ATI Comprehensive Predictor Version 2 Exit Exam. Contains 150 regularly tested Questions and Answers. Best for last minute / quick exam prep.

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Predictor Version 2 1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? ... 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” Answer#2 2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? 1. “I take medication to control my blood pressure” 2. “I have had diabetes for about 10 years now” 3. “I had a knee replacement 5 years ago” 4. “I am allergic to penicillin and sulfa medications” Answer#3 3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? 1. Feed the newborn 30mL of infant formula 2. Administer low flow oxygen to the newborn 3. Wrap the newborn in a warmed blanket 4. Perform a guaiac test on the newborns stool Answer#3 4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? 1. Turn the patient from side to side at 2 PM 2. Offer pain medication to the patient at 3:30PM 3. Encourage the patient to use the incentive spirometer at 3PM 4. Cough and deep-breathe the patient at 2:30PM Answer#1 5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? 1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction. 2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight. 3. A 42 year old female who has problems with decision making who pacescontinuously, wringing her hands. 4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses. Answer#4 (photosensitivity;causes sensitivity to sun) 6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? 1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks” 2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch” 3. “Allergic skin reaction to medication experienced by patient. Started several hours ago” 4. “Vital signs stable. Patient scratching arms and chest area frequently” Answer#2 7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? 1. Schedule an in-service with the staff about emphysema 2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed 3. Tell the patient she will be well cared for in the hospital 4. Convey the patient’s concern to the nursing staff Answer#2 8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? 1. “You are 24 weeks pregnant. It is good that you came in for prenatal care” 2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby” 3. “You are 16 weeks pregnant. Let’s talk about what that means” 4. “You are 8 weeks pregnant. Are your periods usually irregular?” Answer#3 9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? 1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside. 2. Ask the client if she has swallowed the medication completely. 3. Watch the client’s behavior to see if the medication is having its desired effect.4. Observe the clients throat while she swallows several times after putting the medication in her mouth. Answer#1 10. The nurse assesses a patient 72 hours after a total joint replacement of the right hip. Which finding requires an intervention by the nurse? 1. There is a pillow between the patients legs 2. The patient’s legs are internally rotated 3. The patients hip joint is flexed at a 70 degree angle when the patient sits in the chair 4. The patient has not requested pain medication for 12 hours. Answer#2 (prevent internal or external rotation, that means se safó) 11. A client newly diagnosed with Meniere’s disease plans a trip to an amusement park with the family. The client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the following rides? 1. Roller coaster 2. Merry go round 3. Ferris wheel 4. Train Answer#4 12. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During discharge teaching, the client asks the nurse “When can I resume sexual intercourse with my wife?” it is best for the nurse to make which of the following statements? 1. “You can resume sexual activity when you feel strong enough” 2. “You can resume sexual activity when you are able to walk one block without chest pain or discomfort” 3. “You may have difficulty maintaining an erection because of your recent surgery” 4. “You should abstain from sexual activity because it may be detrimental to your recovery” Answer#2 (one block or two flights of stairs without chest pain) 13. A woman complains to the nurse about the care provided to her husband by the nursing staff the previous night. Initially, the nurse should take which of the following actions? 1. Ask the wife to voice her expectations about a solution to the problem 2. Gain consensus with the woman on the specific steps that will be taken care for her husband 3. Explain to the wife that the problems she identified will be fixed 4. Notify the wife that everything possible is being done for her husband Answer#1 14. A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the patients leg should be placed in which of the following positions? 1. One hand on the patients knee and the other hand on the patients ankle2. One hand directly above the patient’s knee and the other hand directly above the patient’s ankle 3. Both hands side by side on the patients thighs 4. One hand at the patients groin and the other hand at the patients mid-calf area Answer#2 15. The nurse in the community mental health center works with a client who is diagnosed with depression. Cognitive therapy is initiated. The nurse should take which of the following actions? 