ATI LEVEL 2 CBC PRACTICE B
A nurse who is assisting a client who has right-sided hemiparesis with ambulating
should stand on the client's affected side and support the client using a gait belt.
R side assistance
gait belt
anterior assistance
L side assistance - answer GAIT BELT.
A nurse who is assisting a client who has right-sided hemiparesis with ambulating
should stand on the client's affected side and support the client using a gait belt.
A nurse is reviewing the labs of an AIDS patient. Which of the following labs should the
nurse review to determine if the client's at risk for malnutrition?
WBC
Albumin
CD4 T cell count
C-reactive protein - answerALBUMIN.
The nurse should review albumin levels to determine a client's risk for malnutrition. A
client who is malnourished will have an albumin level below the expected reference
range of 3.5 to 5 g/dL.
A nurse is providing teaching about home care to the patient of an adolescent who has
infectious mononucleosis. Which of the following manifestations should the nurse
instruct the parent to report to the provider?
Swollen cervical lymph nodes
Exudate on tonsils
Lack of energy
Onset of abd pain - answerONSET OF ABD PAIN.
The nurse should instruct the parent to report the onset of abdominal pain to the
provider because this is an indication of splenomegaly. Splenic hemorrhage or rupture
can occur and is usually caused by trauma.
A nurse is admitting an infant who has pertussis. Which of the following actions should
the nurse take?
Administer antiviral med to infant.
Initiate droplet precautions for infant.
Limit the infant's oral intake of fluids to 60ml/day.
Monitor infant for manifestations of increase intracranial pressure. - answerINITAITE
DROPLET PRECAUTIONS FOR THE INFANT.
,The nurse should initiate droplet precautions for an infant who has pertussis. Other
actions the nurse should take include providing humidified oxygen and suctioning
secretions to prevent choking.
A nurse is providing teaching to a client who has osteoporosis. Which of the following
info should the nurse include in the teaching?
Increase daily intake of foods containing Vit A.
Limit alcohol consumption to 10oz daily.
Perform exercises to strengthen abdominal core.
Start a daily jogging regimen. - answerPERFORM EXERCISES TO STRENGTHEN
ABD CORE.
The nurse should instruct the client to perform exercises to strengthen the abdominal
and back muscles to maintain stability of the spinal column and prevent vertebral
fractures.
A nurse is assessing a client who's experiencing diarrhea and vomiting and has a NA
level of 124mEq/L. Which of the following manifestations should the nurse expect?
Orthostatic hypotension.
Hoarse voice.
Neck vein distention.
Muscle twitching. - answerORTHOSTATIC HYPOTENSION.
The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic
hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other
manifestations of hyponatremia include decreased deep tendon reflexes, headache,
confusion, and lethargy.
A nurse is providing discharge teaching to parents of a newborn about crib use. Which
of the following statements should the nurse make?
Arranging small stuffed animals in crib is recommended to provide security.
Moving the crib near a window will provide baby with necessary fresh air and light.
Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a
blanket or sheet.
Placing your baby on her tummy in the crib will hasten drowsiness and provide a more
restful night's sleep. - answerONE PIECE SLEEPER AND NO BLANKET/SHEET.
The nurse should instruct the parents to dress the newborn in a one-piece sleeper or a
"sleep-sack" at bedtime, which keeps the newborn's body covered. Blankets and quilts
significantly increase the newborn's risk of suffocation and should be avoided.
Nurse is assessing a client who has musculoskeletal trauma following a MVC 2 days
ago. Which of the following findings should the nurse report to the provider?
Labs.
, BP.
Pain.
ECG results.
Diagnostic Results
Hct 42%
Hgb 14 g/dL
ECG Sinus tachycardia
Graphic Record
Temperature 38.3°C (100.9°F)
Heart rate 106/min
Respiratory rate 22/min
Blood pressure 144/90 mm Hg
Nurses' Notes
Client reports pain level of 8 on a scale of 0 to 10 in casted left arm
IV morphine administered 45 min ago
Client is diaphoretic and anxious - answerPAIN.
The nurse should report the client's pain level of 8 on a scale of 0 to 10 to the provider.
Excessive pain in a casted arm that is unrelieved by analgesics can be an indication of
compartment syndrome, which is a medical emergency.
A nurse is assessing an 18mo toddler with gastroenteritis w/ dehydration. The toddler is
able to consume 3mL of oral rehydration solution every 5 min but still has emesis and
diarrhea. Which of the following meds should the nurse anticipate administering to the
toddler?
Polyethylene glycol.
Bumetanide.
Loperamide.
Ondansetron. - answerONDANSETRON.
The nurse should anticipate administering ondansetron to the toddler. Ondansetron is
administered to toddlers who have gastroenteritis and dehydration to decrease the
episodes of emesis and to help eliminate the need for intravenous fluids.
A nurse is reviewing a client's home med list during admission to a LTC facility. The
nurse should identify that the client takes which of the following meds to manage OA?
Lidocaine 5% patches.
Celecoxib.
Vancomycin.
Cyclobenzaprine.
Glucosamine. - answerLIDOCAINE 5% PATCH,
CELECOXIB,
CYCLOBENZAPRINE,
& GLUCOSAMINE.
