CBC Exam (ATI) Terms in this set (100) a nurse manager is developing a facility policy about the use of a fax machine to communicate information from a clients electronic medical record. Which of the following actions should the nurse include in the po

CBC Exam (ATI) Terms in this set (100) a nurse manager is developing a facility policy about the use of a fax machine to communicate information from a clients electronic medical record. Which of the following actions should the nurse include in the policy? use a cover sheet when sending a fax from the health care unit a nurse is caring for a client who is 2 days post operative following an above the knee amputation. the client states he is experiencing a dull burning pain in the leg that was amputated. which of the following actions should the nurse take to treat the clients neuropathic pain? administer a beta blocking medication to the client a nurse is assessing a client who has fibromyalgia. which of the following treatment modality prescriptions should the nurse expect for the clients mixed pain? pregabalin PO twice daily a nurse is planning the menu for a client who practices Seventh-Day Adventism. which of the following food selections should the nurse make? scrambled eggs a nurse is providing teaching to a client who has chronic fatigue syndrome. which of the following statements should the nurse make? "take NSAIDs for body aches and pain" a nurse is using therapeutic communication to attempt to de-escalation with a client who is yelling at staff members. which of the following statement should the nurse make? "tell me what is causing your anger at this moment" a home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. which of the following actions should the nurse manager take to promote interoperability? recommend a single coding system for each department to use a nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. the client reports experiencing chemotherapy-induced nausea and vomiting (CINV) during her previous round of treatment. which of the following interventions should the nurse include in the client's plan of care? administer ondansetron (zofran) to the client prior to chemotherapy administration a nurse is teaching a client about strategies to prevent recurrent constipation. which of the following instructions should the nurse include? *perform moderate exercises daily *add more whole grains to your diet *increase your fluid intake a nurse is documenting an assessment in a clients electronic health record when as assistive personnel (AP) asks to enter the morning blood glucose for the client. which of the following actions should the nurse take? request that the AP use another computer to enter the data a nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. which of the following questions should the nurse ask to assess the quality of the clients pain? "can you describe what the pain feels like?" a nurse is preparing to leave the room of a client who is on isolation precautions. which of the following actions should the nurse take when removing a tied surgical mask? remove the mask by securely holding the ties and moving it away from the face a nurse is assessing for acute pain in a client who is postoperative. the client has dementia and is nonverbal. which of the following findings should the nurse identify as a need for administration of a PRN medication? rapid breathing a nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. which of the following actions should the nurse take have the client lie supine a nurse is preparing a client for an elective vaginal hysterectomy when the client states "my doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already singed the consent form." which of the following responses should the nurse make? "you have the right to refuse this and any other procedure, even after you have signed the consent form." a nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. which of the following information should the nurse plan to include? an adult client may be in a mechanical restraint for up to 4 hours the nurse is preparing to administer intermittent enteral nutrition via a clients NG tube. in which order should the nurse take the following steps 1. assist the client into a high Fowler's position and raise the head of the bed at least 30 degrees to help prevent aspiration 2. the nurse should verify the tube's placement by aspirating 5 mL of gastric contents 3. the nurse should test the aspirate pH 4. then the nurse should check for gastric residual volume (GRV) 5. finally the nurse should flush the tubing with 30 mL of water to ensure the tube is clear and patent a nurse is planning a community health program about substance use disorders. which of the following information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? a healthy woman of any age should consume no more than 7 drinks in a week a nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion. which of the following actions should the nurse take? document the clients status every 15 minutes a nurse is preparing to administer acetaminophen 120 mg PO to a toddler. available is acetaminophen drops 80mg/0.8mL. how many mL should the nurse administer? 