ATI Fundamentals
A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg's test, indication what alteration? - ANSWER Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception) which results in positive Romberg's sign.
A nurse is caring for a client who had human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? - ANSWER Standard precautions
a nurse is teaching a middle-aged female client about disease prevention and health
maintenance.Which of the following diagnostic test should the nurse recommend as part of the client's routine?
annual papanicolaou (pap) testing
mammogram every 2 years
eye examination every 2 years annual colonoscopy - ANSWER eye examination every 2 years
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. which of the following activities should the nurse include as an example of concrete operational thinking? playing in the sand
playing dress-up with old clothes
collecting and trading game cards
describing interpersonal relationships - ANSWER collecting and trading game cards
A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should identify that the client is in which of the following stages of dying? - ANSWER Depression
A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? - ANSWER Death is viewed as an interruption of what might have
been
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? - ANSWER Montgomery straps
A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? - ANSWER Excessive wax in the ear canal
A nurses planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?
use the pain scale to determine the client's pain level
discuss the adverse effects of pain medication with the client obtain the client's vital signs
check the client's allergies - ANSWER use the pain scale to determine the client's pain level
a nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump
to deliver morphine for pain management. which of the following statements should the nurse identify as an indication that the client understands the instructions?
I'll limit pushing the button so I don't get an overdose
if I push the button and still have pain after 2 minutes, I'll push it again
I'll ask my niece to push the button when I am sleeping
I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing
the PCA button - ANSWER I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button
a nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?
auscultate over the stomach while injecting air
request an x-ray of the client's abdomen place the head of the client's bed in a flat position administer the feeding if the pH of the aspirated contents is >6 - ANSWER request an x-ray of the client's abdomen
A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. the nurse should anticipate that the client
who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?
coronary artery stents
aneurysm clip
hearing aids
automated internal defibrillator - ANSWER hearing aids
A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg's test, indication what alteration? - ANSWER Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception) which results in positive Romberg's sign.
A nurse is caring for a client who had human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? - ANSWER Standard precautions
a nurse is teaching a middle-aged female client about disease prevention and health
maintenance.Which of the following diagnostic test should the nurse recommend as part of the client's routine?
annual papanicolaou (pap) testing
mammogram every 2 years
eye examination every 2 years annual colonoscopy - ANSWER eye examination every 2 years
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. which of the following activities should the nurse include as an example of concrete operational thinking? playing in the sand
playing dress-up with old clothes
collecting and trading game cards
describing interpersonal relationships - ANSWER collecting and trading game cards
A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should identify that the client is in which of the following stages of dying? - ANSWER Depression
A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? - ANSWER Death is viewed as an interruption of what might have
been
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? - ANSWER Montgomery straps
A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? - ANSWER Excessive wax in the ear canal
A nurses planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?
use the pain scale to determine the client's pain level
discuss the adverse effects of pain medication with the client obtain the client's vital signs
check the client's allergies - ANSWER use the pain scale to determine the client's pain level
a nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump
to deliver morphine for pain management. which of the following statements should the nurse identify as an indication that the client understands the instructions?
I'll limit pushing the button so I don't get an overdose
if I push the button and still have pain after 2 minutes, I'll push it again
I'll ask my niece to push the button when I am sleeping
I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing
the PCA button - ANSWER I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button
a nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?
auscultate over the stomach while injecting air
request an x-ray of the client's abdomen place the head of the client's bed in a flat position administer the feeding if the pH of the aspirated contents is >6 - ANSWER request an x-ray of the client's abdomen
A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. the nurse should anticipate that the client
who has which of the following devices can safely undergo magnetic resonance imaging (MRI)?
coronary artery stents
aneurysm clip
hearing aids
automated internal defibrillator - ANSWER hearing aids