1. Assist the client to review past intellectual achievements 2. Help the client develop more positive thoughts 3. Help the client to identify the source of his depression 4. Change the client’s values and beliefs. Answer#3 Cognitive Therapy; determined that how individuals feel and behave is determined by how they think about the world and their place in it. 16. The nurse plans to perform a physical assessment of a young adult who has been deaf since birth. Although the client indicates using sign language, no interpreter is available. The nurse should take which action? 1. Face the client and speak slowly using low-pitched voice 2. Write out each question, and ask the client to write out each answer 3. Sit on the clients right side and use gestures and nonverbal clues 4. Show the client pictures of the parts of the body that will be examined Answer#2 17. A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom privileges. The nurse should take which of the following actions? 1. Obtain a bedside commode for the patient to use 2. Provide a warmed fracture bedpan for the patient to use 3. Tell the patient to breathe deeply as he walks to the bathroom 4. Ask the patient sit on the side of the bed before proceeding to the bathroom Answer#4 18. The nurse cares for a patient on the psychiatric unit with a history of drug use and poor impulse control. After the patient’s mother visits, the patient begins pacing rapidly, with arms swinging, and kicking at chair legs. The nurse should approach the patient and take which of the following actions? 1. Sit in a chair several feet away from the patient and lean forward with hands clasped together 2. Stand facing the patient with legs apart, knees locked, and weight on back leg 3. Sit in a chair next to the patient and lean back with arms folded 4. Stand facing the patient, legs together, knees locked, with weight on both legs Answer#219. The nurse observes the nursing assistant giving morning care to an elderly client who has an area of warm, reddened skin on the sacrum that does not blanch with pressure. Which action by the nursing assistant requires an intervention by the nurse? 1. The aide cleanses and then applies A and D ointment to the reddened area 2. The aide firmly massages the reddened area in a circular motion 3. The aide placed a piece of sheepskin under the patients sacrum 4. The aide positions the patient on the left side with head of the bed flat Answer#2 (Stage I pressure ulcer, do not massage can damage capillary beds and cause tissue necrosis) 20. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child? 1. Call 911, call the physician, administer EpiPen, call the parents 2. Administer the EpiPen, call 911, call the physician, call the parents 3. Call the physician, administer the EpiPen, call 911, call the parents 4. Call the parents, administer the EpiPen, call the physician Answer#2 21. A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The client states that the client’s company forced the client into early retirement. The client says that the client has been sick ever since the client stopped working. The nurse should take which of the following actions first? 1. Encourage the patient to find outlets for his job skills in a consultative or volunteer basis in the community 2. Help the client see a connection between his symptoms and emotions, while investigating each symptom 3. Tell the client that anger is an unacceptable reason to something being taken away 4. Explain to the client what retirement should be like, and contrast this with what he has experienced Answer#2 22. The nurse teaches the woman diagnosed with type 1 diabetes who is pregnant for the first time. The nurse teaches the client that as the pregnancy advances, the client may require which implementation? 1. Decreased amounts of insulin 2. Increased amounts of insulin 3. Decreased amounts of carbohydrates in her diet 4. Increased amounts of protein in her diet Answer#2 23. The nurse cares for a patient after a colon resection. The patient has a Salem sump tube connected to intermittent suction. The patient asks the nurse, “When will I be able to eat?” Which is the BEST response by the nurse? 1. “You will be given a high-calorie, high-fiber diet in a few days” 2. “You will be started on clear liquids when we hear your stomach make noises”3.”You can eat food when the NG tube is removed in about 5 to 6 days” 4. A soft diet will be given to you after you have your first bowel movement” Answer#2 24. The nurse supervises care provided for a client immediately after cardioversion. Which observation, if made by the nurse, indicates the need for an intervention? 1. A cold cloth has been applied to the paddle sites on the patient’s chest 2. The patient’s dentures remain in a cup at the bedside 3. There is an NPO sign above the patients bed 4. The oxygen the patient was receiving before the procedure remains disconnected Answer#4 25. The nurse cares for a client diagnosed with bursitis of the right shoulder. The nurse expects the client to experience which of the following? 