1.2 mL a nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. the clients parent shouts at the nurse, asking why her son is dying instead of the driver. which of the following actions should the nurse take to provide emotional support to the parent? inform the parent that anger is a natural response when dealing with loss a nurse is preparing to document care in a clients medical record. in adherence with the Joint Commission National Patient Safety Goals regarding communication errors, which of the following entries should the nurse make? "client medicated with morphine 5 mg IM for pain" a nurse is preparing to administer a medication via intermittent IV bolus to a client who is receiving a continuous infusion via an infusion pump. the clients IV fluid solution is incompatible with the bolus. which of the following actions should the nurse plan to take first? stop the continuous IV infusion a nurse on a medical-surgical unit is caring for a group of clients. the nurse should *spinal nerve pain *postherpetic neuralgia pain CBC Exam (ATI) a nurse on a pediatric unit is admitting an infant who has pertussis. which of the following isolation precautions should the nurse initiate? droplet a nurse is preparing to collect a stool specimen from a client who has had diarrhea for 3 days, with fever and abdominal cramping. when reviewing the clients recent medication administration record, the nurse should recognize that treatment with which of the following medications increases the clients risk of developing clostridium difficile infection? ciprofloxacin (fluoroquinolones) a nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. which of the following statement should the nurse include in the teaching? "websites ending in "dot-gov" are reliable sites for obtaining health information from government agencies" a nurse is caring for a client who has a clostridium difficile infection and is incontinent of stool following long term antibiotic therapy. which of the following actions should the nurse take? wear a gown when providing care for the client a charge nurse is teaching a group of newly licensed nursed how to prevent errors during administration of blood transfusions. which of the following actions should the nurse include? use a new blood administration tubing set for each blood bag infused a nurse is preparing to admit a client to the hospital. which of the following actions should the nurse take first? determine the need for an interpreter a nurse is providing teaching to the parent of a 6yr old girl about preventing urinary tract infections. which of the following statements by the parent indicates an understanding of the teaching "I will increase her intake of foods high in fiber" a nurse is planning to implement bladder training for a client who has urge urinary incontinence. which of the following actions should the nurse plan to take? gradually lengthen the time between the client scheduled voids a nurse in an emergency room is caring for an infant who requires emergency surgery. the infant is accompanied by his 16yr old mother and his maternal grandfather. which of the following actions should the nurse take when assisting with informed consent? witness consent obtained from the infants mother a nurse at a providers office is counseling a client who reports insomnia. which of the following statements should the nurse make to include the clients preferences into a "sleep in the location of your home where you feel you rest the best" CBC Exam (ATI) a nurse is providing dietary teaching to a client who has diarrhea. which of the following instructions should the nurse include? "increase your intake of potassium rich foods while you are experiencing diarrhea" (tomatoes, potatoes) a nurse is teaching sleep hygiene to a client who has insomnia. which of the following statement should the nurse make? "exercise in the morning after arising" a nurse is caring for an older client who has a leg wound following a fall on the stairs. the nurse should identify which of the following factors as an expected, age-related change in older adults that can impair wound healing? elastin fibers separate and thicken a nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, an ibuprofen gel cap, an a delayed-release omeprazole capsule. which of the following actions should the nurse take? crush the levothryoxine tablet into a powder and dissolve it in 30 mL of warm sterile water a nurse is preparing to administer morphine 5 mg IM from a 10mg/mL vial to help manage a clients acute pain. which of the following actions should the nurse plan to take after administering a controlled substance? have a second nurse witness and initial the disposal of the remaining medication a nurse in an orthopedic clinic is documenting data about several clients. which of the following actions should the nurse take to comply with the regulations of the health insurance portability and accountability act (HIPAA)? lock or log off computers whenever he leaves the area a nurse is caring for a 2 year old toddler who is immediately postoperative. which of the following pain scales should the nurse use to assess the toddlers pain level? FLACC scale (face, leg, activity, cry, and consolability) a nurse is caring for a 47yr old female client who has urinary incontinence. which of the following actions should the nurse take first? obtain a specimen from the client for culture a nurse is reviewing a clients new prescriptions that were just documented in the clients medical record by the provider. which of the following abbreviations should the nurse clarify with the provider? Enoxaparin 40 mg SQ QD a nurse is teaching a client who has RA about chronic pain management. which of the following statements by the client indicates an understanding of the teaching? "I should use a warm paraffin dip for my hands and feet" a nurse is providing discharge teaching about nutrition management to a client who has COPD. which of the following instructions should the nurse include in the teaching? have a high calorie protein drink between meals (anorexia is a manifestation of COPD) a nurse is caring for an older adult client who has osteoarthritis and plans to go to an assisted living facility due to decreased mobility. which of the following actions should the nurse take when acting in the role of client advocate? research facilities for the client that best meet her specific needs a nurse on a medical surgical unit is caring for a group of clients. which of the following clients should the nurse monitor for the development of reflex urinary incontinence? a client who has a T12 spinal cord injury a nurse is teaching a client who is postpartum about preventing injury when using a car seat for her newborn. which of the following instructions should the nurse include? install the car seat so that it is facing