see my son trying so hard to button his shirt.” PRACTICE Active Learning Scenario a nurse is making safety recommendations to the parents of a two preschoolers. Use the atI active learning template: Growth and Development to complete this item. INJURY PREVENTION: list at least four key areas of safety and age appropriate instructions for addressing each area. A nurse is talking with parents of a 12 year old child. Which of the following issues verbalized by the parents should the nurse identify as the priority? A.“We just don’t understand why our son can’t keep up with the other kids in simple activities like running and jumping.” B. “our son keeps trying to find ways around our household rules. he always wants to make deals with us.” c.“We think our son is trying too hard to excel in math just to get the top grades in his class.” d.“our son is always afraid the kids in school will laugh at him because he likes to sing.” 2. A nurse is planning diversionary activities for school age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) A. Building models B. Playing video games c. reading books d. Using toy carpentry tools e. Playing board games 3. A nurse is evaluating teaching about nutrition with the parents of an 11 year old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A.“She wants to eat as much as we do, but we’re afraid she’ll soon be overweight.” B. “She skips lunch sometimes, but we figure it’s okay as long as she has a healthy breakfast and dinner.” c.“We limit fast food restaurant meals to three times a week now.” d.“We reward her school achievements with a point system instead of a pizza or ice cream.” 4. A nurse is talking with the parents of a 10 year old child who is concerned that their son is becoming secretive, such as closing the door when he showers, and dresses. Which of the following responses should the nurse make? A.“Perhaps you should try to find out what he is doing behind those closed doors.” B. “Suggest that he leave the door ajar for his own safety.” c.“At this age, children tend to become modest and value their privacy.” d.“You should establish a disciplinary plan to stop this behavior.” 5. A nurse is planning a health promotion and primary prevention class for the parents of school age children. Which of the following information should the nurse include? (Select all that apply.) A. Provide information about the risk of childhood obesity. B. discuss the danger of substance use disorders. c. Promote discussion about sexual issues. d. recommend the school age child sit in the front seat of the car. e. reinforce stranger awareness. PRACTICE Active Learning Scenario A nurse is explaining to a group of parents in a community center what cognitive development characteristics they should expect of their school age children. Use the Ati Active learning template: growth and development to complete this item. COGNITIVE DEVELOPMENT: list at least eight cognitive and language development expectations during young adulthood. A nurse is teaching the father of a 12 year old boy about manifestations of puberty. the nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae c. enlargement of the testes and scrotum d. deepening of the voice 2. A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (select all that apply.) A. suggest that his parents bring in video games for him to play. B. Provide a television and dVds for the adolescent to watch. c. limit visitors to the adolescent’s immediate family. d. Involve the adolescent in treatment decisions when possible. e. Allow the adolescent to perform his own morning care. 3. A nurse is reviewing the cdc’s immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (select all that apply.) A. rotavirus B. Varicella c. Herpes zoster d. Human papilloma virus e. seasonal influenza 4. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A.“I kind of like this boy in my class, but he doesn’t like me back.” B. “I want to hang out with the kids in the science club, but the jocks pick on them.” c.“I am so fat, I skip meals to try to lose weight.” d.“My dad wants me to be a lawyer like him, but I just want to dance.” 5. A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (select all that apply.) A. obtain a periodic mental status evaluation. B. discuss prevention of sexually transmitted infections. c. regularly screen for tuberculosis. d. Provide education about drug and alcohol use. e. teach monthly breast examinations for girls. PRACTICE Active Learning Scenario A nurse on a pediatric unit is reviewing with a group of newly licensed nurses the cognitive developmental milestones to expect from adolescent clients. Use the AtI Active learning template: Growth and development to complete this item. COGNITIVE DEVELOPMENT: list at least five cognitive development expectations during adolescence. . A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A.“I already had my immunizations as a child, so I’m protected in that area.” B. “It is important to schedule routine health care visits even if I am feeling well.” C.“I will just go to an urgent care center for my routine medical care.” d.“there’s no reason to seek help if I am feeling stressed because it’s just part of life.” 2. A nurse is reviewing CdC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch up, during young adulthood? (select all that apply.) A. Influenza B. Measles, mumps, rubella C. Pertussis d. tetanus e. Polio 3. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse should include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. devoting a great deal of time to establishing an occupation d. Finding oneself “sandwiched” between and being responsible for two generations 4. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A.“I have my own apartment now, but it’s not easy living away from my parents.” B. “It’s been so stressful for me to even think about having my own family.” C.“I don’t even know who I am yet, and now I’m supposed to know what to do.” d.“My girlfriend is pregnant, and I don’t think I have what it takes to be a good father.” 5. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. d. secure firearms in a safe location. e. remove throw rugs from the home. PRACTICE Active Learning Scenario A nurse at a community center is teaching a group of young adults what physical and cognitive development characteristics they should expect at this stage of life. use the AtI Active learning template: growth and development to complete this item. PHYSICAL DEVELOPMENT: list at least five physical development expectations. COGNITIVE DEVELOPMENT: list at least three cognitive development expectations during young adulthood. A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. the client evaluates his behavior after a social interaction. B. the client states he is learning to trust others. C. the client wishes to find meaningful friendships. d. the client expresses concerns about the next generation. 2. A nurse is collecting data to evaluate a middle adult’s psychosocial development. the nurse should expect middle adults to demonstrate which of the following developmental tasks? (select all that apply.) A. develop an acceptance of diminished strength and increased dependence on others. B. spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. d. Commit to finding friendship and companionship. e. Become involved with community issues and activities. 3. A nurse is collecting history and physical examination data from a middle adult. the nurse should expect to find decreases in which of the following physiologic functions? (select all that apply.) A. Metabolism B. Ability to hear low pitched sounds C. Gastric secretions d. Far vision e. Glomerular filtration 4. A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (select all that apply.) A. eye examination every 1 to 3 years B. decrease intake of calcium supplements C. dXA screening for osteoporosis d. increase intake of carbohydrate in the diet e. screening for depressive disorders 5. A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A.“i am struggling to accept that my parents are aging and need so much help.” B. “it’s been so stressful for me to think about having intimate relationships.” C.“i know i should volunteer my time for a good cause, but maybe i’m just selfish.” d.