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Add to cartA nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the clients urinary bag. The nurse recognizes these manifestations as which of the following types of transfusion reaction?
Hemolytic. A hemolytic reaction occurs when the clients blood is incompatible with the donors blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.
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A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
Tachycardia. Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.
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A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?
Bounding pulse. Bounding pulse is an expected finding of fluid volume excess.
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A nurse is caring for a client who has clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
Wear gloves when changing the clients gown. The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.
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A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
When lifting an object, spread your feet apart to provide a wide base of support. The AP should spread his feet apart because a wide base of support increases stability.
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A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states All this equipment is making me nervous. Which of the following responses should the nurse make?
All of this equipment can be frightening. This statement is therapeutic because the nurse is reflecting the clients statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.
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A nurse is using the I-SBAR communication tool to provide the clients provider with information about the client. The nurse should convey the clients pain status in which portion of the report?
Assessment. The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.
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An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
Tell me more about how your friends discourage you. This response encourages the client to elaborate on his situation, providing the nurse with more information to help address the issue.
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Create quizThis set of practice questions is designed to help nursing students prepare for the ATI Fundamentals Final Exam. Each question is followed by the correct answer and a rationale to enhance understanding and retention. These questions cover a variety of fundamental nursing topics, including patient care, medical procedures, and ethical considerations.
64 questions
Nederlands
12-05-2024
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the clients urinary bag. The nurse recognizes these manifestations as which of the following types of transfusion reaction?
Hemolytic. A hemolytic reaction occurs when the clients blood is incompatible with the donors blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
Tachycardia. Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?
Bounding pulse. Bounding pulse is an expected finding of fluid volume excess.A nurse is caring for a client who has clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
Wear gloves when changing the clients gown. The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
When lifting an object, spread your feet apart to provide a wide base of support. The AP should spread his feet apart because a wide base of support increases stability.A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states All this equipment is making me nervous. Which of the following responses should the nurse make?
All of this equipment can be frightening. This statement is therapeutic because the nurse is reflecting the clients statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.A nurse is using the I-SBAR communication tool to provide the clients provider with information about the client. The nurse should convey the clients pain status in which portion of the report?
Assessment. The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
Tell me more about how your friends discourage you. This response encourages the client to elaborate on his situation, providing the nurse with more information to help address the issue.A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pain in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
A hospice nurse is reviewing religious practices of a group of clients with newly licensed nurses. Which statement by a newly licensed nurse indicates an understanding of the teaching?
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the clients understanding of the process within the psychomotor domain of learning?
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?
A client who reports shortness of breath requests her nurses help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the clients balance?
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
A nurse is reviewing the laboratory values for a client who has a positive Chvosteks sign. Which of the following laboratory findings should the nurse expect?
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status?
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
A nurse in a providers office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?
A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
A nurse is responding to a parents question about his infants expected physical development during the first year of life. Which of the following information should the nurse include?
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider had prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the clients death is imminent?
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, You are not putting that hose down my throat. Which of the following statements should the nurse make?
A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the clients wound has eviscerated?
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care?
A nurse is preparing to administer a medication to a client. The nurse notes that the medication is not in the original container and has no label. Which of the following actions should the nurse take?
A nurse is caring for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?
A nurse is planning care for a client who has a new tracheostomy. Which of the following actions should the nurse include in the plan of care?
A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following instructions should the nurse include?
A nurse is caring for a client who is experiencing difficulty sleeping. Which of the following interventions should the nurse implement to promote sleep?
A nurse is providing discharge teaching to a client who has a new prescription for a metered-dose inhaler (MDI). Which of the following instructions should the nurse include?
A nurse is caring for a client who has a urinary tract infection. Which of the following interventions should the nurse implement to promote comfort?
A nurse is planning care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan of care?
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following foods should the nurse instruct the client to avoid?
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?
A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
A nurse is planning care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan of care?
A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
A nurse is providing teaching to a client who has a new prescription for a nitroglycerin patch. Which of the following instructions should the nurse include?
A nurse is caring for a client who is postoperative following a knee replacement. Which of the following interventions should the nurse implement to prevent deep vein thrombosis (DVT)?
A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?
A nurse is planning care for a client who has a new diagnosis of hypertension. Which of the following lifestyle modifications should the nurse include in the teaching?
A nurse is caring for a client who has a new prescription for a low-sodium diet. Which of the following foods should the nurse instruct the client to avoid?