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FUNDAMENTALS PROCTORED ATI RN
EXAM AND CORRECT ANSWERS
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A nurse is preparing to instill an enteral feeding to a client who has an NG
tube in place
...
Check how long the feeding container has been opened
B
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Confirm that the client doesn't have diarrhea
D
...

Which of the following nursing interventions is the highest priority when
the nurse suspects aspiration of the feeding?

A
...
Stop the feeding
C
...
Initiate oxygen therapy - CorreCt Answers -B
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Which of the following is an appropriate
nursing action prior to administering the tube feeding? Select all
...
Auscultate bowel sounds
...
Assist the client to an upright position
...
Test the pH of gastric aspirate
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Warm the formula to body temp
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Discard any residual gastric contents
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Which of the following actions should the nurse perform
prior to beginning the procedure? Select all
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Review a signal the client can use if feeling any distress
B
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Administer oral pain meds
D
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Have a petroleum-based lubricant available - CorreCt Answers -A, B

An adolescent who has diabetes mellitus is 2 days postop following an
appendectomy
...
He has ambulated
successfully around the unit w/assistance
...
His
incision is approximated & free of redness, w/scant serous drainage on the
dressing
...


A
...
Impaired circulation
C
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Malnutrition
E
...
surgery
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Which of the following assessment
findings should the nurse expect? Select all
...
Increase in incisional pain
B
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Reddened wound edges
D
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Decrease in thirst - CorreCt Answers -A, B, C

A nursing instructor is reviewing the wound healing process w/a group of
nursing students
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A
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Sutured surgical incision
C
...
Laceration sealed w/adhesive
E
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surgery 24 hr ago reports a pulling sensation & pain
in his surgical incision
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Which of the following
interventions is appropriate? Select all
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Cover the area w/saline-soaked sterile dressings
B
...

C
...
Position the client supine w/his hips & knees bent
E
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Which of the following interventions should the nurse use
to help maintain the integrity of the client's skin? Select all
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Keep the head of the bed elevated 30 degrees
B
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Apply cornstarch liberally to the skin after bathing
D
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Reposition the client at least Q 3 hr while in bed - CorreCt Answers -A, D

not E because it should be at least every 2 hours

102 - CorreCt Answers A nurse on a med-surg unit has received change-of-shift report & will care
for 4 clients
...
Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia

B
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Reapplying a condom catheter for a client who has urinary incontinence

D
...

Reapplying a condom catheter for a client who has urinary incontinence

Rationale: The application of a condom catheter is a noninvasive, routine
procedure that the nurse may delegate to the AP

A nurse is delegating the ambulation of a client who had knee arthroplasty
5 days ago to an AP
...


A
...

B
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The client uses a front-wheeled walker when ambulating
D
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The client is allergic to codeine
F
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Which of the following assignments should the LPN question?

A
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Collecting a clean-catch urine specimen from a client who was admitted
on the previous shift
C
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Replacing the cartridge and tubing on a PCA pump - CorreCt Answers D
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Which of the
following elements should she identify when presenting the 5 rights of
delegation? Select all
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Right client
B
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Right direction/communication
D
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Right circumstances - CorreCt Answers -B, C, E

A and D are rights of medication administration

A nurse manager of a med-surg unit is assigning care responsibilities for
the oncoming shift
...
To which staff member should the nurse
assign to this client?

A
...
RN
C
...
AP - CorreCt Answers -B
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RNs are responsible for this, especially if the client is
potentially unstable
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The AP tells him she will put a diaper on him if he does not use
the urinal more carefully next time
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Assault
B
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False imprisonment
D
...
Assault

By threatening the client, the AP is committing assault
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The nurse believes that this is
not in the client's best interest, so she administers a PRN sedative med that
the client has not requested along w/his usual meds
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Assault
B
...
Negligence
D
...
False imprisonment