“i love my grandchildren, but my son expects me to relive my parenting days.” PRACTICE Active Learning Scenario A nurse in a community health center is explaining to a group of middle adults what moral and cognitive development characteristics they should expect at this stage of life. use the Ati Active learning template: Growth and development to complete this item. COGNITIVE DEVELOPMENT ● list at least two moral development expectations during middle adulthood. ● list at least four cognitive development expectations during middle adulthood A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A.“I spent my whole life dreaming about retirement, and now I wish I had my job back.” B. “It’s been so stressful for me to have to depend on my son to help around the house.” C.“I just heard my friend Al died. that’s the third one in 3 months.” d.“I keep forgetting which medications I have taken during the day.” 2. A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (select all that apply.) A.“eat three large meals a day.” B. “eat your meals in front of the television.” C.”eat foods that are easy to eat, such as finger foods.” d.”Invite family members to eat meals with you.” e. “exercise every day to increase appetite.” 3. A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination d. Periodic mental health screening e. Annual fecal occult blood test 4. A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (select all that apply.) A. Increase protein intake to increase muscle mass. B. decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. d. limit sodium intake to prevent edema. e. Increase fiber intake to prevent constipation. 5. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (select all that apply.) A. skin thickening B. decreased height C. Increased saliva production d. nail thickening e. decreased bladder capacity a nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) a. address the client with the appropriate title and her last name. B. use a mix of open and closed ended questions. C. reduce environmental noise. D. Have the client complete a printed history form. e. Perform the general survey before the examination. 2. a nurse in a provider’s office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) a. Posture B. Skin lesions C. Speech D. allergies e. immunization status 3. a nurse is collecting data for a client’s comprehensive physical examination. after the nurse inspects the client’s abdomen, which of the following skills of the physical examination process should she perform next? a. olfaction B. auscultation C. Palpation D. Percussion 4. a nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client’s age? (Select all that apply.) a. Collect the data in one continuous session. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. tell the client to take her time answering questions. e. invite the client to use the bathroom before beginning the examination. 5. a nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? a. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers a nurse is caring for an 82 year old client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.) a. Obtain culture specimens before initiating antimicrobials. B. Restrict the client’s oral fluid intake. C. Encourage the client to rest and limit activity. D. allow the client to shiver to dispel excess heat. E. assist the client with oral hygiene frequently. 2. a nurse is instructing an assistive personnel (aP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a.“Do not measure the client’s temperature rectally.” B. “Count the client’s radial pulse for 30 seconds and multiply it by 2.” C.“Do not let the client know you are counting her respirations.” D.“let the client rest for 5 minutes before you measure her blood pressure.” 3. a nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) a. Place the client in semi Fowler’s position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is irregular. E. Count and report any sighs the client demonstrates. 4. a nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. the client denies any history of hypertension. Which of the following actions should the nurse take first? a. Request a prescription for an antihypertensive medication. B. ask the client if she is having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client’s blood pressure. 5. a nurse is performing an admission assessment on a client. the nurse determines the client’s radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit? PRACTICE Active Learning Scenario a nurse is explaining to a group of nursing students the various factors that can affect a client’s heart rate. Use the ati active learning template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: list at least five factors that can cause tachycardia and at least five factors that can cause bradycardia. a nurse in a provider’s office is preparing to test a client’s cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply.) a.“close your eyes.” B. “Tell me what you can taste.” c.“clench your teeth.” d.“Raise your eyebrows.” e. “Tell me when you feel a touch.” 2. a nurse is assessing a client’s thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck c. Hearing a bruit when auscultating the thyroid d. Feeling the thyroid ascend as the client swallows e. Finding symmetric extension off the trachea on both sides of the midline 3. a nurse is assessing an adult client’s internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) a. Pull the auricle down and back. B. Insert the speculum slightly down and forward. c. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). d. Make sure the speculum does not touch the ear canal. e. Use the light to visualize the tympanic membrane in a cone shape. 4. a nurse is caring for a client who asks what her Snellen eye test results mean. The client’s visual acuity is 20/30. Which of the following responses should the nurse make? a.“Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.” B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.” c.“Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.” d.“Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.” 5. a nurse is performing a head and neck examination for an older adult client. Which of the following age related findings should the nurse expect? (Select all that apply.) a. Reddened gums B. Lowered vocal pitch c. Tooth loss d. Glare intolerance e. Thickened eardrums PRACTICE Active Learning Scenario a nurse is assessing a client’s lymph nodes as part of a comprehensive physical examination. Use the aTI active Learning Template: nursing Skill to complete this item. DESCRIPTION OF SKILL: List the nine chains of lymph nodes and the location of each, in the appropriate sequence for palpating them. a nurse in a provider’s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) a. Smaller nipples b. Less adipose tissue C. nipple discharge d. more pendulous e. nipple inversion 2. a nurse in a provider’s office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. rhonchi b. Crackles C. resonance d. Tactile fremitus e. bronchovesicular sounds 3. during an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? a. Fat b. Fluid C. Flatus d. hernias 4. during a cardiovascular examination, a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) a. Ventricular gallop b. Closure of the mitral valve C. Closure of the pulmonic valve d. Closure of the tricuspid valve e. murmur 5. a nurse in a provider’s office is preparing to auscultate and percuss a client’s abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Tympany b. high pitched clicks C. borborygmi d. Friction rubs e. bruits PRACTICE Active Learning Scenario a nurse is teaching a group of newly licensed nurses about identifying chest landmarks to help them find the optimal locations for auscultation of the thorax. Use the aTI active Learning Template: basic Concept to complete this item. UNDERLYING PRINCIPLES: List the seven key chest landmarks, along with their location on the thorax. a nurse in a provider’s office is preparing to assess a client’s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply.) a. capillary refill less than 2 seconds B. 1+ pitting edema in both feet c. Pale nail beds in both hands d. thick skin on the soles of the feet e. numerous light brown macules on the face 2. a nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (select all that apply.) a. thin, parchment like skin B. loss of adipose tissue c. dehydration d. diminished skin elasticity e. excessive wrinkling 3. a nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. the nurse should include which of the following? (select all that apply.) a. range of motion B. skin color