An older client is admitted for repair of a broken hip. To reduce the risk for infection
postoperative period., which nursing care intervention should the nurse include the
ATI Comprehensive 2025 edition client's plan of care? (Select all that apply)
with correct answers A) Administer low molecular weight heparin as prescribed.
B) Teach client to use incentive spirometer every 2 hours while awake.
C) Remove urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed. E) Assess pain level and
After 2 days treatment for dehydration, a child continues to vomit and have diarrhea.
medicate PRN as prescribed. - ANSWERSB) Teach client to use incentive spirometer
Normal saline is infusing and the child's urine output is 50ml/hour. During morning
every 2 hours while awake.
assessment, the nurse determines that the child is lethargic and difficult to arouse.
C) Remove urinary catheter as soon as possible and encourage voiding.
Which should the nurse implement?
The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client with insulin shock.
A) Increase the IV fluid flow rate.
How should the nurse administer the medication?
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
D) Perform a finger stick glucose test. - ANSWERSD) Perform a finger stick glucose test.
B. Push undiluted slowly though the currently infusing IV.
C. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
After receiving IV fluids in the emergency department, an elderly client is admitted to the
D. Ask the pharmacist to add the Dextrose to a TPN solution. - ANSWERSB. Push
acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9%
undiluted slowly though the currently infusing IV.
normal saline at 125 ml/hour via saline lock and has a bounding pulse, tachycardia, and
pedal edema. When contacting the healthcare provider, the nurse anticipates a
A client with arthritis has been receiving treatment with naproxen and now reports
prescription what intervention?
ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should
the nurse monitor?
A) Remove the saline lock from the client's arm.
B) Increase the rate of the normal saline infusion. C) Decrease the rate of the normal
A) Serum Calcium.
saline infusion. D) Change the IV solution to 0.45% saline solution. - ANSWERSA)
B) Erythrocyte sedimentation rate. C) Osmolality.
Remove the saline lock from the client's arm.
D) Hemoglobin. - ANSWERSD) Hemoglobin.
A male client with an antisocial personality disorder is admitted to an inpatient mental
A client who is admitted to the care unit with syndrome of inappropriate antidiuretic
health unit for multiple substance dependency. When providing a history, the client
hormone (SIADH) has developed osmotic demyelination. Which intervention should the
justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's
nurse implement first?
history is most likely to include which finding?
A) Patch one eye.
A) Multiple convictions for misdemeanors and Class B felonies.
B) Evaluate swallow.
B) Delusions of grandiosity and persecution.
C) Reorient often.
C) Suicidal ideations and multiple attempts.
D) Range of motion. - ANSWERSB) Evaluate swallow.
D) Photos and panic attacks when confronted by authority figures. - ANSWERSA)
Multiple convictions for misdemeanors and Class B felonies.
The nurse is preparing a client who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
(Select all that apply)
, D) Irrigate the NGT with sterile normal saline. - ANSWERSA) Administering a prescribed
A) Wash the stump with soap and water. antiemetic agent.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to
D) Inspect skin for redness. be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many
E) Use a residual limb shrinker - ANSWERSA) Wash the stump with soap and water. gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.) -
D) Inspect skin for redness. ANSWERSFlow rate(gtt/min) = volume(ml)/ time(min) × drop factor(gtt/mL).
E) Use a residual limb shrinker
Flow rate=1000ml/240min×10gtt/ml.
A client with bleeding esophageal varices receives vasopressin IV. What should the Flow rate = 41.667gtt/min
nurse monitor for during the IV infusion of this medication?
Answer=42
A) Vasodilatation of the extremities.
B) Chest pain and dysrhythmia. At 40-week gestation, a laboring client who is lying is a supine position tells the nurse
C) Hypotension and tachycardia. that she has finally found a comfortable position. What action should the nurse take?
D) Decreasing GI cramping and nausea. - ANSWERSD) Decreasing GI cramping and
nausea. A) Place a pillow under the client's head and knees.
B) Place a wedge under the client's right hip.
C) Encourage the client to turn on her left side.
D) Explain to the client that her position is not safe. - ANSWERSB) Place a wedge under
A client with bacterial meningitis is receiving phenytoin. Which assessment finding the client's right hip.
indication to the nurse that the client is experiencing a therapeutic response to the
phenytoin? A family member reports that the client who is bedridden has not been turned or
repositioned all night and is sleeping on a special air mattress with no sheets. What
A) Increased time of ambulation between periods of rest. information should the nurse provide to the family member?
