ATI Comprehensive Test B

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ATI Comprehensive Test B A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of the following actions is the priority? A. Assess fluid intake every 24 hours B. Ambulate th... ree times a day C. Assist with deep breathing and coughing D. Monitor the incision site for findings of infection - ✔✔C The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia. A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? A. I have experienced physical discomfort when intimate with my partner since my diagnosis B. I wish other women would stop socializing with my partner C. I told my doctor that I would like to start a support group for other women who are sick in my community D. I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness - ✔✔C This statement indicates that the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept. A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the clients IV site every 8 hours B. Check the clients WBC count every 48 hours C. Monitor the clients mouth every 8 hours D. Change the clients IV tubing every 48 hours - ✔✔C A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? A. Eyes area B. Chest area C. Lower abdominal area - ✔✔C Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems with passing stool. This is present at birth (congenital) as a result of missing nerve cells in the muscle of the baby's colon A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers D. A client states that they did not get a job promotion because the boss did not like them - ✔✔B A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. irritability B. increased urination C. vomiting D. facial flushing - ✔✔A A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? A. A client who transfers their anger about their job onto their family and then apologizes B. A client who misses provider appointments because they say they are too busy C. A client who channels their energy into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place for him at dinner each night - ✔✔C The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby. A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. A hospice nurse will come to the house each time our mother needs pain medication C. Now that my mother is receiving hospice services, we will not be able to get respite care D. Hospice care focuses on arranging treatment that will prolong our mother's life - ✔✔A Hospice care includes bereavement services after a family member's death. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors maintain a distance of 1.8m (6 feet) from the client C. Restrict fresh flowers from the clients room D. Assign the client to a private room with negative air pressure - ✔✔D A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? A. Limit your fat intake for 72 hours before the test B. You will need to fast the night before the test C. We will collect a urine sample the day after testing D. A blood sample will be collected every 15 minutes during the test - ✔✔B A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? A. A 6month old infant who has croup and an O2 saturation of 92% on room air B. A 15 year old adolescent who is 2 hour postop following an open reduction and internal fixation of the left ankle and is requesting pain medication C. A 3 year old toddler who has gastroenteritis, moderate dehydration, and had 2 loose bowel movements over the past 24 hours D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain. - ✔✔D A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? A. Diarrhea B. Urinary retention C. Purulent discharge D. Abdominal bloating - ✔✔D A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? A. Check the clients temperature B. Prepare to administer acetylcysteine to the client C. Place the client in the Trendelenburg position D. Check the client's oxygen saturation level - ✔✔D Restlessness and lightheadedness are indications of hypoxia. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A. An older adult client who reports constipation of 4 days B. A preschooler who has a skin rash C. An adolescent who has a closed fracture D. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? - ✔✔D A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weightbearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? A. Adjust the crutches for comfort as needed B. Use a three-point gait. C. Wear leather soled shoes D. Advance the affected leg first when walking upstairs - ✔✔B A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand - ✔✔A A nurse is planning to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP? A. Perform gastrostomy feedings through a clients established gastrostomy tube B. Administer glycerin suppository to a client who is constipated C. Provide instructions about client care to a family member over the telephone D. Teach a client how to measure their own blood pressure - ✔✔A A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? A. Dry the newborn immediately after birth B. Maintain an ambient room temp of 24 celcius C. Use a protective cover on the scale when weighing the infant [Show More]

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