c. edema d. skin lesions e. skin temperature 4. a nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (select all that apply.) a. acne B. Warts c. Psoriasis d. herpes simplex e. Varicella 5. a nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a. Pallor B. cyanosis c. Jaundice d. erythema . a nurse in a provider’s office is preparing to assess a young adult male client’s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply.) a. concave thoracic spine posteriorly B. exaggerated lumbar curvature c. concave lumbar spine posteriorly d. exaggerated thoracic curvature e. Muscles slightly larger on his dominant side 2. a nurse is assessing a client’s neurosensory system. to evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? a. a word she whispers 30 cm from his ear B. a number she traces on the palm of his hand c. the vibration of a tuning fork she places on his foot d. a familiar object she places in his hand 3. a nurse is caring for a client who reports pain with internal rotation of her right shoulder. the nurse should identify that this discomfort can affect the client’s ability to perform which of the following activities? a. Mopping her floors B. Brushing the back of her hair c. Fastening her bra behind her back d. reaching into a cabinet above her sink 4. a nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client’s balance? (select all that apply.) a. romberg test B. Heel to toe walk c. snellen test d. spinal accessory function e. rosenbaum test 5. a nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (select all that apply.) a. slower light touch sensation B. some vision and hearing decline c. slower fine finger movement d. some short term memory decline e. slower superficial pain sensation a nurse is caring for a client who states, “i have to check with my wife and see if she thinks i am ready to go home.” The nurse replies, “how do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client? a. pacing B. reflecting c. paraphrasing D. restating 2. Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply.) a. use an open posture. B. Write down what the client says to avoid forgetting details. c. establish and maintain eye contact. D. nod in agreement with the client throughout the conversation. e. respond positively when giving feedback. 3. a nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) a.“You will do great! You just have to get used it.” B. “Why are you worried about going home?” c.“Your daily routines will be different when you get home.” D.“Tell me about your support system you’ll have after you leave the hospital.” e. “Let me tell you about a friend of mine with a colostomy who also enjoys swimming.” 4. Which of the following strategies should a nurse use to establish a helping relationship with a client? a. make sure the communication is equally reciprocal between the nurse and the client. B. encourage the client to communicate his thoughts and feelings. c. Give the nurse client communication no time limits. D. allow communication to occur spontaneously throughout the nurse client relationship. 5. a nurse is caring for a school age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? a. Touch the child’s arm. B. Sit at eye level with the child. c. Stand facing the child. D. Stand with a relaxed posture. PRACTICE Active Learning Scenario a nurse manager is reviewing nonverbal communication with staff members. use the aTi active Learning Template: Basic concept to complete this item. RELATED CONTENT: List at least four examples of nonverbal communication. UNDERLYING PRINCIPLES: explain their effect on the communication. A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, “How could you possibly understand what i am going through?” Which of the following responses should the nurse make? A.“it takes time to get over the loss of a loved one.” B. “You are right. i cannot really understand. perhaps you’d like to tell me more about what you’re feeling.” C.“Why don’t you try something to take your mind off your troubles, like watching a funny movie.” D.“i might not share your exact situation, but i do know what people go through when they deal with a loss.” 2. A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client’s vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (gAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction 3. A nurse is caring for a client who has left sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client’s role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain 4. A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) A. Suggest coping skills for the client to use in this situation. B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client’s priorities. D. provide extensive instructions on the client’s treatment regimen. E. Encourage the client in the expression of feelings and concerns. 5. A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting PRACTICE Active Learning Scenario A nurse manager is reviewing coping factors with the members of her team. Use the ATi Active Learning Template: Basic Concept to complete this item. RELATED CONTENT: List at least four factors that influence an individual’s ability to cope. NURSING INTERVENTIONS: List three interventions the nurse can take to assist the client in coping with a stressful event or situation. a nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. the client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, “My body is so different now.” Which of the following responses should the nurse make? a.“Really, you look just fine to me. there’s no need to feel undesirable.” B. “i’m interested in finding out more about how your body feels to you.” C.“Consider an afternoon at a spa. a facial will make you feel more attractive.” d.“it’s still too soon to expect to feel normal. Give it a little more time.” 2. a nurse is caring for a group of clients on a medical surgical unit. Which of the following clients are at risk for body image disturbances? (Select all that apply.) a. 30 year old male client following laparoscopic appendectomy B. 45 year old female client following mastectomy C. 20 year old female client following left above the knee amputation d. 65 year old male client following cardiac catheterization e. 55 year old male client following stroke with right sided hemiplegia 3. a nurse is caring for a client who is 3 days postoperative following a below the knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? a.“i’ll be able to function exactly as i did before the accident.” B. “i just can’t stop crying.” C.“i am so mad at that guy who hit us. i wish he lost a leg.” d.“i don’t even want to look at my leg. you can check the dressing.” 4. a nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. the client states, “i am concerned that things might be a little, you know, ‘different’ with my wife when i get home.” Which of the following statements should the nurse make? a.“Sounds like something you should discuss with her when you get home.” B. “it sounds like you are concerned about sexual functioning. let’s discuss your concerns.” C.“oh, i wouldn’t be too concerned. things will be fine as soon as we get you home.” d.“Just make sure you take your medication as directed, and you should be fine.” 5. a nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self concept? a.“i was having difficulty with attaching the appliance at first, but my wife was able to help.” B. “i’ll never be able to care for this at home. Can’t you just send a nurse to the house?” C.“i met a neighbor who also has a colostomy, and he taught me a few things.” d.“it may take me a while to get the hang of this. i have to admit, i am pretty nervous.” PRACTICE Active Learning Scenario a nurse manager is reviewing self concept assessment findings with her staff. use the ati active learning template: System disorder to complete this item. EXPECTED FINDINGS: list at least six. a nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply.) a. talk to the interpreter about the family while the family is in the room. B. ask the family one question at a time. C. look at the interpreter when asking the family questions. d. use lay terms if possible. e. do not interrupt the interpreter and the family as they talk. 2. a nurse is caring for a client who shares the nurse’s religious background. Which of the following information should the nurse anticipate? a. Members of the same religion share similar feelings about their religion. B. a shared religious background generates mutual regard for one another. C. the same religious beliefs can influence individuals differently. d. the nurse and client should discuss the differences and commonalities in their beliefs. 