B) Decrease in intracranial pressure and cerebral edema.
C) Absence of seizure activity for the duration of treatment. A) Clarify that an aerated support surface does not use sheets that often cause skin
D) Normal electroencephalogram after drug administration. - ANSWERSC) Absence of B) Described the night staff's plan of care to ensure the client's sleep is not disturbed.
seizure activity for the duration of treatment. C) Explained that turning is only necessary to reposition the client during waking hours.
D) Suggest that a family member turn the client during the night when someone is there.
A client peptic ulcer disease receives a prescription for intermittent suction via a - ANSWERSA) Clarify that an aerated support surface does not use sheets that often
SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffee- cause skin
ground gastric contents, the nurse clamps the NGT because the client must leave the
unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin
action should the nurse implement first? infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which
action should the nurse implement? (Select all that apply.)
A) Administering a prescribed antiemetic agent.
B) Provide oral suction using a Yankauer tip. A) Monitor stools for presence of blood.
C) Connect the NGT to low intermittent suction. B) Auscultate bowel sounds in all quadrants.
, C) Assess characteristics of pain. D) Blood urea nitrogen (BUN) increase from 8 to 12 mg/dL (2.9 to 4.3 mmol/L) -
D) Review last partial thromboplastin time results. ANSWERSC) Daily weight decreases of 2 pounds (0.9 kg)
E) Prepare to administer warfarin. - ANSWERSA) Monitor stools for presence of blood.
C) Assess characteristics of pain. The nurse is preparing to administer an oral antibiotic to a client with unilateral
E) Prepare to administer warfarin. weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority
nursing assessment that should be done before administering this medication?
The healthcare provider prescribes potassium chloride 25 mEq in 500ml D5W to infuse
over 6 hours. The available 20ml vial of potassium chloride is labeled, "How many ml of A) Ask the client about soft food preferences.
potassium chloride should the nurse add to the IV fluid? (Round to the nearest tenth.) - B) Determine which side of the body is weak.
ANSWERSUsing the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml C) Obtain and record the client's vital signs.
D) Auscultate the client's breath sounds. - ANSWERSB) Determine which side of the
A male client reports to the on-call clinic nurse that he took Tadalafil 10 mg PO two hours body is weak.
age and his skin now feels flushed. He reports a history of stable angina, but denies
experiencing any current or recent chest pain. What action should the nurse take? The nurse is demonstrating correct transfer procedures to the unlicensed assistance
personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely
A) Tell the client to have someone bring him to an emergency department immediately. move a physically disabled client from the wheelchair to a bed. What action should the
B) Advise the client to place one nitroglycerin tablet under his tongue as a precaution. nurse recommend?
C) Reassure the client that skin flushing is a common side effect of the medication.
D) Instruct the client to increase his intake of oral until the skin flushing is relieved. - A) Apply a gait belt around the client's waist once a standing position has been
ANSWERSA) Tell the client to have someone bring him to an emergency department assumed.
immediately. B) Pull the client into position by reaching from the opposite side of the bed.
C) Hold the client at arm's length while transferring to better distribute the body weight.
The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney D) Place the client's locked wheelchair on the client's strong side next the bed. -
disease (CKD). Which assessment finding should the nurse report to the healthcare ANSWERSD) Place the client's locked wheelchair on the client's strong side next the
provider? bed.
A) The client complains of abdominal fullness and cramping during installation. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene
B) The client complains of a slight shortness of breath during installation. mutation and asks the nurse what to expect next. How should the nurse respond?
C) The amount of the returning dialysis fluid is greater than the amount instilled.
D) The appearance of the returning dialysate fluid is cloudy. - ANSWERSD) The A) Provide information about survival rates women who have this genetic mutation.
appearance of the returning dialysate fluid is cloudy. B) Gather additional information about the client's family history for all types of cancer.
C) Offer assurance that there are a variety of effective treatments for breast cancer.
The healthcare provider prescribed furosemide for a 4-year old child who has a D) Explain that counseling will be provided to give her information about her cancer risk.
ventricular septal defect. Which outcome indicates to the nurse that this pharmacological - ANSWERSD) Explain that counseling will be provided to give her information about
intervention was effective? her cancer risk.
A) Urinary output decrease of 5 ml/hour. The nurse is supervising an unlicensed assistive personnel (UAP) who will be providing
B) Urine specific gravity change from 1.021 to 1.031 personal care for a client with watery diarrhea caused by Clostridium difficile. Which
C) Daily weight decreases of 2 pounds (0.9 kg) action by the nurse takes priority?
postoperative period., which nursing care intervention should the nurse include the
ATI Comprehensive 2025 edition client's plan of care? (Select all that apply)
with correct answers A) Administer low molecular weight heparin as prescribed.
