MAIN VERSION PRIORITY ONE Exit Exam. 180 Commonly Tested Questions and Answers.

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MAIN VERSION PRIORITY ONE 1. Missing 2. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should ... the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hr (for asthma) c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short term (24 to 48 hr) around the clock administration of opioids is preferable to following a PRN schedule. ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated on ATI. 3. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR, decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress, tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur after injury usually within 12-48 hrs 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) b. Wear gloves to apply the patch to the client’s skin c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) Rationale https://medlineplus.gov/druginfo/meds/a601084.html: How to apply patch Rationale ATI Skills Module Medication Administration: Topical medications include lotions, creams, ointments, patches, and paste. Because topical medications are absorbed by the skin, wear gloves when applying them to protect yourself against accidental exposure Shaving may cause skin irritation and change the absorption of the drug. 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hr (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain Rationale Med Surg ATI PDF p529: assess for improvement or worsening of hypoglycemia. Repeat the administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens. 6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial Rationale ATI MS p309: Complications: Aspiration of gastric secretion Causes: Reflux of gastric fluids into the esophagus can be aspirated into the trachea. 7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an INCREASED in which of the following laboratory values? a. Serum glucose level- increased b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased Rationale ATI MS PDF p518: Cushing disease→ everything is UP except Potassium & Calcium: DECREASED. 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? P . 235 pharm ch 30 a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. 9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison Rationale ATI MH p185: Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Rationale ATI COMMUNITY p50: Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level Rationale POTTER & PERRY SKILLS & TECH p187: Remove sterile seal and cap from bottle in upward motion. 11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. 13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. “Can you tell me who visited you today?” b. “What high school did you graduate from?” c. “Can you list your current medications?” d. “What did you have for breakfast yesterday?” Rationale ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g. birthdate). OR ask the client to state a fact from their past that is verifiable. Memory of events that occurred in the distant past. 14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? P .528 med surg ch 82 a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON COMPLIANT b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% 15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive impairment (http://emedicine.medscape.com/article/816447-clinical#b4 also states that this is an indication of phenytoin toxicity); According to my Davis Drug Guide book, progressive s/s of phenytoin toxicity include ataxia, nystagmus, confusion, nausea, slurred speech & dizziness. 16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC 17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom Rationale ATI PDF p: PEDS p. 120 Monitor VS, cardiac status. Maintain cardiac monitoring. Assess for HF ( decrease urine output, gallop heart rhythm, tachycardia, respiratory distress) Kawasaki disease cause inflammation in the walls of medium-sized arteries throughout the body. It primarily affects children. The inflammation tends to affect the coronary arteries, which supply blood to the heart muscle. 18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction Rationale ATI PDF p:33 PEDS Age appropriate activities for highschool students: sports, video games, music, social events. 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? P . 146 ch 19 CONFIRMED a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia 20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. “I will let the client know that I am available as the interpreter.” b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m available today, but when I’m not, you can use a family member.” d. “I will let the client know that an interpreter is unavailable during the night shift.” Rationale ATI PDF p: Makes most sense (best rationale yet) 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? P . 156 ch 23 MATERNITY PDF a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal they can be is RESPIRATORY DISTRESS b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool c. A 2 day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal 22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin Rationale: circulation is affected; ABCs 23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? a. Weight gain b. Dry mouth→ anticholinergic effects c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to the provider. ATI PHARM 110 Rationale: e book pg 69 ch 10 24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? P . 177 ch 26 a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths b. The cord stump will fall off in 5 days- about 10 - 14 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry. 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas b. Potato pancakes c. Wheat crackers d. Canned barley soup Rationale: no wheat, flour, or barley 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech → alterations in speech d. Hypochondriasis ( anxiety disorder) pg 108 ebook ch 20 Rationale : e book pg 79 under expected findings ch 15 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the clients legs b. Place a towel roll under the clients neck c. Apply an orthotic to the clients foot d. Position a pillow under the client's knees Rationale: Casting or splinting techniques are used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint from prolonged immobilization. It is also popular for treating contractures resulting from an increase in muscle tone from nerve injury. After an initial holding cast is applied for seven to 10 days, a series of positional casts are applied at weekly intervals. Before the application of each new cast, the joint is moved as much as can be tolerated by the patient, and measured by a goniometer. When as much motion as possible is obtained after stretching, another final cast is applied to maintain the newly acquired motion. 28. