ATI TESTING Engage Adult Medical Surgical RN- RN Exam

A nurse is caring for a client who reports pain. When documenting the quality of the client’s pain on an initial pain assessment. the nurse should record which of the fallowing client statements? - The pain is like a dull ache in my stomach. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the fallowing actions should the nurse take next? - Evacuate the client. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? - Rapid heart rate A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? - 0.3mg A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 8 mL/hr A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? - Cleanse the wound from the center outward. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? - skin blanching A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - when descending stairs, i will first shift my weight to my right leg. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? - Tell the client to keep the head of the bed elevated at least 30 degrees. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question? - Medication dose. A nurse is caring for a patient with behind the ear hearing aid. - I will be sure to remove my hearing aid before taking a shower. A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of the incident? - Client found lying on the floor. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? - compare prescriptions with medications the client received while at the facility. A nurse is caring for a client who requires an informed consent for a surgical procedure. which of the fallowing actions it the nurses responsibility? - witness the clients signature on the consent form. A nurse is planning an educational program for a group of older adults at a senior living center. which of the fallowing recommendations should the nurse include? - you should receive a pneumococcal immunization every 10 years A nurse is caring for a client who is refusing a scheduled blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? - Withhold the blood transfusion. A nurse is admitting a client who has rubella. which of the fallowing types of transmission based precautions should the nurse initiate? - Droplet. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? - Auscultate lung sounds. A middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? - People in middle adulthood often find satisfaction in nurturing and guiding young people. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? - 1. Check the cord routinely for frays or tearing2. consider purchasing a generator for power backup3. observe for signs of hypoxia A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? - select a suction catheter that is half the size of the lumen. A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. which of the fallowing actions should the nurse take? - Instruct the family to refrain from pushing the button for the client while she is asleep. A nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care? - Wrap blankets around all four sides of the bed. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPPA? - A nurse asks a nurse from another unit to assist with documentation for a client. A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficlile infection. which of the fallowing information should the nurse include in the teaching? - have family members wear gown and gloves when visiting. A nurse is preparing to administer 0.5mL of oral single dose liquid med to a client. What action should the nurse take? - gently shake the container of medication prior to administration. A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? - have the client use a trapeze bar when changing position. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the fallowing tasks should the nurse delegate? - Ambulating a client who is postoperative. A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to long term care facility. which of the fallowing documentations should the nurse include? - current medications. A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? - what could i have done to deserve this illness? A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? - 8oz of ice chips. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? - practice sessions A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpated the popliteal pulse after 92 mm Hg. Which of the following images displays the appropriate mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? - 122 A nurse is planning care for a client who has vision loss. which of the fallowing interventions should the nurse include in the plan of care to assist the client with feeding - Arrange food in consistent pattern on the clients plate.