The nurse gave the med as a chemical restraint to keep the client from
leaving the facility against medical advice
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A client who will undergo neurosurgery the following week tells the nurse
in the surgeon's office that he will prepare his advance directives before he
goes to the hospital
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"I'd rather have my brother make decisions for me, but I know it has to
be my wife
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"I know they won't go ahead w/the surgery unless I prepare these
forms
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"I plan to write that I don't want them to keep me on a breathing
machine
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"I will get my regular doctor to approve my plan before I hand it in at the
hospital
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The client has the right to decide and specify which medical procedures he
wants when a life-threatening situation arrives

A client is about to undergo an elective surgical procedure
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A
...
Witness the client's signature on the consent form
C
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Describe the consequences of choosing not to have the surgery
E
...
Today,
she found the nurse asleep in a chair in the break room when she was not
on break
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Remind the nurse that safe client care is a priority on the unit
B
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Report observations to the nurse manager on the unit
D
...

Any nurse who notices behavior that could possibly jeopardize client care or
indicate a substance abuse problem has a duty to report the situation
immediately to the nurse manager

A nurse is preparing info for a change-of-shift report
...
The client's input & output for the shift
B
...
A bone scan that is scheduled for today
D
...
A bone scan that is scheduled for today

This is important because the nurse might have to modify the client's care
to accommodate them leaving the unit

A nurse enters a client's room & finds him sitting in his chair
...
" How should
the nurse document this in the client's chart?

A
...


B
...
The nurse should not document this info because she did not witness the
fall
D
...

By writing what the client states, the info is subjective data

A nursing instructor is reviewing documentation w/a group of nursing
students
...


A
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Put the date & time on all entries
C
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Use as many abbreviations as possible
E
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The nurse has reapplied it twice during the shift,
but it remains intact only when the client is supine in bed
...

The client sat in a chair during lunch w/an absorbent pad over the fistula
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The wound care nurse confirmed that
she will see the client later today
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Which of the following information should the nurse include in
the change-of-shift report? Select all
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The physical therapist didn't ambulate the client today
B
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Which of the following
nursing actions are appropriate? Select all
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Repeat the details of the prescription back to the provider
B
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Obtain the prescriber's signature on the prescription within 24hrs
D
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Tell the charge nurse that the provider has prescribed morphine by
telephone - CorreCt Answers -A, B, C

A nurse is caring for an older adult client who lives alone & is to be
discharged in 3 days
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To which of the following
members of the health care team should the nurse refer him?

A
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Occupational therapist
C
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Social worker - CorreCt Answers -D
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The nurse caring for the client should
initiate a referral w/which of the following members of the
interprofessional care team?

A
...
Certified nursing assistant
C
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Occupational therapist - CorreCt Answers -D
...

Which of the following members of the interprofessional care team may
assist the client in understanding the medication's effects? Select all
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Provider
B
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Pharmacist
D
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Respiratory therapist - CorreCt Answers -A, C, D

A client who has had a cerebrovascular accident has persistent problems
w/dysphagia
...
Social worker
B
...
Occupational therapist
D
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When she gives examples of the types of tasks CNAs
may perform, which of the following client activities should she include?
Select all
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Bathing
B
...
Toileting
D
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Measuring vital signs - CorreCt Answers -A, B, C, E

Determining pain level requires assessment, which is the job of the licensed
personnel
...
Which of the following findings should the nurse expect?
Select all
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A concave thoracic spine posteriorly
B
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A concave lumbar spine posteriorly
D
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Muscles slightly larger on his dominant side - CorreCt Answers -C, E

A nurse is evaluating a client's neurosensory system
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A word she whispers 30cm from his ear
B
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The vibration of a tuning fork she places on his foot
D
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Stereognosis is tactile recognition

A nurse is assessing a client who reports pain when the nurse evaluates the
internal rotation of her right shoulder
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Mopping her floors
B
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Fastening her bra behind her back
D
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Fastening a bra from behind requires internal rotation of the shoulder, so
this activity will illicit pain

A nurse is preforming a neurosensory examination for a client
...


A
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Heel-to-toe walk
C
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Spinal accessory function
E
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A nurse is collecting data from an older adult client as part of a
neurosensory examination
...