1. Pain and numbness in the first two fingers and thumb of her right hand 2. Spasms of the right hand when a blood pressure cuff is initiated and left in place for 2 minutes 3. A constant dull ache originating in the neck and radiating down the right arm 4. Pain with extension, flexion, and internal rotation of the right arm Answer#4 26. The nurse supervises care provided by the nursing assistive personnel (NAP) to the older client in the convalescent phase after a stroke. The nurse should intervene if which action is observed? 1. The client is supine with a pillow under the head 2. The client is positioned laterally on the left side with the head of the bed flat 3. The client sits with the head of the bed elevated and the knee gatch up 4. The client is positioned laterally on the right side with the head of the bed flat Answer#1 (Brain attack or CVA; keep head unaffected side, no neck flexion or extension, head of bed flat) 27. The nurse cares for a client who is receiving amitriptyline (Elavil) 25 mg q A.M. and 100 mg at HS. The nurse understands that the medication schedule will accomplish which of the following? 1. Make therapeutic use of an expected side effect of the medication 2. Decrease interference between digestion of food and absorption of medication 3. Utilize the increased permeability of the blood-brain barrier that occurs during sleep 4. Reduce the side effects experienced by the client Answer#4 (Antidepressant, tryciclic; it has a sedative effect, administer larger dose at night it causes increased sedation) 28. An older patient falls on the floor of the psychiatric unit. To determine the cause of the fall, it is MOST important for the nurse to do which of the following? 1. Check the patients eyeglasses2. Examine the condition of the patients shoes 3. Monitor the patients’ blood pressure 4. Evaluate the floor where the patient fell Answer#4 29. The nurse instructs a prenatal class for first-time mothers. A group of mothers state they are afraid because they have heard that babies often die in their sleep before their first birthday. The mothers ask what they can do to prevent this. It is BEST for the nurse to make which of the following responses? 1. it’s important for you to focus on your pregnancy and upcoming labor and not to focus on negative things that may happen in the future 2. This does not happen very often. With good nutrition and loving care your babies should thrive and develop normally 3. Unfortunately, the cause of this condition is not definitely known, so there is little you can do to prevent this from happening 4. It’s best to position the baby on its back or side in bed. There seems to be an increase in this condition when babies are put to sleep on their stomach Answer#4 30. A client attends a support group for incest survivors at the community mental health center. The client tells the nurse, “I don’t get it. People keep telling me I talk just like my father. He’s the last person I’d want to act like!” which response by the nurse is BEST? 1. Genetically, you are like your father 2. You need to be more open-minded. I’m sure your father had some good qualities 3. Don’t worry about what everyone else is saying 4. Sometimes people unconsciously take on the characteristics of people who exert power over them Answer#4 To exert is to apply or use. Waleska=mami 31. The family of a patient admitted to the psychiatric unit 3 days ago arrives for a visit carrying two suitcases. The nurse informs the family that before they can proceed into the unit, the suitcases need to be searched. The family asks why this needs to be done. Which is the BEST response by the nurse? 1. “We know what is best for our patients” 2. “We have to make sure you’re not bringing contraband” 3. “Were just following the rules established by administration” 4. “Things that you may not think of as being harmful may be used for harm by the patient Answer#4 32. The nurse asks the nursing assistant to obtain morning vital signs on several patients. It is best for the nurse to make which of the following statements? 1. “Go check the vital signs for the patient in rooms 321 and 322. Record your findings on this sheet and then return it to me” 2. “Today you’ll check patient’s vitals. Please start with rooms 321 and 322. Be sure towrite them down” 3. “Since you have been taught to check vital signs for patients, you can take them on patients in rooms 321 and 322. Let me know your findings” 4. “The patients in room 321 and 322 need to have their morning vital signs taken. This allows us to compare the results to what the night nurse documented.” Answer#1 33. The nurse reviews basic communication skills with a new group of nursing assistants. It is BEST for the nurse to make which of the following statements? 1. “Understanding nonverbal behavior assures success in interpersonal relationships 2. “Nonverbal behavior is best considered in combination with verbal communication” 3. “There is no specific meaning for each type of nonverbal behavior” 4. “Altering nonverbal behavior is a form of manipulation” Answer#2 34. The nurse cares for a woman at 7 months gestation diagnosed with preeclampsia. The client comes to the outpatient clinic for her weekly checkup. The nurse is MOST concerned if which of the following is observed? 