B) Teach client to use incentive spirometer every 2 hours while awake.
C) Remove urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed. E) Assess pain level and
After 2 days treatment for dehydration, a child continues to vomit and have diarrhea.
medicate PRN as prescribed. - ANSWERSB) Teach client to use incentive spirometer
Normal saline is infusing and the child's urine output is 50ml/hour. During morning
every 2 hours while awake.
assessment, the nurse determines that the child is lethargic and difficult to arouse.
C) Remove urinary catheter as soon as possible and encourage voiding.
Which should the nurse implement?
The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client with insulin shock.
A) Increase the IV fluid flow rate.
How should the nurse administer the medication?
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
D) Perform a finger stick glucose test. - ANSWERSD) Perform a finger stick glucose test.
B. Push undiluted slowly though the currently infusing IV.
C. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
After receiving IV fluids in the emergency department, an elderly client is admitted to the
D. Ask the pharmacist to add the Dextrose to a TPN solution. - ANSWERSB. Push
acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9%
undiluted slowly though the currently infusing IV.
normal saline at 125 ml/hour via saline lock and has a bounding pulse, tachycardia, and
pedal edema. When contacting the healthcare provider, the nurse anticipates a
A client with arthritis has been receiving treatment with naproxen and now reports
prescription what intervention?
ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should
the nurse monitor?
A) Remove the saline lock from the client's arm.
B) Increase the rate of the normal saline infusion. C) Decrease the rate of the normal
A) Serum Calcium.
saline infusion. D) Change the IV solution to 0.45% saline solution. - ANSWERSA)
B) Erythrocyte sedimentation rate. C) Osmolality.
Remove the saline lock from the client's arm.
D) Hemoglobin. - ANSWERSD) Hemoglobin.
A male client with an antisocial personality disorder is admitted to an inpatient mental
A client who is admitted to the care unit with syndrome of inappropriate antidiuretic
health unit for multiple substance dependency. When providing a history, the client
hormone (SIADH) has developed osmotic demyelination. Which intervention should the
justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's
nurse implement first?
history is most likely to include which finding?
A) Patch one eye.
A) Multiple convictions for misdemeanors and Class B felonies.
B) Evaluate swallow.
B) Delusions of grandiosity and persecution.
C) Reorient often.
C) Suicidal ideations and multiple attempts.
D) Range of motion. - ANSWERSB) Evaluate swallow.
D) Photos and panic attacks when confronted by authority figures. - ANSWERSA)
Multiple convictions for misdemeanors and Class B felonies.
The nurse is preparing a client who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
(Select all that apply)
, D) Irrigate the NGT with sterile normal saline. - ANSWERSA) Administering a prescribed
A) Wash the stump with soap and water. antiemetic agent.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to
D) Inspect skin for redness. be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many
E) Use a residual limb shrinker - ANSWERSA) Wash the stump with soap and water. gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.) -
D) Inspect skin for redness. ANSWERSFlow rate(gtt/min) = volume(ml)/ time(min) × drop factor(gtt/mL).
E) Use a residual limb shrinker
Flow rate=1000ml/240min×10gtt/ml.
A client with bleeding esophageal varices receives vasopressin IV. What should the Flow rate = 41.667gtt/min
nurse monitor for during the IV infusion of this medication?
Answer=42
A) Vasodilatation of the extremities.
B) Chest pain and dysrhythmia. At 40-week gestation, a laboring client who is lying is a supine position tells the nurse
C) Hypotension and tachycardia. that she has finally found a comfortable position. What action should the nurse take?
D) Decreasing GI cramping and nausea. - ANSWERSD) Decreasing GI cramping and
nausea. A) Place a pillow under the client's head and knees.
B) Place a wedge under the client's right hip.
C) Encourage the client to turn on her left side.
D) Explain to the client that her position is not safe. - ANSWERSB) Place a wedge under
A client with bacterial meningitis is receiving phenytoin. Which assessment finding the client's right hip.
indication to the nurse that the client is experiencing a therapeutic response to the
phenytoin? A family member reports that the client who is bedridden has not been turned or
repositioned all night and is sleeping on a special air mattress with no sheets. What
A) Increased time of ambulation between periods of rest. information should the nurse provide to the family member?
B) Decrease in intracranial pressure and cerebral edema.