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution ATI COMMUNITY: Providing education to achieve community health goals is a component of identifying and intervening to meet health needs of the local community, which is responsibility to local health departments. 29. A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → ESI Level 2 required immediate pain control per Triage, hypotension with signs of hypoperfusion. -Patients with signs and symptoms of compartment syndrome are at high risk for extremity loss and should be assigned ESI level 2. Other patients with high-risk orthopedic injuries include any extremity injury with compromised neurovascular function, partial or complete amputations, or trauma mechanisms identified as having a high risk of injury such as serious acceleration, deceleration, pedestrian struck by a car, and gunshot or stab wound victims. Patients with possible fractures of the pelvis, femur, or hip and other extremity dislocations should be carefully evaluated and vital signs considered. These fractures can be associated with significant blood loss. Again, hemodynamically unstable patients who need immediate life-saving intervention such as high-level amputations meet ESI level-1 criteria. High level amputations meet ESI level 1. -Patients with inhalation injuries from closed space smoke inhalation or chemical exposure should be considered high-risk for potential airway compromise. If the patient presents with significant airway distress and requires immediate intervention, they meet level-1 criteria. Patients with third-degree burns should also be considered high-risk and be assigned ESI level 2. It is possible that they will require transfer to a burn center for definitive care. 30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED a. Hgb 12.8 g/dl - 12- 16 b. Potassium 4.2 meq/l 3.5 - 5.0 meq c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding Rationale: all other options are okay; except the platelets which is in an abnormal range. 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl (normal: 16-40) c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl Rationale: prealbumin is low (normal is 18-36). Prealbumin = nutritional status ATI MH 111 Hypoalbuminemia 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? a. A client who is postoperative following a bowel resection with an NGT set to continuous suction b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs 33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? p . 88 ch 13 maternity a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMED b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 35. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. Rationale: CDC states that: There is no documented evidence that breastfeeding spreads HCV. Therefore, having HCV-infection is not a contraindication to breastfeed. HCV is transmitted by infected blood, not by human breast milk. There are no current data to suggest that HCV is transmitted by human breast milk. However, HCV is spread by infected blood. Therefore, if the HCV-positive mother’s nipples and/or surrounding areola are cracked and bleeding, she should stop nursing temporarily. Instead, she should consider expressing and discarding her breast milk until her nipples are healed. Once her breasts are no longer cracked or bleeding, the HCV-positive mother may fully resume breastfeeding. 37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen d. Initiate seizure precautions Rationale: Hyperthermia occurs when a person's body temperature rises and remains above the normal; 98.6°F Most frequently, this occurs during the heat of summer and among the elderly. However, it may also be triggered by other medical conditions or certain medications. Rapid cooling may be the single most important action to prevent death or permanent disability. To mitigate organ damage, the goal should be to reduce rectal temperature to below 40°C within 30 minutes of beginning cooling therapy. The question does not indicate whether it is malignant hyperthermia which could have been caused by a medication. The question simply asks that the person has hyperthermia. 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. a. Document the client's conditions every 15 minutes b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? P. 482 ch 75 CONFIRMED a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have questions about your mom dying. Let’s talk about it. Rationale: Therapeutic communication 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) Rationale: The skin test( Mantoux tuberculin skin test) should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will probably need to be rescheduled for another skin test. 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone Rationale: Clarify! 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information - HIPAA rules b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner Rationale: HIPAA ( Patient has the right to make their own health decisions and also decide who they want the information to be shared with.) 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3% Rationale: 15lb/200lb = 0.075 x 100 = 7.5% weight loss percentage 46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage ( massage if fundus is boggy) b. Pour water from a squeeze bottle over the client’s perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client’s perineal area.( warm) 47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. Rationale: According to manufacturer, do not expose the site to heat sources such as heating pad, electric blanket, sauna, hot tub, heated waterbed, excessive sun exposure, or hot climate. The body absorbs too much medicine with excessive heat. *48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? Ch 55 p. 333 a. Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) b. Place the client upright on a donut-shaped cushion- UPright causes increased pressure on the sacrum c. Assess pressure points every 24 hr.- must assess FREQUENTLY so i would rule out b then yeah it does. d. Turn and reposition the client every 3 hrs while in bed. - must be q 2 hours in bed , 1 hour in chair. Rationale: impairment or loss of motor or sensory function in areas of the body served by the thoracic, lumbar, or sacral neurological segments owing to damage of neural elements in those parts of the spinal column. It spares the upper limbs but, depending on the level, may involve the trunk, pelvic organs, or lower limbs. 49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress d. We should establish our roles in the initial session. Rationale: Orientation Phase: • The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship). • Trust, respect, honesty and effective communication are key principles in establishing arelationship. • The expectations the nurse and the client have of each other and of their relationship are discussed and clarified • The nurse gathers information and ensures that priority issues are appropriately addressed. • Consistency and listening are considered by clients to be critical at the beginning of the relationship • The nurse assists in promoting client comfort that may include reducing anxiety or tension. 50. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon Rationale: MAOIs = antidepressants; avoid foods with high tyramine content (eg, aged cheeses, sour cream, red wines, beer, bologna, pepperoni, salami, summer sausage, pickled herring, liver, meat prepared with tenderizers, canned figs, raisins, bananas, avocados, soy sauce, fava beans, yeast extracts), drink alcohol, or consume large quantities of caffeine (coffee, tea, chocolate, or cola) 51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit (1) b. Activate the facility’s fire alarm system (2) c. Close all nearby windows and doors (3) d. Use the unit’s fire extinguisher to attempt to put out the fire (4) Rationale: RACE *52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? Ch 4 p. 23 funds a. Heightened perceptual field b. Rapid speech -severe c. Feelings of dread d. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) CONFIRMED a. Tremors b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis e. Inability to concentrate 54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension (Upper HYPERtension) b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses Rationale: Pg.112 (Pediatrics) A narrowing of the major artery (the aorta) that carries blood to the body. This narrowing affects blood flow where the arteries branch out to carry blood along separate vessels to the upper and lower parts of the body. CoA can cause high blood pressure or heart damage. *55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd) Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviours that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: • legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) • education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) • immunization against infectious diseases. 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative = ASSESSMENT= RN b. Administering oral fluids to a client who has dysphagia- RN- complex patient who is also UNSTABLE + basic nursing skills c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke- Assessment = RN 57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” ::::Pg. 315 (Medsurg) Drink alcohol in moderation. Stop smoking. Avoid NSAIDs. Limit Caffeine-containing. 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech Rationale: dry mouth 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? CONFIRMED a. Assess effectiveness of antiemetic medication- ASSESS = RN b. Perform chest compressions during cardiac resuscitation- BASIC LIFE SUPPORT- CNA can do c. Perform a dressing change for a new amputee- BASIC NUR’SING SKILLS= LVN d. Apply a transdermal nicotine patch- BASIC NURSING SKILLS =LVN *60. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily 61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? P. 57 pharm a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss c. Urinary retention- ANTICHOLINERGIC EFFECTS- dry dry dry. Also tachycardia, blurred vision,constipation d. Hypertension- orthostatic hypotension it will cause instead 62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. Hypertension : p . 245 ch 31 pharm c. Fibromyalgia d. Fibrocystic breast condition 63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure Rationale: fund ati pg 27 64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. “You should not have this procedure if you are allergic to iodine.” b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” Rationale: med-surg ati pg 39. Nursing actions: assess for allergy to shellfish or iodine, which would require the use of a different contrast media 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? P . 125 ch 21 a. Initiate IV fluid replacement- BLOOD IS TOO VISCOUS = obstruction = tissue hypoxia. CONFIRMED b. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's disease . d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? a. b. C and D not shown From the two pictures shown I think it is B. Rationale: https://www.whattoexpect.com/first-year/infant-car-seat-safety Dress baby comfortably, set the seat at 45 degrees, rear facing until 2 years old, make sure baby’s head is secure (usually with special cushioned inserts), the straps on a rear facing safety seat should be at or below baby’s shoulders, strap and fasten them at armpit level, straps should lie flat and untwisted;tight enough so that you get fit two fingers between harness and baby’s collarbone 68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion- assess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr- 2- 4 hours for blood transfusion p . 250 c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- prime blood administration set with NS only d. Administer the blood via a 21-gauge IV needle- page 249 says 18 -20 gauge 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? CONFIRMED a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: fund ati pg 17 - When a client decides to leave the facility against medical advice (without a discharge prescription), the nurse notifies the provider and discusses with the client the risks to expect when leaving the facility prior to discharge. *70. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. “I try to respond to the baby quickly so she doesn’t cry very long.” b. “I think the baby should be sleeping through the night by now.”??????? c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.” 71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? P . 180 ch 26 maternity a. Temperature 38 C(100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability c. Pale and 24-hour fluid deficit of 30 mL - pale= Respiratory distress ????? d. Sunken fontanels and dry mucous membranes 72. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? a. Request a female translator interpreter through the facility b. Ask a student nurse who speaks the same language to translate c. Have the child translate d. Allow the clients partner to translate 73. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? p. 253 ch 41 med surg pdf A. Folate level B. INR level C. Vitamin b12 level CONFIRMED D. Creatinine level 74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device 75. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus) c. Uterine atony( fundus not firm which means possible hemorrhage) d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly) 76. A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ? p. 391 ch 60 med surg pdf a. Polyuria- oliguria b. Hypotension- hypertension c. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine d. Weight loss - weight gain 77. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ? p. 50 ch 7 pharm pdf SSRI for social anxiety , PTSD, A. Excessive sweating - diaphoresis, nausea, fatigue , drowsiness ( early adverse ) B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 78. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? a. your baby will be given 2 ounces of water to drink prior to the test b. this test will be repeated when your baby is 2 months old c. a nurse will draw blood from your baby’s inner elbow d. this test should be performed after you baby is 24 hours old ATI MATERNITY 281■ Newborn genetic screening is mandated in all states. A capillary heel stick should be done 24 hr following birth. For results to be accurate, the newborn must have received formula or breast milk for at least 24 hr. If the newborn is discharged before 24 hr of age, the test should be repeated in 1 to 2 weeks. 79. a nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? P . 106 ch 10 pediatrics a. perform the procedure prior to meals : AVOID Before or AFTER meals b. perform the procedure twice a day c. administer a bronchodilator after the procedure- must be given BEFORE d. hold hand flat to perform percussions on the child- NO has to be CUPPED!!! 80. a nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls→ correct approach; yellow bracelet indicates fall risk b. administering potassium via IV bolus → incomplete info; i don't see anything wrong with administering K+ IV bolus? - IV bolus vit K Push has been used to murder patients, should be diluted or pushed very slowly c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication → If they’re conscious and can swallow and the NGT is clamped, OK! However, Malpractice (Professional Negligence) A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. 81. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness. R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? P . 106 CH 19 PEDs a. Take pancrelipase b. Complete oral hygiene c. Eat a meal d. Use an albuterol inhaler ATI PEDS 85 Administer a bronchodilator medication or nebulizer treatment prior to postural drainage if prescribed. 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P . 164 ch 27 medsurge a. Monitor the dorsalis pedis pulse every 15 minutes → circulation b. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usally are up to 4 hours. c. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the procedure , and npo b4 the procedure is uP to 8 hours. d. Place the client in Fowler’s position- supine they must be http://micunursing.com/cardiaccathpreandpostcare.htm → Generally, the nurse should monitor vital signs, and distal pulses every 15 minutes X 4, every 30 minutes X 2, then every hour X 2, then routine. If there is any change in the patient's neurovascular status for physician should be notified immediately. 84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? a. Offer high-calorie, high protein snacks to the client b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? a. Non maleficence b. Veracity c. Autonomy d. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? p . 287 ch 43 A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. 87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? CONFIRMED a. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow b. Hyperkalemia- LESS c. Hypercalcemia d. hypoglycemia ATI PHARM 237 A/E Hyponatremia, dehydration, and hypochloremia 88. a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) _____140??(not sure)_______ pounds 1 lb per week x 25 week= 25 lbs 75 x 2.2= 165 lbs 165 lbs-25 lbs=140 lbs or 63.6 kg (64 kg) 89. a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will change my baby’s diaper at least every 4 hours b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change R:p178 Maternal newborn Teach the parents to keep the area clean. Change the newborn’s diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. 90. a home health nurse is caring for an adult client who reports, “I keep coughing when I try to swallow my food, but not at other times.” Which of the following actions should the nurse take? a. encourage the client to increase fluid intake b. initiate a consultation with a speech→ language pathologist; swallow eval c. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. 91. A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% Glycosylated hemoglobin (HbA1c): best indicator of an average blood glucose level for the past 120 days 92. A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication? A. BUN B. Blood pressure C. Respiratory rate D. aPTT Beta blocker - blood pressure medication. 93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? A. Encouraging the client to use jet therapy on her lower back for 1 hr - (as long as a patient in active labor has no contraindications, she can generally stay in the bath for 30-60 mins) B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen (some therapies vary - such as TENS may require trained practitioners and sometimes specialized equipment) C. Using effleurage on a client’s lower abdomen - (light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions) D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30 min - (consistent pressure is applied using the heel of the hand/fist against the client’s sacral area to counteract pain in the lower back) 94. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 D. Evaluate the APs’ performance of each task 4 95. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I should take antibiotics when I have a virus.” (antibiotics doesn’t fight viral infections) B. “I should wash my hands for 10 seconds with hot water after working in the garden.” (ok burn your hands) C. “I can clean my cat’s litter box during my pregnancy.” Toxoplasmosis D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” Contagious from the beginning of the illness (up to 2 days before the spots appear) until about 5 days after the first spots appear. So long as there are no new blisters or moist crusts on spots, person will not be contagious even if there are still crusts on the skin. 96. A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take? A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site. B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site. C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site. to localize pressure over the vessel puncture D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. 97. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? A. Phlebitis B. Abdominal aortic aneurysm C. Osteoarthritis D. Peripheral neuropathy Contraindications include acute inflammatory diseases, skin lesions, and peripheral neuropathy because of the risk of BURNS...has loss of sensation 98. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? A. Sensation of skin warmth Feeling of warmth and fluttering of heart is felt as catheter is passed B. Headache C. Increased salivation D. Numbness and tingling of the extremities 99. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? A. Lorazepam .5 mg PO one tablet daily (needs a preceding zero - “0.5” ) B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 100. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face Preeclampsia B. Urinary frequency Pressure on bladder from enlarging uterus C. Faintness upon rising D. Bleeding gums Caused by increase of blood flow to gums, normal 101. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest From pathological skin-picking B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 Idgaf betch D. Xerostomia Dry mouth 102. A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus 103. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming” (can be brief that sometimes they are mistaken for daydreaming and may not be detected for months) B. “The child usually has an aura prior to onset” C. This type of seizure last 30-60 sec” (begin and end abruptly) D. “This type of seizure has a gradual onset” (generalized onset) 104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use (supply a latex-free cart) B. Tape stockinet over monitoring device and cords (place all monitoring devices, cords/tubes in stockinet and secure with tape to prevent direct skin contact) C. Schedule the client as the last surgery of the day (allergen from latex can circulate in the air for an hour after procedure where latex was used - schedule surgery FIRST case of the day) D. Remove stopcocks from IV tubing (Use IV tubing ports without latex ports - utilize STOPCOCKS if available) http://latexallergyresources.org/articles/aana-latex-protocol 105. A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication? (there is a exhibit. The answer the person picked was A) A. Dumping syndrome B. Ketoacidosis C. Hepatotoxicity D. Thyroid storm 106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room (private room) B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft from the client (6ft for reg visitors, no preggerz allowed) E. Close the door to the client's room 107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem 108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one Don’t just offer, prepare gifts ahead of time so the sibling doesn’t feel left out. Provide a gift from the infant to give to sibling B. Move your son to a toddler bed when the baby arrives 2 months before C. Tell your son to kiss the baby Don’t force interactions b/t child and the baby D. Teach your son to change the baby diapers - allow older siblings to help in providing care for the infant 109. A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics- this would cause diarheaa C. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen Peritonitis D. Bounding pulse A condition in which the normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left to right shunt) ●● Murmur (machine hum) ●● Wide pulse pressure ●● Bounding pulses ●● Asymptomatic (possibly) ●● Heart failure 111. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occur. Rationale: OB ati book. Page 66. Monitor for magnesium sulfate toxicity, and discontinue for any of the following adverse e ects: loss of deep tendon re exes, urinary output less than 30 mL/hr, respiratory depression (less than 12/min), pulmonary edema, and chest pain. 112. A nurse is caring for a client who has end stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension impairs kidney function b. Primary glaucoma c. Osteoarthritis d. Amputation Rationale: pretty sure its A. Page 373. Age younger than 2 years • ● Age older than 70 years: Older adult clients are at risk for developing advanced heart disease and malignancies, which increases the risk for complications with kidney transplantation surgery. ● Advanced, untreatable cardiac disease ● Active cancer ● Chemical dependency ● Chronic infections or systemic disease(HIV, hepatitis B or C) ● Coagulopathikmes and certain immune disorders ● Morbid obesity ● Diabetes mellitus ● Chronic pulmonary disease 113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. BEFORE MEALS b. Request non gas forming foods from the dietary department Gas forming foods bloat the abd, making breathing difficult c. Limit the client’s food consumption between meals. SMALL FREQUENT MEALS d. Arrange for a low protein diet. HIGH PROTEIN. 114. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department? https://medlineplus.gov/ency/article/001929.htm a. Candidiasis b. Herpes simplex virus c. Human papillomavirus d. Chlamydia https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/ 115. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? a. Place a cardiac monitor on the client CONFIRMED b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hr urine collection Rationale: potassium level is too high so yeah place a cardiac monitor on the client b/c hyperkalemia can lead to dysrhythmias. 116. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks. -Avoid vigorous activities. b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds. c. I can resume activities, such as sewing. May resume most routine chores/activities around the house d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level. Rationale: http://wps.prenhall.com/wps/media/objects/737/755395/eye_surgery.pdf 117. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min to avoid infusion reactions such as Red Man syndrome: rashes, flushing, tachycardia, and hypotension - administer slowly over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose Rationale: page 597. PHARM ati book. 118. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching ? a. Take magnesium hydroxide for indigestion -not for pts with CKD or dialysis. b. Eat 1g/kg of protein per day - each exchange during dialysis depletes protein, requiring the client to increase protein intake over predialysis limitations, but it still might require some restriction. c. Drink at least 3L of fluid daily -too much fluid d. Consume foods high in potassium -low potassium diet Rationale: http://www.nutritionmd.org/health_care_providers/renal/renal_nutrition.html https://www.gicare.com/medication/mylanta-liquid/ 119. A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology- b. Take the vital signs of the clients on the side of the unit c. Tell me the standing weight of the client in room 102 before breakfast d. The client in room 109 has spilled his water pitcher Rationale: right direction/communication. Leadership. 120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site necrosis with extravasation - discontinue IV b. Blood pressure 92/68 mm Hg - Increases workload of the heart, works to increase BP/HR c. Urine output 35mL/hr d. Pedal pulse of +1 bilaterally Rationale: Page 277. PHARM ATI. ADVERSE EFFECT: Necrosis. 121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward first (Both crutches ONLY forward first) Rationale: . CRUTCH INSTRUCTIONS ● Do not alter crutches after fitting. 
 ● Follow the prescribed crutch gait. 
 ● Support body weight at the hand grips with elbows flexed at 30°. 
 ● Position the crutches on the unaffected side when sitting or rising from a chair. 