3. a nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? a. Contact the hospital’s spiritual services. B. ask him what is making him cry. C. provide quiet times for these moments. d. turn on the television for a distraction. 4. a nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. the client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? a.“i will make sure the menu includes kosher options.” B. “i will discuss the daily schedule with the client to make sure the client will have time for prayer.” C.“i will make sure to use direct eye contact when speaking with this client.” d.“i will make sure daily communion is available for this client.” 5. a nurse is caring for a client who is a Jehovah’s Witness and is scheduled for surgery as a result of a motor vehicle crash. the surgeon tells the client that a blood transfusion is essential. the client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make? a.“i believe in this case you should really make an exception and accept the blood transfusion.” B. “i know your family would approve of your decision to have a blood transfusion.” C.“Why does your religion mandate that you cannot receive any blood transfusions?” d.“let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.” a nurse is caring for a client who has terminal lung cancer. the nurse observes the client’s family assisting with all adLs. Which of the following rationales for self care should the nurse communicate to the family? a. allowing the client to function independently will strengthen her muscles and promote healing. B. the client needs to be given privacy at times for self reflecting and organizing her life. C. the client’s sense of loss can be lessened through retaining control of certain areas of her life. d. Performing adLs is required prior to discharge from an acute care facility. 2. a nurse is caring for a client who has stage iv lung cancer and is 3 days postoperative following a wedge resection. the client states, “i told myself that i would go through with the surgery and quit smoking, if i could just live long enough to attend my daughter’s wedding.” Based on Kübler ross’ model, which stage of grief is the client experiencing? a. anger B. denial C. Bargaining d. acceptance 3. a nurse is consoling the partner of a client who just expired after a long battle with liver cancer. the partner is displaying grief and states, “i hate him for leaving me.” Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (select all that apply.) a.“Would you like me to contact the chaplain to come speak with you?” B. “You will feel better soon. You have been expecting this for a while now.” C.“Let’s talk about your children and how they are going to react.” d.“You know, it is quite normal to feel anger toward your husband at this time.” e. “tell me more about how you are feeling.” 4. a nurse is caring for a client who has a terminal illness. death is expected within 24 hr. the client’s family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? a. regular breathing patterns B. Warm extremities C. increased urine output d. decreased muscle tone 5. a nurse is assisting a newly licensed nurse with postmortem care of a client. the family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (select all that apply.) a.“i will remove the dentures from the body.” B. “i will make sure the body is lying completely flat.” C.“i will apply fresh linens and place a clean gown on the body.” d.“i will remove all equipment from the bedside.” e. “i will dim the lights in the room.” PRACTICE Active Learning Scenario a nurse educator is teaching a module on palliative care to a group of newly licensed nurses. Use the ati active Learning template: Basic Concept to complete this item. NURSING INTERVENTIONS: List five physical care interventions and five psychological care interventions appropriate for the care of a client who is dying. A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client’s head to the side. B. Place two fingers in the client’s mouth to open. C. Brush the client’s teeth once per day. D. inject a mouth rinse into the center of the client’s mouth. 2. A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over the counter products to treat abrasions. e. Wear cotton socks. 3. A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client’s plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client. 4. A nurse is beginning a complete bed bath for a client. After removing the client’s gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms 5. A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them. PRACTICE Active Learning Scenario A nurse is about to perform perineal care for a client whose ability to assist with care is limited. Use the ATi Active Learning Template: nursing Skill to complete this item. DESCRIPTION OF SKILL: List the steps the nurse should take to perform this procedure. a nurse in a provider’s office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the client’s difficulty sleeping? (select all that apply.) a.“does your lack of sleep interfere with your ability to function during the day?” B. “do you feel confused in the late afternoon?” C.“do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?” d.“Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?” e. “tell me about any personal stress you are experiencing.” 2. a nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (select all that apply.) a. practice muscle relaxation techniques. B. exercise each morning. C. take an afternoon nap. d. alter the sleep environment for comfort. e. limit fluid intake at least 2 hr before bedtime. 3. a nurse is caring for an older adult client who has been following the facility’s routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? a. Rub the client’s back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. allow the client to take a bath in the evening. d. ask the provider for a sleeping medication. 4. a nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (ReM) sleep, which of the following characteristics should the nurse include? (select all that apply.) a. ReM sleep provides cognitive restoration. B. ReM sleep lasts about 90 min. C. It is difficult to awaken a person in ReM sleep. d. sleepwalking occurs during ReM sleep. e. Vivid dreams are common during ReM sleep. 5. a nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a.“I’ll add plenty of carbohydrates to my meals.” B. “I’ll take a short nap whenever I feel a little sleepy.” C.“I’ll make sure I stay warm when I am at my desk at work.” d.“It’s okay to drink alcohol as long as I limit it to one drink per day.” PRACTICE Active Learning Scenario a nurse on a medical unit is collecting data from a client who reports a persistent inability to sleep. Use the atI active learning template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: list at least three common factors that might be interfering with the client’s sleep. NURSING INTERVENTIONS: list at least three strategies the nurse can implement to help the client sleep while in the hospital. a nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? a. Give the client thin liquids. B. instruct the client to tuck her chin when swallowing. C. Have the client use a straw. d. Encourage the client to lie down and rest after meals. 2. a nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? a. Fat B. Protein C. Glycogen d. Carbohydrates 3. a nurse is caring for a client who requires a low residue diet. the nurse should expect to see which of the following foods on the client’s meal tray? a. Cooked barley B. Pureed broccoli C. Vanilla custard d. lentil soup 4. a nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate her body mass index (BMi) and determine whether this client’s BMi indicates that she is of a healthy weight, overweight, or obese. 5. a nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) a. older adults are more prone to dehydration than younger adults are. B. older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. d. older adults need more calories than they did when they were younger. E. older adults should consume a diet low in carbohydrates. PRACTICE Active Learning Scenario a nurse is preparing a presentation in a community center on eating disorders that affect adolescents and young adults. use the ati active learning template: Basic Concept to complete this item. RELATED CONTENT: list two common eating disorders and their characteristics. a nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. the nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? a. Presence of associated manifestations B. Location of the pain C. Pain quality D. aggravating and relieving factors 2. a nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client’s pain? a. ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure his pain. D. Use open ended questions to identify the client’s pain sensations. 3. a nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain. B. a client who has incisional pain 72 hr following pacemaker insertion. C. a client who has food poisoning and reports abdominal cramping. D. a client who has episodic back pain following a fall 2 years ago. 4. a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply.) a. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension e. nausea 5. a nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCa) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? a.“i’ll wait to use the device until it’s absolutely necessary.” B. “i’ll be careful about pushing the button too much so i don’t get an overdose.” C.“i should tell the nurse if the pain doesn’t stop while i am using this device.” D.“i will ask my adult child to push the dose button when i am sleeping.” PRACTICE Active Learning Scenario a nurse on a medical surgical unit is reviewing with a group of newly licensed nurses the various types of pain the clients on the unit have. Use the ati active Learning template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: List the four different types of pain, their definitions, and characteristics. a nurse is caring for a client scheduled for abdominal surgery. the client reports being worried. Which of the following actions should the nurse take? a. offer information on a relaxation technique and ask the client if he is interested in trying it. B. request a social worker see the client to discuss meditation. C. attempt to use biofeedback techniques with the client. d. tell the client many people feel the same way before surgery and to think of something else. 2. a nurse is assessing a client as part of an admission history. the client reports drinking an herbal tea every afternoon at work to relieve stress. the nurse should suspect the tea includes which of the following ingredients? a. Chamomile B. Ginseng C. Ginger d. echinacea 3. a nurse is reviewing complementary and alternative therapies with a group of nursing students. the nurse should classify which of the following interventions as a mind body therapy? (select all that apply.) a. art therapy B. acupressure C. yoga d. therapeutic touch e. Biofeedback 4. a nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (select all that apply.) a. Guided imagery B. massage therapy C. meditation d. music therapy e. therapeutic touch 5. a nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind body intervention? a. tell the client the goal of the therapy is to promote healing. B. ask whether the client is comfortable with using prayer. C. encourage the client participate actively for best results. d. instruct the client to relax during the therapy. PRACTICE Active Learning Scenario a nurse is reviewing the various categories of complementary and alternative therapies with a group of newly licensed nurses. Use the ati active learning template: Basic Concept to complete this item. RELATED CONTENT: list at least four different types of therapies with examples of each. . a nurse is caring for a client who will perform fecal occult blood testing at home. which of the following information should the nurse include when explaining the procedure to the client? a. eating more protein is optimal prior to testing. B. one stool specimen is sufficient for testing. C. a red color change indicates a positive test. D. the specimen cannot be contaminated with urine. 2. a nurse is talking with a client who reports constipation. when the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. macaroni and cheese B. Fresh fruit and whole wheat toast C. Bread pudding and yogurt D. Roast chicken and white rice 3. a nurse is caring for a client who has had diarrhea for 4 days. when assessing the client, the nurse should expect which of the following findings? (Select all that apply.) a. Bradycardia B. Hypotension C. elevated temperature D. Poor skin turgor e. Peripheral edema 4. while a nurse is administering a cleansing enema, the client reports abdominal cramping. which of the following actions should the nurse take? a. Have the client hold his breath briefly and bear down. B. Discontinue the fluid instillation. C. Remind the client that cramping is common at this time. D. lower the enema fluid container. 5. a nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. which of the following steps should the nurse take? (Select all that apply.) a. warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 5 cm (2 in). e. Hang the enema container 61 cm (24 in) above the client’s anus. a nurse in a provider’s office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. the client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client’s incontinence? (Select all that apply.) a. limit total daily fluid intake. B. Decrease or avoid caffeine. C. take calcium supplements. D. avoid drinking alcohol. E. Use the Credé maneuver. 2. a client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent. B. reassure the client that it is not possible for her to urinate. C. recatheterize the bladder with a larger gauge catheter. D. Collect a urine specimen for analysis. 3. a nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take? a. Discard the first voiding. B. Keep the urine in a single container at room temperature. C. ask the client to urinate and pour the urine into a specimen container. D. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. 4. a nurse is reviewing factors that increase the risk of urinary tract infections (Utis) with a client who has recurrent Utis. Which of the following factors should the nurse include? (Select all that apply.) a. Frequent sexual intercourse B. lowering of testosterone levels C. Wiping from front to back D. location of the urethra in relation to the anus E. Frequent catheterization 5. a nurse is preparing to initiate a bladder retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) a. Establish a schedule of urinating prior to meal times. B. Have the client record urination times. C. Gradually increase the urination intervals. D. remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine. PRACTICE Active Learning Scenario a nurse is teaching a group of nursing students about the various types of urinary incontinence. Use the ati active learning template: System Disorder to complete this item. ALTERATION IN HEALTH (DIAGNOSIS): list at least four of the six types of urinary incontinence, along with a brief example or description of each. RISK FACTORS: list at least 10 common risk factors for urinary incontinence. A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.) A. increase the volume of your voice. B. Make sure only one person speaks at a time. c. Avoid discouraging the client by saying that you do not understand him. D. Allow plenty of time for the client to respond. e. Use brief sentences with simple words. 2. A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. immediately complete a thorough assessment. B. Put the client in a room with a client who has a hearing loss. c. Provide a private room, and limit stimulation. D. Speak at a higher volume to the client, and encourage ambulation. 3. A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o’clock in the left ear c. indications of obstruction in the left ear canal D. rinne test showing less time for air and bone conduction e. rinne test showing air conduction less than bone conduction in the left ear 4. A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide B. ibuprofen c. cimetidine D. Simvastatin e. Amiodarone 5. A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A.“i use a damp cloth to clean the outside part of my hearing aids.” B. “i clean the ear molds of my hearing aids with rubbing alcohol.” c.“i keep the volume of my hearing aids turned up so i can hear better.” D.