the rear of the vehicle a nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. which of the following online sources should the nurse select to research this infant care issue? cumulative index to Nursing and Allied Health Literature (CINAHL) a nurse is caring for a child who has contact dermatitis due to poison ivy. the parent asks the nurse how to prevent further reactions. which of the following responses should the nurse make? "wash your child's exposed clothing with hot water and detergent" a nurse is preparing to contact a clients provider regarding the need for a prescription for pain medication. when using the SBAR communication tool, the nurse should provide which of the following information in the assessment portion of the tool? "the client is in audible distress and rates her pain as an 8 on a scale from 0 to 10" a nurse is asked by a provider to perorm an invasive procedure for which he has not received training. which of the following actions should the nurse take to ensure that it is within his legal scope of practice to perform this procedure? check the states nurse practice act before performing the procedure a nurse is caring for a client who has dysphagia following a stroke. which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? delay the clients meal time is he is fatigued a newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. which of the following responses should the charge nurse make? "the state board of nursing can provide this information" a home health nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. which of the following statements should the nurse make? "have your child rest with his head elevated after meals" a nurse is admitting a client who has pulmonary tuberculosis. which of the following transmission based precautions should the nurse initiate? airborne a nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent GI cancers. Which of the following indicates a food the nurse should encourage the client to include liberally in his diet? fruits and vegetables (at least 2.5 cups per day) a nurse is developing a plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty. Which of the following interventions should the nurse include? place grab bars by the toilet a nurse is assessing the spiritual wellbeing and development of a preschooler. the nurse asks the preschooler "why is it wrong to kick your baby sister?" which of the following responses would the nurse expect? "it is wrong because my dad said I can't kick her" a nurse is assessing a preschooler who has a UTI. which of the following findings should the nurse expect? abdominal pain a community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. which of the following plans should the nurse recommend as part of tertiary prevention? start a needle-exchange program a hospice nurse is planning care for a client who has terminal cancer. the client tells the nurse that she practices the Hindu religion. which of the following interventions should the nurse include in the plan of care to support the client's religious beliefs? allow time for a family member to perform a ritual bath after the client dies a community health nurse is planning prevention strategies for hypertension among members of her community. the nurse should identify that which of the following ethnic groups in the community is African Americans CBC Exam (ATI) a nurse in a long-term care facility is admitting a new client following a brief stay in acute care. in adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? compare a list of the client's current medications with the ones he will take in long-term care a nurse is preparing to administer 0.9% sodium chloride 1,000mL over 8 hours IV to a client. the nurse should set the infusion pump to deliver how many mL/hr? 125mL/hr a nurse is caring for a client who has cancer and is planning discharge to home with hospice care. which of the following statements by the client indicates that he is experiencing spiritual distress? "I wish God had not allowed this cancer to invade my body" a nurse is reviewing the medication administration record of a client who is 2 days postoperative following abdominal surgery. the nurse should identify that which of the following medications can result in delayed wound healing? Prednisone (corticosteroid) a nurse in a community health clinic is screening a 10 yr old girl for scoliosis. which of the following instructions should the nurse give the child for this examination? "bend forward at the waist and let your arms hang down" a charge nurse is educating unit staff about the cultural aspects of client care following death. which of the following statements by an AP indicates an understanding of the teaching? "the body of a client who practices Islam is washed and wrapped in a cloth following death" a nurse is beginning nutrition counseling with a client who has a BMI of 34.2. which of the following should the nurse ask first to address the client's excessive nutrition and obesity? "are you ready to make a lifelong commitment to a healthier lifestyle?" a nurse is preparing to extinguish a small fire in a client's room. which of the following actions should the nurse take when using the fire extinguisher? slide the pin on the top of the fire extinguisher straight out a nurse is providing teaching about nutrition management to the parent of an 18 month old toddler who has phenylketonuria. which of the following foods should the nurse recommend? baked potato (low protein) a nurse is preparing to administer a unit of packed RBCs to a client. in adherence with the Joint Commission National Patient Safety Goals regarding blood administration, which of the following actions should the nurse verify the client and blood component using a two-person process CBC Exam (ATI) a nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel incontinence. which of the following interventions should the nurse include to prevent skin breakdown? offer the client a glass of water every 2 hours when repositioning