1. The clients temperature is 98.2 F (36.7 C) 2. The client has 2+ pitting edema of her feet 3. The client gained 1 pound since the last visit 4. The client’s skin is dry Answer#2 35. A client with a history of arterial insufficiency is seen in the outpatient clinic. The client complains to the nurse about frequent awakenings during the night because of a burning numbness in the lower extremities. The nurse should advise the client to take which of the following actions? 1. Elevate the legs on several pillows 2. Get up and walk around the room 3. Place the legs in a dependent position 4. Perform leg exercises Answer#3 (Elevate veins; dangle arteries) 36. A 31-year-old female undergoes a tubal ligation. When the patient regains consciousness, the nurse elevates the head of the bed 60 degrees. The patient says to the nurse, “I feel dizzy.” The nurse should take which of the following actions? 1. Lower the head of the bed slowly 2. Tell the patient the dizziness will go away soon 3. Turn the patient onto her left side 4. Elevate the foot of the bed Answer#1 37. The nurse completes the preoperative checklist for an elderly woman before a vaginal hysterectomy. Which assessment would require an intervention by the nurse before thepatient can go to the operating room? 1. The patient’s partial dentures are in a denture cup at the bedside 2. A religious medal is pinned to the patients hospital gown 3. The patients long hair is pulled back using hairpins 4. The patient’s wedding ring is taped in place Answer#4 38. The nurse suspects that a patient has autonomic dysreflexia (hyperreflexia). Which symptom supports the nurse’s conclusion? 1. The nurse documents that the patients pulse has changed from 82 to 98 2. The patients’ blood pressure changes from 120/80 to 150/96 3. The nurse finds that the patents reflexes are hyperactive 4. The nurse noted that the patient is becoming drowsy Answer#2 (Paroxysmal HTN, bradycardia, excessive sweating, facial flushing, nasal congestion, pilomotor responses, and headache, to bring blood pressure down, sit patient upright). 39. A newborn’s birth weight is above the 95th percentile for estimated gestational age of 39 weeks. Which term should the nurse use for documentation about this infant? 1. Post-term, LGA 2. Term, LGA 3. Preterm, SGA 4. Term, AGA Answer#2 40. The nurse completes an incident report after a complaint about nursing care from the family of a patient. Which is the BEST statement for the nurse to make? 1. “Patients daughter complained about the poor nursing care delivered to father on 6/2 and 6/3. Staff meeting held. Will check on patient more often during the night.” 2. “Patients daughter unsatisfied with care given to father on room 322, bed A on 6/2 and 6/3. No evidence of poor care or injury to patient. Plan of care for patient revised” 3. “Patients daughter stated that she found her father lying in bed wet with urine when she arrived on 0730 on 6/2 and 6/3. Skin intact on patients back, buttocks, and perineal areas. Discussed situation with nursing staff” 4. “Patients daughter voiced concern about the care provided to father by the staff on 6/2 and 6/3. Assured daughter that every effort will be made to make sure his needs are met” Answer#3 41. The nurse plans care for a patient with catatonic schizophrenia admitted to the inpatient psychiatric unit. Which is the best goal for the nurse to establish for this patient INITIALLY? 1. The patient will report to the nurse to obtain the prescribed medications 2. The patient will select the clothes to wear everyday 3. The patient will attend group meetings in the unit 4. The patient will eat at mealtime with help from the nursing assistantAnswer#4 Assess client’s physical needs FIRST, MASLOW. 42. At the bedside of a patient, the nurse is preparing for insertion of a percutaneous intravenous catheter (PICC) line. The patient holds out the left arm and says, “Please put it in this arm; I’m right handed.” Which response by the nurse is best? 1. The placement of the line won’t affect the use of your hand. The line is always placed on the left side, near the heart 2. The line needs to go into your right arm. It is important for you to move your arm while the line is in place 3. That is helpful to know. We will put the line in your left arm as you wish 4. The line won’t go into either of your arms. The line will go through a spot under your collarbone Answer#4 43. The nurse is caring for a client undergoing internal radiation therapy to treat cervical cancer. The client is receiving Osmolite half-strength at 100 ml/h per Salem sump tube. Before hanging a new container of Osmolite, the nurse aspirates the residual gastric contents. The nurse should take which of the following actions? 