 122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot (4 years old) B. Kick a ball forward C. Climb Stairs with alternate feet 3 years old → 2 years old climbs stairs by placing both feet on each step D. Ride a tricycle (3-6 years old) 123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. Im sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. Rationale: Case Manager Role: Also D is the most therapeutic. ● Coordinating care, particularly for clients who have complex health care needs 
 ● Facilitating continuity of care 
 ● Improving efficiency of care and utilization of resources 
 124. A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures Rationale: . COMPLICATIONS WITH ISCHEMIC STROKE . Dysphagia and aspiration . ● Dysphagia can result from neurological involvement of the cranial nerves that innervate the face, tongue, soft palate, and throat. As a result, the client’s risk of aspiration is great. . ● Not all clients who have experienced a stroke have dysphagia, but all should be evaluated prior to reestablishing oral nutrition and hydration. 125. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. B. Check the client's serum albumin levels (Check possible albumin for possible complication not for effectiveness) C. Examine for leakage at thes site of the procedure D. Confirm that the client is able to urinate (To check for complication not effectiveness) Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and remove ascites fluid in the abdominal wall. 126. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with this leg extended. (With leg Flexed) B. Maintain eye contact with the newborn during feedings. Avoid eye contact C. Minimize noise in the newborn environment decrease environmental stimuli D. Administer naloxone to the newborn use morphine, naloxone may precipitate seizures Rationale: Nursing care for maternal substance use and neonatal effects or withdrawal include the following in addition to normal newborn care. ● Monitor the newborn’s ability to feed and digest intake. Offer small frequent feedings. ● Offer non-nutritive sucking. 
 ● Monitor the newborn’s fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, and I&O. 
 ● Reduce environmental stimuli (decrease lights, lower noise level). 127. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? A. Participate in community drills and mock events. Just think about it…..give it a while LOL :))))) B. Vaccinate susceptible children and adults against smallpox C. Assess types, levels and scopes of disasters. Meanwhile here comes a disaster and you’re still assessing LOL...BOOM!! D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First Nurses and other members of the healthcare team should be involved in the development of an EOP for such emergencies. 128. A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect? A. Ritualistic behavior (OCD) B. Exhibits separation anxiety (Dependent) C. Preoccupied with aging D. Suspicious of others. (Paranoid) Rationale: Narcissistic: Characterized by arrogance, grandiose views of self-importance, the need for consistent admiration, and a lack of empathy for others that strains most relationships; often sensitive to criticism 
 129. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Withdraw the client's TV privileges if he does not attend group therapy use therapeutic communication techniques, avoid power struggles B. Place the client in seclusion when exhibits signs of anxiety (Seclusion when on Acute Manic Episode) C. Encourage the client to take frequent rest periods. D. Encourage the client to spend time in the day room.May escalate behavior because of stimulation Rationale: Page 76 of Mental Health Book. NURSING CARE involves implement frequent rest period. 130. A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. (Stage IV Kidney Disease) B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. 131. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area 132. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet • People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato 133. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Seizure disorder b. Polycystic ovary syndrome c. Renal insufficiency- due to the increase of lactic acidosis alcohol will increase risk of lactic acidosis with concurrent use of metformin; renal insufficiency will result in accumulation of medication in the body and resulting in hypoglycemia d. Gluten intolerance 134. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Contractions - Advise the client to report to her provider if she experiences fever, chills, leakage of fluid, or bleeding from the insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure b. Vomiting c. Hypertension d. Epigastric pain -google • Amniocentesis -performed at 14 weeks. Finds out abnormalities, lung maturity. Empty bladder before procedure. complications : fluid emboli, hemorrhage, fetal death, premature rupture of membranes, leakage of amniotic fluid (Epigastric pain is mostly heartburn and other digestive complications, would not make sense to report this problem. Complication: miscarriage or preterm labor; ATI MATERNITY pg 34 135. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120 c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing - bleeding 136. A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after i first feel the urge to urinate d. I will determine which muscles to contract by stopping and starting my stream of urine 137. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? a. I need to have an enema before the test b. I should urinate before the test c. I will lie on my left side during the test supine position with wedge under right hip d. I will drink an oral glucose solution during the test Instruct pt to empty bladder prior to procedure to reduce size & reduce risk of inadvertent puncture 138. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect? a. Memory loss b. Slurred speech c. Elevated temperature d. hypotension • Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension Cocaine (STIMULANT) - dizziness, irritability, tremor, blurred vision, hallucinations, seizures, extreme fever, tachycardia, HTN, chest pain, possible CV collapse, death 139. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules Pericarditis: inflammation of the pericardium that commonly follows a respiratory infection. Can be due to a myocardial infarction. Findings include chest pressure/pain aggravated by breathing (mainly inspiration), coughing, and swallowing; pericardial friction rub auscultated at left lower sternal border; SOB; and relief of pain when sitting and leaning forward 140. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Consume food high in bran fiber c. Sweeten foods with fructose corn syrup d. Increase intake of milk product • Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids 141.A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client’s condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client’s condition. Rationale: Assess the situation by interviewing the client alone so they will speak freely. Need to find out who caused the abuse and neglect. Don’t contact family until you confirm from the client that the family is not responsible. 