A nurse who is assisting a client who has right-sided hemiparesis with ambulating
should stand on the client's affected side and support the client using a gait belt.
R side assistance
gait belt
anterior assistance
L side assistance - answer GAIT BELT.
A nurse who is assisting a client who has right-sided hemiparesis with ambulating
should stand on the client's affected side and support the client using a gait belt.
A nurse is reviewing the labs of an AIDS patient. Which of the following labs should the
nurse review to determine if the client's at risk for malnutrition?
WBC
Albumin
CD4 T cell count
C-reactive protein - answerALBUMIN.
The nurse should review albumin levels to determine a client's risk for malnutrition. A
client who is malnourished will have an albumin level below the expected reference
range of 3.5 to 5 g/dL.
A nurse is providing teaching about home care to the patient of an adolescent who has
infectious mononucleosis. Which of the following manifestations should the nurse
instruct the parent to report to the provider?
Swollen cervical lymph nodes
Exudate on tonsils
Lack of energy
Onset of abd pain - answerONSET OF ABD PAIN.
The nurse should instruct the parent to report the onset of abdominal pain to the
provider because this is an indication of splenomegaly. Splenic hemorrhage or rupture
can occur and is usually caused by trauma.
A nurse is admitting an infant who has pertussis. Which of the following actions should
the nurse take?
Administer antiviral med to infant.
Initiate droplet precautions for infant.
Limit the infant's oral intake of fluids to 60ml/day.
Monitor infant for manifestations of increase intracranial pressure. - answerINITAITE
DROPLET PRECAUTIONS FOR THE INFANT.
,The nurse should initiate droplet precautions for an infant who has pertussis. Other
actions the nurse should take include providing humidified oxygen and suctioning
secretions to prevent choking.
A nurse is providing teaching to a client who has osteoporosis. Which of the following
info should the nurse include in the teaching?
Increase daily intake of foods containing Vit A.
Limit alcohol consumption to 10oz daily.
Perform exercises to strengthen abdominal core.
Start a daily jogging regimen. - answerPERFORM EXERCISES TO STRENGTHEN
ABD CORE.
The nurse should instruct the client to perform exercises to strengthen the abdominal
and back muscles to maintain stability of the spinal column and prevent vertebral
fractures.
A nurse is assessing a client who's experiencing diarrhea and vomiting and has a NA
level of 124mEq/L. Which of the following manifestations should the nurse expect?
Orthostatic hypotension.
Hoarse voice.
Neck vein distention.
Muscle twitching. - answerORTHOSTATIC HYPOTENSION.
The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic
hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other
manifestations of hyponatremia include decreased deep tendon reflexes, headache,
confusion, and lethargy.
A nurse is providing discharge teaching to parents of a newborn about crib use. Which
of the following statements should the nurse make?
Arranging small stuffed animals in crib is recommended to provide security.
Moving the crib near a window will provide baby with necessary fresh air and light.
Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a
blanket or sheet.
Placing your baby on her tummy in the crib will hasten drowsiness and provide a more
restful night's sleep. - answerONE PIECE SLEEPER AND NO BLANKET/SHEET.
The nurse should instruct the parents to dress the newborn in a one-piece sleeper or a
"sleep-sack" at bedtime, which keeps the newborn's body covered. Blankets and quilts
significantly increase the newborn's risk of suffocation and should be avoided.
Nurse is assessing a client who has musculoskeletal trauma following a MVC 2 days
ago. Which of the following findings should the nurse report to the provider?
Labs.
, BP.
Pain.
ECG results.
Diagnostic Results
Hct 42%
Hgb 14 g/dL
ECG Sinus tachycardia
Graphic Record
Temperature 38.3°C (100.9°F)
Heart rate 106/min
Respiratory rate 22/min
Blood pressure 144/90 mm Hg
Nurses' Notes
Client reports pain level of 8 on a scale of 0 to 10 in casted left arm
IV morphine administered 45 min ago
Client is diaphoretic and anxious - answerPAIN.
The nurse should report the client's pain level of 8 on a scale of 0 to 10 to the provider.
Excessive pain in a casted arm that is unrelieved by analgesics can be an indication of
compartment syndrome, which is a medical emergency.
A nurse is assessing an 18mo toddler with gastroenteritis w/ dehydration. The toddler is
able to consume 3mL of oral rehydration solution every 5 min but still has emesis and
diarrhea. Which of the following meds should the nurse anticipate administering to the
toddler?
Polyethylene glycol.
Bumetanide.
Loperamide.
Ondansetron. - answerONDANSETRON.
The nurse should anticipate administering ondansetron to the toddler. Ondansetron is
administered to toddlers who have gastroenteritis and dehydration to decrease the
episodes of emesis and to help eliminate the need for intravenous fluids.
A nurse is reviewing a client's home med list during admission to a LTC facility. The
nurse should identify that the client takes which of the following meds to manage OA?
Lidocaine 5% patches.
Celecoxib.
Vancomycin.
Cyclobenzaprine.
Glucosamine. - answerLIDOCAINE 5% PATCH,
CELECOXIB,
CYCLOBENZAPRINE,
& GLUCOSAMINE.