1. Reinsert the solution into the Salem sump tube before starting the feeding 2. Discard the solution in a lead-lined container in the patients room 3. Flush the solution down the sink in the dirty utility room 4. Replace the solution into the Salem sump tube after completing the feeding Answer#1 44. A patient diagnosed with schizophrenia approaches the nurse and reports a very sore throat, feeling hot, and experiencing aches. It is flu season, and several patients and staff have been ill. Which is the BEST action for the nurse to take? 1. Move the patient to a private room so she is less likely to infect others 2. Check to see when the patient last received her antipsychotic medication 3. Tell the patient she is probably getting the flu and will feel better in a few days 4. Notify the physician so appropriate blood work can be ordered Answer#4 45. The nurse cares for a client scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which statement, if made by the client, is MOST important for the nurse to communicate to the physician? 1. I’m so glad to be going on dialysis. Maybe now the backaches I’ve had for so long will go away 2. I know I have to be careful not to gain weight, but it is good to have my appetite back 3. The last thing I want to do is die, so I’ll put whatever I have to do to make this dialysis work 4. I like the idea of being independent with my own care. I just hope I do the procedure correctly Answer#2(Main cause of insufficient outflow is a full colon; encourage a high fiber diet because constipation can cause inflow and outflow problems.) 46. The physician order phenytoin (Dilantin) 200 mg PO daily for a teenager. It is MOST important for the nurse to include which of the following instructions when teaching the client? 1. Visit your dentist frequently 2. If you miss a dose, take an extra one the next day 3. Avoid contact sports for the next several weeks 4. Be sure to take the medication between meals Answer#1 (causes gingival hyperplasia and bleeding). 47. The nurse evaluates a patient in the emergency department for admission to the psychiatric unit. The nurse is MOST concerned if the patient’s history reveals which of the following? 1. Past episodes of violence and alcohol ingestion 2. Lack of a support system and family friction 3. Current unemployment and lack of pleasurable activities 4. Presence of a chronic illness and recent death of a parent Answer#1 (alcohol withdrawal) 48. The nurse visits a 24-hour –old newborn at home. The nurse notes the newborns axillary temperature is 96.1 F (35.6 C). The nurse notes the newborn is pink with a small amount of jaundice on the nose. The mother states that the newborn has been spitting up most feedings and has been “too sleepy to eat” since early that morning. The newborn does not awake during the nurse’s exam and has decreased muscle tone. The nurse should prepare implementations for which medical diagnosis? 1. Erythroblastosis fetalis 2. Neonatal sepsis 3. Physiologic jaundice 4. Hypoglycemia Answer#2 (newborns decrease temperature with infection, pallor, anorexia, poor feeding) 49. The nurse expects a ventilator-perfusion (V/Q) scan to be ordered for which client? 1. A client diagnosed with asthma 2. A client diagnosed with emphysema 3. A client diagnosed with cystic fibrosis 4. A client diagnosed with a pulmonary embolism Answer#4 50. If reported in a 24-hour diet recall, which action is the BEST indication that the client understands the nurse’s teaching regarding a high-fiber diet? 1. The client sprinkles granola over vanilla ice cream for dessert 2. The client munches on pork rinds between meals 3. The client peels and mashes potatoes with whole milk 4. The client removes skin from the chicken before cooking itAnswer#1 51. The physician’s office nurse checks the incision of a client 48 hours after a hernia repair. Which finding, if observed by the nurse, is unexpected? 1. There is slight swelling under each individual suture 2. There is crusting around the incision line 3. The incision line is bright red 4. The incision line is approximated Answer#3 52. An agitated patient grabs another patient’s hair from behind and begins to pull on it. INITIALLY, the nurse should take which of the following actions? 1. Pull the other patients head and body away from the patient that is pulling the hair 2. Stabilize the patient’s hand against the other patient’s head 3. Twist the patient’s fingers off the other patient’s head 4. Quickly get help to separate the two patients Answer#2 53. The nurse cares for a client after abdominal surgery for a gunshot wound. The large abdominal dressing is to be changed every 4 hours. While changing the dressing, the nurse notes that the area surrounding the dressing is edematous and red. The nurse should take which of the following actions? 1. Apply tape to the dressing lightly 2. Allow the wound to air-dry 3. Use Montgomery straps 4. Apply a tubular elastic dressing Answer#3 For frequent dressing changes to prevent skin irritation from frequent tape removal. 