142.A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client’s extremities. d. Place the clients right hand in supination position. Rationale: Med-surg ebook pg 84, Assess for swallowing and gag reflex, may cause aspiration if client has difficulty swallowing, keep NPO until cleared. B and C are also nursing actions but not priority. 143. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. “I will decrease my protein intake during the third trimester”( increase protein for basic growth) b. “I will need to increase my insulin doses later in my pregnancy” c. “I will increase my carbs at breakfast and limit them the rest of the day” d. “I will decrease my calorie consumption during the first trimester”(increase calorie) Rationale: OB Ebook pg 26,monitor and limit intake of carbs which include sweets and desserts, due control blood glucose levels. From the second trimester of pregnancy, especially after 18 weeks your insulin requirements will usually start to rise. By around 30 weeks you may need as much as two or three times your daily pre- pregnancy insulin dose. This is because the hormones made by the placenta interfere with the way your insulin normally works - as the pregnancy hormones rise, so does your need for insulin. Link: http://pregnancyanddiabetes.com.au/en/for-women-with-diabetes/contraception/diabetes-during-pregnancy/insulin-changes-during-pregnancy/ 144.A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau’s sign b. Assess the client’s skin turgor c. Check the client’s motor strength d. Measure the client’s pupil size Rationale: Medsurg PDF pg. 277 Sign for hypocalcemia, tetany. Early sign of hypocalmemia and paresthesia of fingers and lips. 145. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. “I should clean my stoma with warm water”( can use low ph soap and water) b. “ My stoma should be bright pink or red”(pink,red and moist) c. “I should change the stoma pouch every day” d. “I should cut my pouch opening ⅛ inch larger than my stoma”(allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. 146.A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hr) Rationale: OB PDF pg.61, decreased or absent DTRs. 147.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 148.A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “Your desire to be an organ donor must be documented in writing” b. “I cannot be a witness for your consent to donate”( nurses can witness consent to donate) c. “You must be at least 21 years of age to become an organ donor”( no age limit) d. “Your name cannot be removed once you are listed on the organ donor list”( can remove whenever they want, it's a choice by the client not forced once it's signed) Rationale: Leadership PDF pg. 37 advance directives and will are all written and documented 149.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr.( fluid restriction, monitor fluid intake and I/O, may overload the patient since they are already in HF they will have edema) Rationale: Med-surg PDF pg. 199 medication for HF , ACE to help pump blood easily, afterload reducing agents. 150.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen 5mL syringe d. Obtain the urinalysis specimen before the culture specimen Rationale: Urine collection ATI video, clamp for collection of urine, allows urine collection to be easier with urine in the tube. 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension Rationale: Pg. 474 in Chapter 43 Fluid Imbalances. Diarrhea falls under risk factors of fluid imbalances. Orthostatic hypotension is one of the manifestation to assess for. 152. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic Rationale: Pg. 129 in ATI Chapter 15 Personality Disorders. BPD falls under Cluster B and is characterized by “instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often tries self-injury and may be suicidal.” 153. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension Rationale: 154. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure. Rationale: Pg. 194 in ATI book Chapter 18 Under Chest Tube Removal. “Provide pain medication 30 min before removing chest tubes.” 155. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. Rationale: I could not find a rationale but it is the most critical piece of information that the med-surg nurse would need to know. 156. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. “You can add the medication to a half-cup of your child’s favorite juice.” B. “Repeat the dose if your child vomits within 1 hour after taking the medication.” C. “Limit your child’s potassium intake while she is taking this medication.” D. “Have your child drink a small glass of water after swallowing the medication.” Rationale: Pg 117 in ATI Nursing Care of children. “Give water following administration to prevent tooth decay if the child has teeth.” 157. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension Rationale: Pg 298 in Med Surg ATI just says Left Heart- PAWP with no specific information. On www.austincc.edu I found, “PAWP, it measures pressure generated by the left ventricle. It is used to assess left ventricular function.” 158. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation treatment. C. A client who is 1 day postoperative following a vertebroplasty.????? 1528 of lewis book says ppl who do this procedure can be discharged as soon as they learn how to perform care , and that this procedure is very minimal -- Procedure healing time is also 1-2 hours to recover D. A client who is receiving heparin for deep vein thrombosis. - Repeated below Heparin for Hospital coumadin for home. Rationale: I could not find a specific rationale but this patient is the least urgent. 159. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl (WNL) B. WBC 9,800/mm (WNL) C. Creatinine 0.9 mg/dl (WNL) D. Potassium 5.2 mEq/L Rationale: All other lab values are within normal range. Potassium is elevated. This can cause dysrhythmias and even sudden death. 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? Paul for 158 would u pick D ? A. Engage the client in activities that increase sensory stimulation.Overstimulation = Increased confusion B. Discourage physical activity during the day. C. Establish a toileting schedule for the client. Maximizes the ability to learn, less confusion D. Use clothing with buttons and zippers. Aspiration risk (repeated) 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations p . 