“i take the batteries out of my hearing aids when i take them off at night.” PRACTICE Active Learning Scenario A nurse is teaching a group of nursing students how to intervene for clients who have sensory impairment. Use the Ati Active Learning template: System Disorder to complete this item. NURSING CARE ● List at least six interventions for clients who have hearing loss. ● List at least six interventions for clients who have vision loss. . a nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. the client states his pain level is 10 on a scale of 0 to 10. after reviewing the client’s medication administration record, which of the following medications should the nurse administer? a. meperidine 75 mg im B. fentanyl 50 mcg/hr transdermal patch c. morphine 2 mg iV d. oxycodone 10 mg Po 2. a nurse is teaching a client about taking multiple oral medications at home to include time release capsules, liquid medications, enteric coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a.“i can open the capsule with the beads in it and sprinkle them on my oatmeal.” B. “if i am having difficulty swallowing, i will add the liquid medication to a batch of pudding.” c.“i can crush the pills with the coating on them.” d.“i will eat two crackers with the pain pills.” 3. a nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? a.“flush the tube before and after each medication.” B. “mix your medications with your enteral feeding.” c.“Push tablets through the tube slowly.” d.“mix all the crushed medications prior to dissolving them in water.” 4. a nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? a. use a 22 gauge needle. B. select a site on the client’s abdomen. c. spread the skin with the thumb and index finger. d. observe for bleb formation to confirm proper placement. 5. a nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? a.“i will straighten my ear canal by pulling my ear down and back.” B. “i will gently apply pressure with my finger to the front part of my ear after putting in the drops.” c.“i will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.” d.“after the drops are in, i will place a cotton ball all the way into my ear canal.” PRACTICE Active Learning Scenario a nurse educator is teaching a module on biotransformation as a phase of pharmacokinetics during nursing orientation to a group of newly licensed nurses. use the ati active Learning template: Basic concept to complete this item. RELATED CONTENT: List four areas of the body where biotransformation takes place. UNDERLYING PRINCIPLES: List at least three factors that influence the rate of biotransformation. a nurse prepares an injection of morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? a. offer to assist the client who needs the bedpan. B. administer the injection the other nurse prepared. c. Prepare another syringe and administer the injection. d. tell the client who needs the bedpan she will have to wait for her nurse. 2. a nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? (Select all that apply.) a. 0905 B. 0825 c. 1000 d. 0840 e. 0935 3. a nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? a. taking all medications out of the unit dose wrappers before entering the client’s room B. checking with the provider when a single dose requires administration of multiple tablets c. administering a medication, then looking up the usual dosage range d. relying on another nurse to clarify a medication prescription 4. a nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the group understands how to implement medication therapy? (Select all that apply.) a.“i will observe for side effects.” B. “i will monitor for therapeutic effects.” c.“i will prescribe the appropriate dose.” d.“i will change the dose if adverse effects occur.” e. “i will refuse to give a medication if i believe it is unsafe.” 5. a nurse is preparing to administer digoxin to a client who states, “i don’t want to take that medication. i do not want one more pill.” Which of the following responses should the nurse make? a.“Your physician prescribed it for you, so you really should take it.” B. “Well, let’s just get it over quickly then.” c.“okay, i’ll just give you your other medications.” d.“tell me your concerns about taking this medication.” PRACTICE Active Learning Scenario a nurse educator is teaching a module about the rights of safe medication administration to a group of newly licensed nurses. use the ati active Learning template: Basic concept to complete this item. RELATED CONTENT: List the rights of safe medication administration. UNDERLYING PRINCIPLES: List at least three acceptable identifiers to use to verify the client’s identity a nurse is preparing to administer methylprednisolone 10 mg by iV bolus. the amount available is methylprednisolone injection 40 mg/ml. How many ml should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.) 2. a nurse is preparing to administer lactated Ringer’s (lR) iV 100 ml over 15 min. the nurse should set the iV infusion pump to deliver how many ml/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.) 3. a nurse is preparing to administer 0.9% sodium chloride (0.9% naCl) 250 ml iV to infuse over 30 min. the drop factor of the manual iV tubing is 10 gtt/ml. the nurse should adjust the manual iV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.) 4. a nurse is preparing to administer metoprolol 200 mg Po daily. the amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Do not use a trailing zero.) 5. a nurse is preparing to administer ketorolac 0.5 mg/kg iV bolus every 6 hr to a school age child who weighs 66 lb. the amount available is ketorolac injection 30 mg/ml. How many ml should the nurse administer per dose? (Round the answer to the nearest tenth. use a leading zero if it applies. Do not use a trailing zero.) 6. a nurse is preparing to administer dextrose 5% in water (D5W) 1,000 ml iV to infuse over 10 hr. the nurse should set the iV infusion pump to deliver how many ml/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.) 7. a nurse is preparing to administer acetaminophen 320 mg Po every 4 hr PRn for pain. the amount available is acetaminophen liquid 160 mg/5 ml. How many ml should the nurse administer per dose? (Round the answer to the nearest whole number. Do not use a trailing zero.) 8. a nurse is preparing to administer dextrose 5% in lactated Ringer’s (D5lR) 1,000 ml to infuse over 6 hr. the drop factor of the manual iV tubing is 15 gtt/ml. the nurse should adjust the manual iV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.) a nurse is demonstrating how to insert an Iv catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? a.“I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood.” B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.” C.“I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle.” D.“I will choose a vein in the antecubital fossa for Iv insertion due to its size and easily accessible location.” 2. a nurse is collecting data from a client who is receiving Iv therapy and reports pain in his arm, chills, and “not feeling well.” the nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the Iv insertion site. Which of the following actions should the nurse plan to take first? a. obtain a specimen for culture. B. apply a warm compress. C. administer analgesics. D. Discontinue the infusion. 3. During new employee orientation, a nurse is explaining how to prevent Iv infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? a.“I will leave the Iv catheter in place after the client completes the course of Iv antibiotics.” B. “as long as I am working with the same client, I can use the same Iv catheter for my second insertion attempt.” C.“If my client needs to use the rest room, it would be safer to disconnect his Iv infusion as long as I clean the injection port thoroughly with an antiseptic swab.” D.“I will replace any Iv catheter when I suspect contamination during insertion.” 4. a nurse on the Iv team is conducting an in service education program about the complications of Iv therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (select all that apply.) a.“the temperature around the Iv site is cooler.” B. “the rate of the infusion increases.” C.“the skin at the Iv site is red.” D.“the Iv dressing is damp.” e. “the tissue around the venipuncture site is swollen.” 5. a nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride Iv at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (select all that apply.) a.“I feel lightheaded.” B. “I feel as though my heart is racing.” C.“I feel a little short of breath.” D.