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ATI NCLEX Questions 10 studiers in 3 days 5.0 (4 reviews) Students also studied Terms in this set (204) Science MedicineNursing Save
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Unit 1: T
23 terms kiau A client is exhibiting early signs of hemorrhage. Which findings should the nurse anticipate?
- Cold, clammy skin
- Heart rate 120/min
- Weak, thready pulse
- Blood pressure 80/60
- Heart rate 120/min
- Position the left leg dependently
- Elevate the left leg above the heart
- Immobilize the left leg to prevent further injury
- Assess dorsiflexion and extension of the left foot
- Position the left leg dependently
An older adult client reports recurring calf pain after walking one to two blocks that disappears with rest. The client has weak pedal pulses, and skin on the left lower leg is shiny and cool to the touch. Which nursing intervention is appropriate at this time?
A client who has just been diagnosed with rheumatoid arthritis is required to receive 3 months of methotrexate therapy. The nurse recognizes which of the following are adverse effects associated with the therapy? SATA
1. WBC 1,200
- Weight gain 2.27 kg (5 lbs.)
- Oral temperature of 37.2 (99)
- Urine Specific Gravity 1.003
- Platelets 5,000
1. WBC 1,200
- Platelets 5,000
A nurse prepares a staff in-service on incident reports.Which information should the nurse include? SATA
- Risk management investigates the incident
- A copy of report is placed in client's health record
- Reports include description of incident and actions
- Reports are confidential and not shared with
- Completion of report should be documented in the
- Risk management investigates the incident
- Reports include description of incident and actions taken
- Reports are confidential and not shared with noninvolved staff
- Ask the charge nurse for step-by-step directions
- Call the provider for specific instructions
- Consult the unit procedure manual for guidance
- Delegate task to a LPN to complete the feedings.
- Consult the unit procedure manual for guidance
- Verify the admission medications prescribed by the
- Review the current medication regimen with the client
- Obtain the most recent list of mediations from the
- Locate a list of discharge medications from the most
- Discuss any discrepancies with the health care provider
- Verify the admission medications prescribed by the provider
- Review the current medication regimen with the client
- Obtain the most recent list of medications from the long-term care facility
- discuss any discrepancies with the health care provider
- Encourage client to express feelings about the terminal
- Assist the client to ambulate to the bedside chair twice
- Demonstrate to client the proper use of a
- Complete vital signs that include oxygen saturation
- Obtain a urine specimen from the client's indwelling
- Assist the client to ambulate to the bedside chair twice a day
- Complete vital signs that include oxygen saturation every 4 hours
- Newly diagnosed DM2
- Facial lacerations and a subdural hematoma
- Bronchitis receiving bronchodilator treatments
- Exacerbation of myasthenia gravis admitted three
- Advanced regular diet two days post chole
- Bronchitis receiving bronchodilator treatments
- Advanced regular diet two days post chole
taken
noninvolved staff
nurses' notes
A nurse is unsure of the proper technique when caring for a client who is prescribes enteral feedings. Which action should the nurse take?
A nurse admits a client from a long-term care facility.Which action should be implemented? SATA
provider
long-term care facility
recent hospitalization.
A nurse cares for a client with terminal lung cancer. Which action should be delegated to the UAP? SATA
diagnosis
a day
bronchodilator inhaler
every 4 hours
bladder catheter
A nurse cares for a group of clients on a med-surg unit.Which client should be delegated to the LPN? SATA. A client with
hours ago
A nurse enters the room of a client who is at the foot of the bed lying on the floor. Which should be the initial nursing action?
- Examine the client for injuries
- Obtain HR and BP
- Assess vital signs and LOC
- Determine intensity of pain with ROM
- Assess vital signs and LOC
- Administer ondansetron hcl IV
- Encourage pursed lip breathing
- Assess the surgical incision site
- Apply low dose oxygen via nasal cannula
- Assess the surgical incision site
- Fixed pupils an agonal respirations
- Burns to the face and respiratory stridor
- Type 2 DM who is disoriented
- A closed fracture reporting "a pain level of 3"
- Burns to the face and respiratory stridor
- "I am so glad to be of those blood thinners"
- "I will keep a pillow under my knee when I am in bed"
- "I am planning to use a wheelchair to help me get
- "I plan to take ibuprofen instead of the prescribed
- "I am so glad to be of those blood thinners"
- Increase suction to the chest drainage system.
- Reposition the client to a high-fowler's position
- Apply to the client low-flow oxygen via nasal cannula
- Immerse the end of the chest tube in a bottle of sterile
- Immerse the end of the chest tube in a bottle of sterile water
Four days after a ventral hernia repair, a client who is obese and has a history of COPD vomits and reports severe abdominal pain. The oxygen saturation is 90%.Which action should the nurse implement first?
A nurse arrives at a work site explosion. Which client should be triaged first? A client who has
A home health nurse is performing an admission assessment on a client who has a knee arthroplasty one week ago. Which client statement should concern the nurse the most?
around"
hydrocodone with acetaminophen for pain control"
A nurse provides care for a client who has a chest tube.The nurse notes the chest tube has become disconnected from the chest drainage system. Which action should the nurse take?
water
A client receives a transfusion of packed RBC's and tells the nurse "My IV site is painful and looks like it is swollen" Which action should the nurse take?
- Continue to monitor the site for signs of infection or
- Double check the blood type of the unit of blood with
- Start a new IV at another site and resume the
- Discontinue the transfusion and send the remaining
- Start a new IV at another site and resume the transfusion at the new site
- Suctions intermittently for 15 seconds
- Places an air humidifier at the bedside
- Cuts a 4x4 gauze to put around the tracheostomy tube
- Removes the ties before cleaning the tracheostomy
- Removes the ties before cleaning the tracheostomy
- Receiving long-term IV abx who has a rash in his left
- with baseline regular apical pulse of 88 who has an
- Who has a recent diagnosis of terminal cancer and
- eight hours post laparoscopic surgery who reports
- with baseline regular apical pulse of 88 who has an irregular apical pulse of 120
- A scheduled IV abx for a client with resolving
- Pain medication to a client who rates their pain a 4-5 on
- An antidiarrheal for a client with one diarrhea stool in
- The antipyretic to a client with a temperature of 100.7
infiltration
another nurse
transfusion at the new site
blood and tubing to the lab
A client who has recently undergone surgery for a tracheostomy is now at home. The nurse recognizes a need for immediate intervention when the caregiver does which of the following?
A nurse assigns four clients to the LPN. Which finding should the LPN immediately report to the nurse? A client
groin
irregular apical pulse of 120 today
refuses to eat or participate in hygiene care.
abdominal distention and shoulder pain.
today A nurse plans to administer the following medication.Which medication should the nurse administer first?
pneumonia.
a 0-10 scale
the last hour
(38.2)
- A scheduled IV abx for a client with resolving pneumonia.
- HIV status to the client's coworkers
- Stage IV cancer diagnosis to the client's family
- Uncontrolled seizure disorder to DMV
- Alcohol detoxification recovery status to client's
- Uncontrolled seizure disorder to DMV
A nurse cares for a group of clients. Which information can be disclosed about a client?
employer
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