a nurse is planning care for a client who has bacterial meningitis caused by Haeophilus influenza. which of the following infection control interventions should the nurse include in the plan? place a mask on the client during transport out of the room a nurse is talking with a client who has major depressive disorder. the client states "nobody cares if i am around or not." which of the following responses should the nurse make? "it sounds as though you are feeling hopeless" a nurse in a long term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. the client reports using a tripod cane for ambulation which of the following actions should the nurse take when using this test? observe the client ambulationg a distance of 3m (10 feet) during the TUG test a nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk of thromboembolic events. which of the following actions should the nurse take? pull up a small amount of skin using the thumb and forefinger of the non dominant hand a nurse is planning care for a client who has in indwelling urinary catheter. which of the following interventions should the nurse include in the plan to prevent the development of CAUTI? secure the catheter tubing to the clients leg a nurse in a long term care facility discovers a small fire in a clients trash can. after moving the client to safety which of the following actions should the nurse take next? pull the alarm to notify emergency services a nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. which of the following actions should the nurse plan to take? ensure the client and the interpreter are compatible a nurse is teaching about advance directives with an older adult client who has a terminal illness. which of the following statements should the nurse make? "your advance directives can designate a friend to make your health care decisions" a nurse is caring for a child who has celiac disease. which of the following items should the nurse remove form the child's meal tray? oatmeal with raisins (gluten intolerance) CBC Exam (ATI) a nurse enters a client's room and finds the client laying on the floor. the client states that on the way to the bathroom her "knee locked" causing her to fall. which of the following actions would the nurse take first? check the client for injuries a nurse is developing a plan of care for a client who has urinary incontinence. which of the following actions should the nurse include? apply a moisture barrier cream to the client's skin a nurse is teaching the parent of a toddler about home injury prevention. when discussing snacks, which of the following statements by the parent indicates an understanding of the teaching? "i can give her watermelon pieces after I remove the seeds" a nurse is planning meals for a client who practices Judaism and reports that she strictly adheres to orthodox dietary laws. the nurse should recognize that which of the following dietary practices applies to the client's beliefs? the client is permitted to eat fish that have scales a nurse in a provider's office is caring for a male client who just turned 50 years old. the client has no significant health problems or family history of health problems. which of the following preventive health screenings should the nurse recommend? *initial screening colonoscopy *digital rectal examination *monthly testicular self-examination *annual skin examination a nurse is providing shift change about a group of clients to the oncoming nurse at the end of the shift. which of the following statements should the nurse include? "the client has been very tearful since finding out he has diabetes mellitus" a community health nurse is developing a brochure about the use of smokeless tobacco. which of the following info should the nurse plan to include? smokeless tobacco provides a higher dose of nicotine than cigarettes a nurse is preparing to administer an immunization via IM injection into an adult client's deltoid muscle. which of the following actions should the nurse take? select a 1 inch needle for injection a nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric surgery. which of the following dietary recommendations should the nurse make? eat foods high in protein a nurse is teaching a young female client about health screening for breast cancer. which of the following statements by the client indicates an understanding of the breast self-examination (BSE)? "I should expect to feel a firm ridge along the bottom curve of each breast" CBC Exam (ATI) a community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. which of the following actions should the nurse plan to take first? determine the level of health equity among groups in the community a nurse is talking with a client who reports difficulty adjusting to the death of her partner. which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting? "what do you think would help you cope with your loss?" a nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. which of the following interventions should the nurse include in the plan? perform hand hygiene before touching the IV tubing a nurse is preparing to administer enoxaparin subcutaneously to a client who is postoperative following orthopedic surgery. the nurse should plan to administer this medication in which of the following locations? side of patients belly a nurse is developing a plan of care for an older adult client who is at risk of falling. which of the following fall prevention measures should the nurse include in the plan? ask the client to demonstrate how to use the call light a nurse is planning care for a newly-admitted school-age child who has rubeola (measles). which of the following isolation precautions should the nurse plan to initiate? airborne a charge nurse is observing a newly licensed nurse prepare medications for a client. which of the following actions by the newly licensed nurse adheres to safe medication administration practices? the nurse compares the medication label with the client's medication administration record