C) Absence of seizure activity for the duration of treatment. A) Clarify that an aerated support surface does not use sheets that often cause skin
D) Normal electroencephalogram after drug administration. - ANSWERSC) Absence of B) Described the night staff's plan of care to ensure the client's sleep is not disturbed.
seizure activity for the duration of treatment. C) Explained that turning is only necessary to reposition the client during waking hours.
D) Suggest that a family member turn the client during the night when someone is there.
A client peptic ulcer disease receives a prescription for intermittent suction via a - ANSWERSA) Clarify that an aerated support surface does not use sheets that often
SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffee- cause skin
ground gastric contents, the nurse clamps the NGT because the client must leave the
unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin
action should the nurse implement first? infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which
action should the nurse implement? (Select all that apply.)
A) Administering a prescribed antiemetic agent.
B) Provide oral suction using a Yankauer tip. A) Monitor stools for presence of blood.
C) Connect the NGT to low intermittent suction. B) Auscultate bowel sounds in all quadrants.
, C) Assess characteristics of pain. D) Blood urea nitrogen (BUN) increase from 8 to 12 mg/dL (2.9 to 4.3 mmol/L) -
D) Review last partial thromboplastin time results. ANSWERSC) Daily weight decreases of 2 pounds (0.9 kg)
E) Prepare to administer warfarin. - ANSWERSA) Monitor stools for presence of blood.
C) Assess characteristics of pain. The nurse is preparing to administer an oral antibiotic to a client with unilateral
E) Prepare to administer warfarin. weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority
nursing assessment that should be done before administering this medication?
The healthcare provider prescribes potassium chloride 25 mEq in 500ml D5W to infuse
over 6 hours. The available 20ml vial of potassium chloride is labeled, "How many ml of A) Ask the client about soft food preferences.
potassium chloride should the nurse add to the IV fluid? (Round to the nearest tenth.) - B) Determine which side of the body is weak.
ANSWERSUsing the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml C) Obtain and record the client's vital signs.
D) Auscultate the client's breath sounds. - ANSWERSB) Determine which side of the
A male client reports to the on-call clinic nurse that he took Tadalafil 10 mg PO two hours body is weak.
age and his skin now feels flushed. He reports a history of stable angina, but denies
experiencing any current or recent chest pain. What action should the nurse take? The nurse is demonstrating correct transfer procedures to the unlicensed assistance
personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely
A) Tell the client to have someone bring him to an emergency department immediately. move a physically disabled client from the wheelchair to a bed. What action should the
B) Advise the client to place one nitroglycerin tablet under his tongue as a precaution. nurse recommend?
C) Reassure the client that skin flushing is a common side effect of the medication.
D) Instruct the client to increase his intake of oral until the skin flushing is relieved. - A) Apply a gait belt around the client's waist once a standing position has been
ANSWERSA) Tell the client to have someone bring him to an emergency department assumed.
immediately. B) Pull the client into position by reaching from the opposite side of the bed.
C) Hold the client at arm's length while transferring to better distribute the body weight.
The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney D) Place the client's locked wheelchair on the client's strong side next the bed. -
disease (CKD). Which assessment finding should the nurse report to the healthcare ANSWERSD) Place the client's locked wheelchair on the client's strong side next the
provider? bed.
A) The client complains of abdominal fullness and cramping during installation. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene
B) The client complains of a slight shortness of breath during installation. mutation and asks the nurse what to expect next. How should the nurse respond?
C) The amount of the returning dialysis fluid is greater than the amount instilled.
D) The appearance of the returning dialysate fluid is cloudy. - ANSWERSD) The A) Provide information about survival rates women who have this genetic mutation.
appearance of the returning dialysate fluid is cloudy. B) Gather additional information about the client's family history for all types of cancer.
C) Offer assurance that there are a variety of effective treatments for breast cancer.
The healthcare provider prescribed furosemide for a 4-year old child who has a D) Explain that counseling will be provided to give her information about her cancer risk.
ventricular septal defect. Which outcome indicates to the nurse that this pharmacological - ANSWERSD) Explain that counseling will be provided to give her information about
intervention was effective? her cancer risk.
A) Urinary output decrease of 5 ml/hour. The nurse is supervising an unlicensed assistive personnel (UAP) who will be providing
B) Urine specific gravity change from 1.021 to 1.031 personal care for a client with watery diarrhea caused by Clostridium difficile. Which
C) Daily weight decreases of 2 pounds (0.9 kg) action by the nurse takes priority?