54. A patient is admitted to the psychiatric unit with depression and suicidal ideation. Which action is MOST important for the nurse to take? 1. Instruct the patient to check in with the staff every 15 minutes, and encourage her to comply 2. Ask the staff to assess the patient’s suicidal thoughts every 30 minutes 3. Observe the patient every 15 minutes, and add several unscheduled observations 4. Establish a schedule for the staff to check the patient every 15 minutes Answer#3 55. A client diagnosed with malnutrition secondary to AIDS prepares for total parenteral nutrition (TPN). The client says to the nurse “I know glucose is sugar. I can’t see how giving me sugar is going to help me.” Which is the BEST response by the nurse? 1. This will give you enough calories so that your body won’t have to use protein stores for energy 2. It will all be explained to you when the dietician comes to see you and talks about how TPN works 3. Glucose is the building block of protein, and your disease has caused a serious deficitof protein in your body 4. The doctor knows what to do to help your condition Answer#1 56. The nurse identifies which of the following general environments as BEST for a client diagnosed with depression? 1. An environment that offers structure and support 2. An environment that is cheerful and stimulating 3. An environment that offers privacy and autonomy 4. An environment that is complex and challenging Answer#1 57. The nurse admits the woman in active labor to the birthing center. To monitor the client’s uterine contractions electronically, the nurse should place tocodynamometer (pressure transducer) in which location? 1. Where contractions are felt strong 2. Over the back of the fetus 3. Over the lower uterine segment 4. Over the uterine fundus Answer#4 58. The clinic nurse plans to use an interpreter to communicate with a client while performing a physical assessment. Before beginning the examination, the nurse should instruct the interpreter to do which action? 1. Explain everything said by the nurse to the client 2. Use as few words as possible to communicate with the client 3. Communicate the concepts of the nurse’s questions to the client 4. Summarize the nurse’s statements and questions Answer#1 The nurse talks to the client and the interpreter talks to the client too. No Nurse, interpreter communication. 59. A woman who is HIV-positive just delivered a 6 lb, 13 oz baby. The woman expresses concern to the nurse that her newborn baby will be HIV-positive. The nurse’s response should be based on which of the following? 1. The mother is in no condition to process any additional information because she is exhausted from the labor and delivery process 2. Breastfeeding should be encouraged because it gives the infant added protection against the virus 3. A newborns immune system is more resistant to HIV than an adult’s immune system 4. Testing is inconclusive until 12 to 15 months of age because antibodies are present in the newborns system Answer#460. A client comes to the outpatient clinic for allergy shots. After administering the injection, the nurse should take which of the following actions? 1. Instruct the client stay in the clinic waiting room for at least 30 minutes 2. Ask the client to set up an appointment for the next series of allergy shots 3. Discuss with the client the reason for administering allergy shots 4. Invite the client to watch a 15-minute video about the treatment of allergies Answer#1 61. An older client is brought to the emergency department by the client’s spouse. The client complains of severe headache. The nurse notes the client has slurred speech, as well as facial droop and weak hand grip on the left side. The nurse expects the physician to order which of the following tests? 1. Lumbar puncture 2. CT scan 3. Myelogram 4. Endoscopy Answer#2 To diagnose CVA(stroke), or brain attack. S/S: slow pulse, HTN, Headache, nausea, vomiting, facial drooping, visual changes, nuchal rigidity, ataxia, dysarthria, dysphagia. 62. The nurse administers digoxin (Lanoxin) and theophylline (Accurbron) to an elderly client through a gastroscopy tube. After giving the medications, the nurse should take which of the following actions? 1. Flush the tubing with room-temperature tap water 2. Aspirate the stomach contents and check for residual 3. Elevate the head of the bed 45 degrees 4. Check the patient’s respirations and apical heart rate Answer#4 63. After several months of radiation therapy, a client with lung cancer refuses to continue with treatment. It is MOST important for the nurse to take which of the following actions? 1. Ensure that the client’s family knows that he has made statements about discontinuing treatment 2. Encourage the client to change his mind by telling him that some clients do get well 3. Ask the client what it is about radiation therapy that makes him want to discontinue treatment 4. Record the client’s statements, without judgment in his chart Answer#3 64. The nurse cares for a client immediately after a carotid endarterectomy. It is MOST important for the nurse to have which of the following equipment at the bedside? 1. Crash cart 2. 4x4s and sterile gloves3. Suction machine 4. Tracheostomy set Answer#1 carotid endarterectomy: to remove plaque from artery 65. The nurse cares for a client undergoing radiation therapy of the right breast and axilla after lumpectomy. Which statement, if made by the client, indicates to the nurse that teaching is effective? 