“the nurse technician told me that my blood pressure was 150 over 90.” e. “I think my ankles are less swollen.” A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (ePss)? (select all that apply.) A. orthostatic hypotension B. tremors c. Acute dystonia d. decreased level of consciousness e. restlessness 2. A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication’s anticholinergic effects. Which of the following instructions should the nurse include? (select all that apply.) A. take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. c. Use a soft toothbrush when brushing teeth. d. take the medication with an antacid. e. Urinate prior to taking the medication. 3. A nurse is reviewing a client’s medications. they include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. decreased therapeutic effects of cimetidine B. Increased risk of imipramine toxicity c. decreased risk of adverse effects of cimetidine d. Increased therapeutic effects of imipramine 4. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? A.“Get up and change positions slowly.” B. “Avoid eating aged cheese and smoked meat.” c.“report any usual bruising or bleeding to the doctor immediately.” d.“eat the same amount of foods that contain vitamin K every day.” 5. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. the client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority? A. teaching the client about the purpose of the medication B. Giving the medication at the administration time the provider prescribed c. Identifying the client’s medication allergies d. documenting the client’s anxiety level PRACTICE Active Learning Scenario A nurse is reviewing the fdA’s pregnancy risk categories in an in service presentation. Use the AtI Active Learning template: Basic concept to complete this item. RELATED CONTENT: Include the definition and an example of each of the five pregnancy risk categories. to promote adherence with medication self administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (select all that apply.) a. adjust dosages according to daily weight. B. Place pills in daily pill holders. C. ask for liquid forms if the client has difficulty swallowing pills. d. ask a relative to assist periodically. e. request child resistant caps on medication containers. 2. a young adult client in a provider’s office tells the nurse that she uses fasting for several days each week to help control her weight. the client takes several medications for various chronic issues. the nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? a. Increasing the metabolism of the medications over time B. Increasing the protein binding response C. Increasing medications’ transit time through the intestines d. decreasing the excretion of medications 3. a nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (select all that apply.) a. Increased gastric acid production B. lower blood pressure C. Higher body water content d. Increased absorption of topical medications e. Increased gastric emptying time 4. a nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? a. drink 8 oz milk with each dose of medication. B. use medications that have an extended half life. C. take each dose right after breastfeeding. d. Pump breast milk and freeze it prior to feeding to the newborn. 5. a nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make? a.“You will need to get a rubella immunization if you haven’t had one prior to pregnancy.” B. “You can safely take over the counter medications.” C.“You should avoid any vitamin preparations containing iron.” d.“Your provider can prescribe medication for nausea if you need it.” PRACTICE Active Learning Scenario a nurse is preparing to administer medications to an older adult client who has vascular insufficiency and impaired kidney function. use the atI active learning template: Basic Concept to complete this item. UNDERLYING PRINCIPLES ● discuss medication considerations with vascular insufficiency. ● discuss medication considerations with impaired kidney function. ● Identify at least four physiologic changes with aging that affect pharmacokinetics. NURSING INTERVENTIONS: Identify at least three interventions for reducing the risk for adverse effects. A nurse is determining a client’s ability to learn self monitoring of blood glucose using a glucometer. Which of the following abilities should the nurse confirm that the client has before proceeding with instruction? (Select all that apply.) A. finger dexterity B. Visual acuity c. color vision D. Basic literacy e. Demonstration ability 2. A nurse is reviewing a client’s medication history. the client has an admission blood glucose of 260 mg/dl and no documented history of diabetes mellitus. Which of the following types of medications should alert the nurse to the possibility that the client has developed an adverse effect of pharmacological therapy? (Select all that apply.) A. Diuretics B. corticosteroids c. oral anticoagulants D. opioid analgesics e. Antipsychotics 3. A nurse is providing education on how to check blood glucose levels to a client who has a new diagnosis of type 1 diabetes mellitus. the nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A. Smear the blood onto the strip. B. Squeeze the blood onto the strip. c. touch the puncture to stimulate bleeding. D. Hold the test strip next to the blood on the fingertip. 4. A nurse attempts to collect a capillary blood specimen via finger stick for a blood glucose monitoring from a client who has diabetes mellitus. the nurse is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A. puncture another finger to obtain a capillary specimen. B. test the urine with a urine reagent strip. c. Wrap the hand in a warm, moist cloth. D. perform a venipuncture to obtain a venous sample. 5. A nurse is teaching self monitoring of blood glucose (SmBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. perform SmBG once daily at bedtime. B. Wipe the hand with an alcohol swab. c. Hold the hand in a dependent position prior to the puncture. D. place the puncturing device perpendicular to the site. e. prick the outer edge of the fingertip for the blood sample. PRACTICE Active Learning Scenario A nurse is teaching a group of nursing students how to perform urine glucose testing. use the Ati Active learning template: Diagnostic procedure to complete this item. NURSING INTERVENTIONS: list the steps of the procedure in the three phases (pre , intra , post procedure). A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.) A. restlessness B. tachypnea C. Bradycardia D. Confusion e. Pallor 2. A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. report any nasal stuffiness, nausea, or fatigue. e. Post “no Smoking” signs in a prominent location. 3. A nurse is caring for a client who is having difficulty breathing. the client is lying in bed and is already receiving oxygen therapy via nasal cannula. which of the following interventions is the nurse’s priority? A. increase the oxygen flow. B. Assist the client to Fowler’s position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases. 4. A nurse is preparing to perform endotracheal suctioning for a client. the nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. e. Limit total suctioning time to 5 minutes. 5. A nurse is caring for a client who has a tracheostomy. which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. replace the tracheostomy ties with new ties. e. Cut a slit in gauze squares to place beneath the tube holder. a nurse is delivering an enteral feeding to a client who has an Ng tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? a.“Water helps clear the tube so it doesn’t get clogged.” b. “Flushing helps make sure the tube stays in place.” c.“this will help you get enough fluids.” d.“adding water makes the formula less concentrated.” 2. a nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? a. auscultate breath sounds. b. stop the feeding. c. obtain a chest x ray. d. initiate oxygen therapy. 3. a nurse is preparing to instill an enteral feeding for a client who has an Ng tube in place. Which of the following actions is the nurse’s highest assessment priority before performing this procedure? a. check how long the feeding container has been open. b. Verify the placement of the Ng tube. c. confirm that the client does not have diarrhea. d. Make sure the client is alert and oriented. 