343 ch 57 fundamentals pdf a. Orthostatic hypotension - d/t fluid volume deficit b. Dependant Edema- fluid volume excess c. Decreased Hematocrit - fluid volume excess d/t super diltion d. Neck vein distention - fluid volume excess 152. A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder? p .76 ch 14 mental health a. The client is overly concerned about minor details b. The client exhibits impulsive behavior - spending money giving away money or possessions. c. The client is exceptionally clingy to others d. The client might act seductively 153. A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ? a. 3+ deep tendon reflexes -preeclampsia b. Protruding hemorrhoids c. Urinary frequency ch 4 p. 21 maternal- d. Supine hypotension - teach them side lying position . - COMMON 154. A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first ? a. Inform the provider of the time of the last does of pain medication ????????? - chest tubes may be painful so knowing when pain med was given can help lower the pain threshold during the procedure ??????? b. Document the sequence of events as they occur c. Provide non pharmacological pain management interventions d. Instruct the client about the steps of the procedure 155. A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report ? a. The client was intubated without complication b. The estimated blood loss was 250 milliliters - out of the four, it sounds like the most vital.crucial.descriptive information you can give. c. There was a total of 10 sponges used during the procedure - what kind d. The client is a member of the board of directors 157. A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? P. 199 ch 32 MEDSURGE a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension 157. 158. A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge ? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range b. A client who has cancer with a sealed implant for radiation therapy - an implant is inside them, and its active c. A client who is 1 day postoperative following a vertebroplasty - 1 day seems to soon - p. 1528 of lewis , verteborlplasty patients can be discharge as soon as they lear tge home care . this procdure is not major. d. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for Hospital and that other Coumadin for home 159. A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery ? a. Fasting blood glucose 108 mg/ dl b. WBC 9,800 mm3 > 4,800 is normal c. Creatnine 0.9 mg/dl , < 1.0 is normal d. Potaissium 5.2 meq / L 3.5 - 5.0 = imbalance = CARDIAC DYSRHYTHMIAS Rationale: Med Surg ATI page 382: Avoid NA, K, Mg, Phosphorus. Imbalances before surgery 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching ? a. Engage the client in activities that increase sensory stimulation. b. Discourage physical activity during the day c. Establish a toileting schedule for the client d. Use clothing with buttons and zippers 161. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred Assess the situation first prior to trying to solve it. 162. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. 163. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding - not without crushing them first b. Dissolve the medications together- some medications can mix others can’t c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water- 10ml ATI Fundamentals - “use syringe & allow med to flow in by gravity or push it in w/ the plunger of the syringe” p. 264 164. The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor c. Seductive Behavior d. Lack of remorse They want attention ATI Mental Health - Histrionic: emotional, attention seeking; center of attention; seductive & flirtatious 165. A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor.Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. I can use my ultrasound picture as a focal point during contractions- Distraction 166. A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute - wnr b. ST segment elevations_ Remember this could possibly lead to infarctions c. 2 PVCs per minute d. Widened P wave ST elevation = infarction or injury 167. A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the tpn IV tubing to administer the clients next dose of antibiotics- start another IV/lock for antibiotic, can’t use with TPN d. Increases the tpn infusion rate each hour until the prescribed rate is achieved 168. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? a. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your responsibility to contain it b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - no comparison 169. A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations -either or is fine b. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the right way c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear d. Count respirations for 1 minute if the rhythm is irregular 170. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff c. contact the laboratory manager regarding the situation - you are not high enough up the chain to do that d. Notify the facilities legal department - no need to go that far 171. A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infections d. Migraines with aura Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease. 172. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 (Normal 8-10) b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache 173. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure. b. Position the client over an overbed table prior to the procedure. c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hr prior to the procedure. Rationale: MS RM 10.0 Ch.47 p.299; Preprocedure nursing actions: Have the client void, or insert an indwelling urinary catheter. 174. A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia b. Chorioamnionitis fetal tachycardia c. Fetal anemia fetal tachycardia d. Maternal fever fetal tachycardia Rationale: MN RM 10.0 Ch.13 p.87; FHR <110/min; complications: Uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, prolonged umbilical cord compression, fetal congenital heart block, anesthetic medications, viral infection, maternal hypoglycemia, fetal heart failure, maternal hypothermia 175. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic? a. “You should make sure your partner takes the prescribed medication.” b. “Why do you think your partner’s symptoms are progressing so quickly?” c. “You did the right thing by bringing your partner in for treatment.” d. “Can you talk about what was happening with your partner at home?” 176. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver function test d. Serum creatinine Rationale: MH RM 10.0 Ch.23 p.124; Hepatotoxicity ATI Pharmacology - complication hepatotoxicity → assess baseline liver function & monitor liver function regularly 177. A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” b. “The PCA will deliver a double dose of medication when you push the button twice.” c. “You should push the button before physical activity to allow maximum pain control.” d. “You can adjust the amount of pain medication you receive by pushing on the keypad.” 178. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure. 179. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Potassium 3.2 mEq/L 3.5 - 5.0 is normal b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? a. “How long have you been hearing the voices?” b. “What are the voices telling you?” c. “Have you taken your medication today?” “I realize the voices are real to you, but I don’t hear anything.”- [Show More]

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