A
...
Some vision & hearing decline
C
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Some short-term memory decline

E
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Which of the following
should the nurse teach the client about using oxygen safely in his home?
Select all
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Family members who smoke must be at least 10 ft from the client when
the oxygen is in use
B
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A "No smoking" sign should be placed on the front door
D
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A fire extinguisher should be readily available in the home - CorreCt
Answers -B, C, E

Family members that smoke should do so outside, and wool creates static
electricity so it should be avoided
...
Which of
the following statements made by a participant indicates a need for further
clarification & instruction?

A
...
"
B
...
"
C
...
"

D
...
" - CorreCt Answers -B
Although the baby can hold his head above the water by sitting up, this does
not make the baby safe in the tub
...


A home health nurse is discussing the dangers of carbon monoxide
poisoning w/a client
...
Carbon monoxide has a distinct odor
B
...
The lungs are damaged from carbon monoxide inhalation
D
...

Carbon monoxide is a very dangerous gas because it binds w/hemoglobin &
ultimately reduces the oxygen supplied to the tissues in the body
...

The water heaters, gas-burning furnances, and appliances should be
inspected annually
The lungs are not damaged in the process of inhalation

A nurse educator is presenting a module on basic first aid for newly
licensed home health nurses
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Hypotension

B
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Clammy skin
D
...
Hypotension
Tachycardia, hot dry skin, and tachypnea are other manifestations of heat
stroke

A home health nurse is discussing the dangers of food poisoning w/a client
...


A
...
Immunocompromised individuals are at risk for complications from food
poisoning
C
...
Healthy individuals usually recover from the illness in a few weeks
E
...
coli
...


A nurse is caring for a client diagnosed w/severe acute respiratory
syndrome (SARS)
...
Which of the
following illustrate the rationale for reporting? Select all
...
Planning & evaluating control & prevention strategies
B
...
Ensuring proper medical treatment
D
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Monitoring for common-source outbreaks - CorreCt Answers -A, B, C, E

Not D because endemic disease is already prevalent within a population, so
reporting is not necessary

A nurse is contributing to the plan of care for a client who is being admitted
to the facility w/a suspected diagnosis of pertussis
...


A
...
Wear a mask when providing care within 3 ft of the client
C
...
Use sterile gloves when handling soiled linens
E
...

The nurse should wear a gown when contamination from body fluids might
happen

A nurse is caring for a client who presents w/linear clusters of fluidcontaining vesicles w/some crustings
...
Allergic reaction
B
...
Systemic lupus erythematosus
D
...
Herpes zoster

pink body rash=allergic reaction
red circles w/white centers=ringworm
red cheek rash bilaterally=lupus

A nurse is caring for a client who reports severe sore throat, pain when
swallowing, & swollen lymph nodes
...
Prodromal
B
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Convalescence
D
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Illness
specific s/s present is the illness stage

A nurse educator is reviewing w/a newly hired nurse the difference in
clinical manifestations of a localized vs
...
The nurse
indicates understanding when she states that which of the following are
clinical manifestations of a systemic infection? Select all
...
Fever
B
...
Edema
D
...
Increase in pulse & respiratory rate - CorreCt Answers -A, B, E

Edema and pain and tenderness is localized

A nurse is teaching a young adult client about health promotion & illness
prevention
...
"I already had my immunizations as a child, so I'm protected in that
area
...
"It is important to schedule routine health care visits even if I'm feeling
well
...
"If I'm having any discomfort, I'll just got to an urgent care center
...
"If I am felling stressed, I will remind myself that this is something I
should expect
...

routine health screenings are important at any age

A nursing instructor is explaining the various stages of the lifespan to a
group of nursing students
...
Becoming actively involved in providing guidance to the next generation
B
...
Devoting a great deal of time to establishing an occupation
D
...

Exploring and establishing career options & establishing oneself is
important developmental task in a young adult

A nurse is counseling a young adult who describes having difficulty dealing
w/several issues
...
"I have my own apartment now, but it's not easy living away from my
parents
...
"It's been so stressful for me to even think about having my own family
...
"I don't even know who I am yet, & now I'm supposed to know what to
do
...
"My girlfriend is pregnant, & I don't think I have what it takes to be a
good father
...