4. a nurse is caring for a client in a long term care facility who is receiving enteral feedings via an Ng tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (select all that apply.) a. auscultate bowel sounds. b. assist the client to an upright position. c. test the pH of gastric aspirate. d. Warm the formula to body temperature. E. discard any residual gastric contents. 5. a nurse is preparing to insert an Ng tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply.) a. review a signal the client can use if feeling any distress. b. lay a towel across the client’s chest. c. administer oral pain medication. d. obtain a dobhoff tube for insertion. E. Have a petroleum based lubricant available. PRACTICE Active Learning Scenario a nurse is teaching a group of nursing students about administering enteral feedings. use the ati active learning template: Nursing skill to complete this item. INDICATIONS: list at least four indications for enteral feedings. NURSING INTERVENTIONS (INTRAPROCEDURE): list the steps of administering an enteral feeding. a nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. the client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply.) a. extremes in age B. Impaired circulation c. Impaired/suppressed immune system d. Malnutrition e. Poor wound care 2. a nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply.) a. Increase in incisional pain B. Fever and chills c. reddened wound edges d. Increase in serosanguineous drainage e. decrease in thirst 3. a nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply.) a. stage III pressure ulcer B. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area 4. a client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. the nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (select all that apply.) a. cover the area with saline soaked sterile dressings. B. apply an abdominal binder snugly around the abdomen. c. use sterile gauze to apply gentle pressure to the exposed tissues. d. Position the client supine with his hips and knees bent. e. offer the client a warm beverage, such as herbal tea. 5. a nurse is caring for an older adult client 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? (select all that apply.) a. Keep the head of the bed elevated 30°. B. Massage the client’s bony prominences frequently. c. apply cornstarch liberally to the skin after bathing. d. Have the client sit on a gel cushion when in a chair. e. reposition the client at least every 3 hr while in bed. PRACTICE Active Learning Scenario a nurse is teaching a group of nursing students about the national Pressure ulcer advisory Panel’s classification system for pressure ulcers. use the atI active learning template: Basic concept to complete this item. RELATED CONTENT: list the six pressure ulcer stages along with a brief description of the assessment findings typical for ulcers at each stage a nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents are examples of direct mode of transmission? (select all that apply.) a. a client vomits on a nurse’s uniform. B. a nurse has a needle stick injury. c. a mosquito bites a hiker in the woods. d. a nurse finds a hole in his glove while handling a soiled dressing. e. a person fails to wash her hands after using the bathroom. 2. a nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection? (select all that apply.) a. urinary incontinence B. Malaise c. acute confusion d. Fever e. agitation 3. a nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? a. implement airborne precautions. B. obtain a sputum culture. c. administer prescribed antituberculosis medications. d. recommend a screening test for family members. 4. a nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests the client is experiencing postherpetic neuralgia? a. linear clusters of vesicles present on the right shoulder B. Purulent drainage from both eyes c. decreased white blood cell count d. report of continued pain following resolution of rash 5. a charge nurse is teaching about the care of a client who has methicillin resistant Staphylococcus aureus (Mrsa) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a.“i should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.” B. “Mrsa is usually resistant to vancomycin, so another antimicrobial will be prescribed.” c.“i will need to monitor the client’s serum antimicrobial levels during the course of therapy.” d.“to decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.” a nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (select all that apply.) a. distended neck veins b. Hyperthermia c. Tachycardia d. syncope e. decreased skin turgor 2. a nurse on a medical surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? a. a client who has nasogastric suctioning. b. a client who has chronic constipation. c. a client who has syndrome of inappropriate antidiuretic hormone d. a client who took an overdose of sodium bicarbonate antacids 3. a nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (select all that apply.) a. Hct 55% b. serum osmolarity 260 mOsm/kg c. serum sodium 150 meq/l d. urine specific gravity 1.035 e. serum creatinine 0.6 mg/dl 4. a nurse on a medical surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? a. a client who has a new diagnosis of adrenal insufficiency b. a client who has heart failure c. a client who is receiving treatment for diabetic ketoacidosis d. a client who has abdominal ascites 5. a nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? a. administer antihypertensive on schedule. b. check the client’s weight each morning. c. notify the provider of a urine output greater than 30 ml/hr. d. encourage independent ambulation four times a day a nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? a. Infuse hypotonic IV fluids. b. Implement a fluid restriction. c. Increase sodium intake. D. administer sodium polystyrene sulfonate. 2. a nurse is reviewing the medical record of a client who has hypocalcemia. the nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? a. crohn’s disease b. Postoperative following appendectomy c. History of bone cancer D. Hyperthyroidism 3. a nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/l. When notifying the provider, the nurse should anticipate which of the following actions? a. starting an IV infusion of 0.9% sodium chloride b. consulting with dietitian to increase intake of potassium c. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage 4. a nurse is collecting data from a client who has hypercalcemia as a result of long term use of glucocorticoids. Which of the following findings should the nurse expect? (select all that apply.) a. Hyperreflexia b. confusion c. Positive chvostek’s sign D. bone pain E. nausea and vomiting 5. a nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. the client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? a.“you will receive magnesium in a series of intramuscular injections.” b. “you should receive a prescription for a thiazide diuretic to take with the magnesium.” c.“you should eliminate whole grains from your diet until your magnesium level increases.” D.“you will have your deep tendon reflexes monitored while you are receiving magnesium.” PRACTICE Active Learning Scenario a nurse is caring for a client who has hypokalemia as an adverse effect of furosemide. Use the atI active learning template: system Disorder to complete this item to include the following sections. ALTERATION IN HEALTH (DIAGNOSIS) EXPECTED FINDINGS: Identify at least five expected findings. NURSING CARE: Identify two safety actions for the administration of IV potassium supplementation. References Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (10th ed.). Upper Saddle River, NJ: Prentice Hall. Burchum, J. R., & Rosenthal, L. D. (2016). Lehne’s pharmacology for nursing care (9th ed.). St. Louis: Elsevier. Dudek, S. G. (2014). Nutrition essentials for nursing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Eliopoulos, C. (2014). Gerontological nursing (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Grodner, M., Escott Stump, S., & Dorner, S. (2016). Nutritional foundations and clinical applications of nutrition: A nursing approach (6th ed.). St. Louis, MO: Mosby. Pagana, K. D. & Pagana, T. J. (2014). Mosby’s manual of diagnostic and laboratory tests (5th ed.). St. Louis, MO: Elsevier. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby. Touhy, T. A., & Jett, K. F. (2012) Ebersole & Hess’ toward healthy aging: Human needs and nursing response (8th ed.). St. Lois, MO: Mosby. [Show More]

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