1/. I should apply body cream to the area to keep it lubricated 2. I should wear a loose fitting bra made of 100% cotton to prevent irritation 3. I will apply cold compresses to the area to prevent swelling 4. I will expose the area to air and sun once daily to help it heal Answer#2 66. The nurse cares for patient on the psychiatric unit. A patient becomes verbally abusive and begins swinging arms and kicking anyone who approaches the patient. An order is obtained for mechanical restraints. The nursing team is able to get the patient to the floor and under their physical control. Before being lifted and taken to the patient’s room for restraint application, the patient’s body relaxes and the patient says “I’m sorry. Ill cooperates. I’ll walk to my room. Please don’t hold me down anymore.” Which response by the nurse is BEST? 1. Negotiate an agreement with the patient for nonaggressive behavior 2. Ask the patient if he is sincere 3. Tell the patient that he will be transported as planned 4. Instruct the staff to release their hold on the patient Answer#3 67. The nurse cares for a 3,000 gram newborn who receives ampicillin (Omnipen). The dosage is 100 mg/kg/day with doses divided, and it is administered every 12 hours. How many milligrams should the nurse administer to the newborn every 12 hours? 1. 300 mg 2. 100 mg 3. 15 mg 4. 150 mg Answer#4 100 mg *3 kg=300 mg/2=150 mg 68. The registered nurse leads a patient care team that consists of one LPN/LVN and one nursing assistant. It is considered appropriate for the RN to assign which of the following patient to the LPN/LVN? 1. A 30 year old quadriplegic and ventilator dependent man admitted for skin grafting 2. A 47 year old woman transferred from the intensive care unit 3 hours ago after a coronary artery bypass graft (CABG) 3. A 79 year old man diagnosed with Alzheimer’s disease who is rubbing his chest and has a respiratory rate of 224. A 64 year old woman diagnosed with cirrhosis of the liver who vomited bright red blood two hours ago Answer#3 69. The registered nurse delegates insertion of a Foley catheter to an LPN/LVN. Before the LPN/LVN begins the procedure, it is MOST important for the registered nurse to take which of the following actions? 1. Verify that the LPN/LVN is competent to insert a Foley catheter 2. Demonstrate to the LPN/LVN how to perform a sterile catheterization 3. Ask the patient’s permission for the LPN/LVN to perform the procedure 4. Show confidence in the LPN/LVN’s ability to perform the procedure Answer#3 70. A nurse has lunch in the hospital cafeteria with a nursing assistant from the unit. The nurse asks how the nursing assistant is doing, knowing that the nursing assistant is in nursing school, has three young children, works 30 hours a week, and looks worried. The nursing assistant replies, “I’m okay, just stressed out with finals.” The BEST response by the nurse is which of the following? 1. You’ll be fine. You grades have always been good 2. Maybe you shouldn’t try to do so much next semester 3. Sounds like you feel you’re managing most things fine, but will be relieved when finals are over 4. I know what you mean. Nursing school is harder now than when I went to school Answer#3 71. The nurse administers fentanyl 100 mcg IM to a patient after an appendectomy. After administering the medication, is most important for the nurse to take which of the following actions? 1. Ask the patients family to wait in the hall until the medication takes effect 2. Position the patient on his right side with left leg extended 3. Elevate the head of the patient’s bed 30 to 45 degrees 4. Turn the television off and darken the patient’s room Answer#3 Opioid analgesic: Fentanyl (sublimaze) can cause respiratory depression, dizziness, drowsiness, hypotension, urinary retention, fetal necrosis and distress. 72. After a patient receives naloxone hydrochloride (Narcan) 0.2 mg IV, which of the following actions is essential for the nurse to perform? 1. Encourage fluids 2. Decrease external stimuli 3/. Place the patient in lateral recumbent position 4. Monitor the patient’s rate of respirations Answer#4 73. A client who is 5 feet 1 inch tall and 115 pounds recovers from an abdominal perineal resection. The nurse notes that when the head of the bed is elevated, the client slips downin bed. The nurse should take which of the following actions? 1. Move the patient up in bed frequently and keep firm pillows between the patient’s feet and the foot of the bed 2. Instruct the patient to pull up in bed using the side rails after sliding to the foot of the bed 3. Raise the knee gatch and the side rails, and place the call light within reach 4. Lower the head of the bed and place the patient on back, keeping both legs extended Answer#3 74. A 36 hour old newborn is receiving phototherapy. The infant’s mother asks why this is being done. Which response by the nurse is BEST? 1. This treatment changes the nature of circulating anti bodies in the body 2. This treatment prevents the formation of antibodies in the body 3. This treatment converts bilirubin to a form that can be removed from the body [Show More]

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