Applying Erikson stages of development, knowing oneself is done in
adolescence, and this requires the most urgent help

A nurse is reviewing safety precautions w/a group of young adults at a
community health fair
...


A
...
Wear a helmet while skiing
C
...
Secure firearms in a safe location
E
...
Which of the following recommendations should the nurse
include in this discussion? Select all
...
Human papillomavirus
B
...
Varicella
D
...
Polio - CorreCt Answers -A, B, C

D is not for after 18 months of age and polio is also given as a child and not
usually beyond 18 yrs old

A nurse is caring for an 82-yr-old client in the ER who has an oral body
temp of 38
...
He is
restless & his skin is warm
...


A
...
Restrict the client's oral fluid intake
C
...
Allow the client to shiver to dispel excess heat
E
...


Why E-Oral hygiene helps prevent cracking of dry mucous membranes of
the mouth & lips
...
Which of the following is the nurse's priority
instruction for measuring vital signs for this client?

A
...
"
B
...
"
C
...
"
D
...
" - CorreCt
Answers -A
...
"

The greatest risk to a client w/a low platelet count is injury that results in
bleeding, obtaining a temp this way increases the risk for bleeding
...
Which of the following guidelines should the nurse include? Select all
...
Place the client in semi-Fowler's position
B
...
Observe 1 full respiratory cycle before counting the rate
D
...
Count & report any signs the client demonstrates - CorreCt Answers -A,
B, C

For D, this is if the rate is irregular after initial count, for E, sighs are
expected & don't need to be reported

A nurse who is admitting a client who has a fractured femur obtains a BP
reading of 140/94 mmHg
...
Apply elastic stockings
C
...
Place pillows under the client's knees & lower extremities
E
...
Which of the following statements
should indicate to the nurse that the client understands the teaching?

A
...
"
B
...
"

C
...
"
D
...
" - CorreCt
Answers -B
...


A
...
Keep 2 points of support on the floor
C
...
After advancing the cane, move the weaker leg forward
E
...
pain
...
The nurse is assessing which of the following?

A
...
Location of the pain

C
...
Aggravating & relieving factors - CorreCt Answers -A
...

The nurse can best assess the intensity of the client's pain by:

A
...
questioning the client about the location of the pain
C
...
using open-ended questions to identify the situation - CorreCt Answers C
...
The nurse's guiding
principle throughout this process should be that:

A
...
pain must have an identifiable source to justify the use of opioids
...
objective data are essential in assessing pain
D
...
surgery
...
"I'll wait to use the device until it's absolutely necessary
...
"I'll be careful about pushing the button so I don't get an overdose
...
"I should tell the nurse if the pain doesn't stop after I use this device
...
"I will ask my son to push the dose button when I am sleeping
...

The client should let the nurse know if not receiving adequate pain control,
so they can reevaluate the pain control plan

A nurse is monitoring a client who is receiving opioid analgesia for adv
effects of the med
...


A
...
Diarrhea
C
...
Orthostatic hypotension
E
...


A nurse is assessing a client who takes haloperidol (Haldol) for the tx of
schizophrenia
...


A
...
Fine motor tremors
C
...
Decreased level of consciousness
E
...
Which of
the following are appropriate to include in the teaching? Select all
...
Take frequent sips of water
B
...
Use a soft toothbrush when brushing teeth
D
...
Urinate prior to taking the med - CorreCt Answers -A, B, E

side effects of this med include: dry mouth, photophobia, and urinary
retention

A nurse is reviewing the reported meds of a client who was recently
admitted
...
Knowing that cimetidine decreases the
metabolism of imipramine hydrochloride, the nurse should identify that
this combination is likely to result in which of the following effects?

A
...
Increased risk of imipramine hydrochloride toxicity
C
...
Increased therapeutic effects of imipramine hydrochloride - CorreCt
Answers -B
...
The client currently takes a Category D pregnancy risk med
for the control of seizures
...
"This med is prescribed if necessary but it is known to cause adverse
effects to the fetus
...
"This med has evidence indicating that it is safe to take during pregnancy
& will not harm the fetus
...
"This med cannot be taken during pregnancy because the risk outweighs
the potential benefits
...
"This med hasn't been studied in pregnant women but is believed to be
safe for the fetus
...

Category D meds are known to cause harm to fetuses, however the use
during pregnancy may be warranted based on potential benefits
...
The client has a prescription for preoperative
diazepam (Valium)
...
Teaching the client about the purpose of the med
B
...
Identifying the client's med allergies
D
...

The greatest risk to the client is an allergic reaction to the med

A nurse is preparing to administer methylprednisolone acetate (DepoMedrol) 10 mg by IV bolus
...
How many
mL should the nurse administer? (round to nearest tenth) - CorreCt
Answers -0
...
The nurse should set the infusion pump to deliver how many
mL/hr? (round to nearest whole number) - CorreCt Answers -400 mL/hr

A nurse is preparing to administer 0
...
9% NaCl) 250
mL IV to infuse over 30min
...
The nurse should set the manual IV infusion to deliver how many
gtt/min? (round to nearest whole number) - CorreCt Answers -83 gtt/min

A nurse is caring for a client who is at high risk for aspiration
...
Give the client thin liquids
...
Instruct the client to tuck her chin when swallowing
...
Have the client use a straw
...
Encourage the client to lie down & rest after meals
...

Tucking when swallowing allows food to pass down esophagus more easily
...
She should explain that which of the following is the
body's priority energy reserve?

A
...
Protein
C
...
Carbohydrates - CorreCt Answers -D
...
The nurse should
expect to see which of the following foods on the client's meal tray?

A
...
Pureed broccoli
C
...
Lentil soup - CorreCt Answers -C
...
6 m ( 5 ft 3
in) tall
...
- CorreCt Answers -BMI=30
above 30 equals obese so yes
...
Which of the following info should the
nurse include? Select all
...
Older adults are more prone to dehydration than younger adults are
B
...
Many older men & women need calcium supplementation
D
...
Older adults should consume a diet low in carbs - CorreCt Answers -A, B,
C

D-they need fewer calories not more
E-they need more carbs & fiber

A nurse is caring for a client who is 1 day postop following a total knee
arthroplasty
...
After
reviewing the client's medication administration record, which of the
following medications should the nurse administer?

A
...
Fentanyl 50 mcg/hr transdermal patch
C
...
Oxycodone 10 mg PO - CorreCt Answers -C
...

Which of the following statements by the client indicates an understanding
of the teaching?

A
...
"
B
...
"
C
...
"
D
...
" - CorreCt Answers -D
...
Which of the following instructions should the nurse
include in the teaching?

A
...
"
B
...
"

C
...
"
D
...
" - CorreCt
Answers -A
The client should flush the tube w/15-30 mL of water to prevent clogging of
the tube

A nurse educator is teaching a module on pharmacokinetics to a group of
newly licensed nurses
...
"Some meds block normal receptor activity regulated by endogenous
compounds or receptor activity caused by other meds
...
"Some meds may have to be administered by a nonenteral route to avoid
inactivation as they travel through the liver
...
"Some meds leave the body more slowly & therefore have a greater risk
of accumulation & toxicity
...
"Some meds have a wide safety margin, so there is no need for routine
serum medication level monitoring
...

first pass deals with the liver

A nurse is teaching an adult client how to administer ear drops
...
"I will straighten my ear canal by pulling my ear down & back
...
"I will gently apply pressure w/my finger to the tragus of my ear after
putting in the drops
...
"I will insert the nozzle of the ear drop bottle snug into my ear before
squeezing the drops in
...
"After the drops are in, I will place a cotton ball all the way into my ear
canal
...

The client should apply gentle pressure w/the finger to the tragus of the ear
after administering the drops to help the drops go into the ear canal

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