ATI comprehensive practice B

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A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? - ANSWER hemoglobin 14.9... g/dL a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first? - ANSWER a middle adult client who has unstable vital signs a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse delegate to an assistive personnel? - ANSWER measure the client's daily weight a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer? - ANSWER 18 g a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint? - ANSWER Moving the leg away from the midline of the body (off to the side, not to the front) a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect? - ANSWER tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect? - ANSWER nuchal rigidity also weight loss a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? - ANSWER auscultate the apical pulse at least 1 min a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to perform which of the following actions? - ANSWER instruct the client to avoid coughing during the procedure a nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse should identify which of the following findings as a potential indication of child sexual abuse? - ANSWER the child exhibits discomfort while walking a nurse is preparing to teach about dietary management to a client who has crohn's disease and an enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in their diet? - ANSWER fiber - reduce diarrhea and inflammation a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following a total knee arthroplasty. which of the following actions should the nurse take? - ANSWER Turn off the CPM machine during mealtime promote client comfort and dietary intake 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? - ANSWER radial vein of the inner arm a nurse is developing a client education program about osteoporosis for older adult clients. the nurse should include which of the following variables as a risk factor for osteoporosis? - ANSWER sedentary lifestyle also, small framed body with a thin build, estrogen deficiency a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk and extremities. which of the following interventions should the nurse identify as the priority? - ANSWER initiate transmission based precautions a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the following actions should the nurse take first? - ANSWER change the position of the client a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of the following instructions should the nurse include? - ANSWER empty the appliance when it is one third to one half full a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? - ANSWER sodium 148 mEq/L a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive personnel? - ANSWER Arrange the lunch tray for a client who has a hip fracture a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take? - ANSWER instruct the client to void a nurse has received change of shift report on four assigned clients. for which of the following clients should the nurse intervene to prevent a potential food and medication interaction? - ANSWER a client who is receiving an MAOI and is requesting a cheeseburger for dinner a nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. which of the following actions should the nurse plan to take? - ANSWER allow for frequent rest periods throughout the day a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary output. which of the following actions should the nurse take? - ANSWER irrigate the catheter with 0.9% sodium chloride irrigation a nurse is assessing a client who has COPD. which of the following findings should the nurse expect? - ANSWER pH 7.31 a nurse in a community center is providing an educational session to a group of client about ovarian cancer. which of the following manifestations of ovarian cancer should the nurse include in the teaching? - ANSWER abdominal bloating increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary frequency of urgency a nurse is caring for a client who has active tuberculosis TB. which of the following actions should the nurse plan to take to prevent the transmission of the disease? - ANSWER Have the client wear a surgical mask while being transported outside the room a nurse is caring for a group of clients. which of the following clients should the nurse attend to first? - ANSWER an older adult client who is anxious and attempting to pull out an IV line an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed. for which of the following situations should the nurse intervene? - ANSWER The LPN and the AP grasp the client under his arms to lift him up in bed a nurse is preparing to administer insulin to a client via a pen device. which of the following actions should the nurse take? - ANSWER hold the insulin pen device perpendicular to the client's skin to inject the medication a nurse is caring for a client who has immunosuppression and a continuous IV infusion. which of the following actions should the nurse take? - ANSWER monitor the client's mouth every 8 hours a nurse is providing teaching about advance directives to a middle adult client. which of the following client responses indicates an understanding of the teaching? - ANSWER "I can designate my partner as my health care surrogate" a nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. which of the following medications should the nurse expect to administer? - ANSWER oxytocin a nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? - ANSWER seeks input from the other nurses a nurse is assigning task roles for a group of clients in a community mental health clinic. which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? - ANSWER noting the progress of the group toward assigned goals a nurse is creating a plan of care for a newly admitted child. which of the following actions should the nurse include in the plan? - ANSWER Administer high dose antibiotic therapy cystic fibrosis kid with lung infection 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? - ANSWER use a protective cover on the scale when weighing the infant a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the nurse's priority? - ANSWER assist with deep breathing and coughing 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? - ANSWER a client who channels their energy into a new hobby following the loss of their job a nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. which of the following actions should the nurse take? - ANSWER aspirate contents from the tube and verify the pH level an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions? - ANSWER a client who is at 33 weeks of gestation and has severe gestational hypertension a nurse is providing discharge teaching to a client who is to receive home oxygen therapy. which of the following instructions should the nurse include in the teaching? - ANSWER wear clothing made with cotton fabrics while oxygen is in use use water soluble lubricant not petroleum based lubricant a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place a new prescription for crutches. The client is non weight bearing for 6 weeks. which of the following instructions should the nurse include in the teaching? - ANSWER use a three point gait a nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. which of the following information should the nurse include in the change of shift report? - ANSWER The time of the client's last dose of pain medication a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal VP shunt. Which of the following findings should the nurse report to the provider? - ANSWER irritability when being held - increased intracranial pressure a nurse is caring for a client who has a prescription for chlorpromazine. which of the following findings should the nurse identify as an indication that the medication is effective? - ANSWER decreased hallucinations a nurse is providing teaching about lithium to a client who has bipolar disorder. which of the following statements should the nurse include in the teaching? - ANSWER "Notify your provider if you experience increased thirst" a nurse is caring for a client who has a fecal impaction. which of the following actions should the nurse take when digitally evacuating the stool? - ANSWER insert a lubricated gloved finger and advance along the rectal wall a nurse is planning to delegate client care tasks to an assistive personnel AP. which of the following tasks should the nurse plan to delegate to the AP? - ANSWER perform gastrostomy feedings through a client's established gastrostomy tube a nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. which of the following methods should the nurse include in the teaching? - ANSWER delegate non nursing tasks to ancillary staff a nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. which of the following observations should the nurse identify as an indication for potential violence? - ANSWER The client is pacing around the chair in which their partner is sitting a nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy. The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." which of the following responses should the nurse make? - ANSWER "You have the right to change your mind about this procedure at any time" A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? - ANSWER Agency for healthcare research and quality a nurse is assessing a newborn following a vaginal delivery. which of the following findings should the nurse report to the provider? - ANSWER Nasal flaring A charge nurse is speaking with the partner of a client. the partner states that the client is not receiving adequate care. which of the following actions should the charge nurse take first to resolve the situation? - ANSWER ask the partner to list specific concerns a nurse is providing information to a client immediately before his scheduled Romberg test. which of the following statements should the nurse make? - ANSWER "I will be checking you once with your eyes open and once with them closed" A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. which of the following statements by the client indicates an understanding of the teaching? - ANSWER "I will wear a supportive bra overnight" a nurse is caring for a client who is taking valproic acid for seizure control. for which of the following adverse effects should the nurse monitor and report? - ANSWER jaundice a nurse is providing discharge instructions about newborn care to a client who is postpartum. which of the following statements indicates to the nurse that the client understands the teaching? select all - ANSWER "I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth then in her nose" A nurse on a mental health unit is conducting a mental status examination MSE on a newly admitted client. which of the following components of the MSE is the priority for the nurse to assess? - ANSWER ideas of self-harm a nurse is preparing to administer lactated ringers 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round to nearest whole number - ANSWER 13 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? - ANSWER irritability a nurse is providing teaching to a client who is scheduled for electroconvulsive therapy ECT. The nurse should inform the client that which of the following findings is an adverse effect of ECT? - ANSWER short term memory loss a charge nurse notices that one of the nurses on the shift frequently violates unit polices by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? - ANSWER "I would like to talk to you about the unit polices regarding break time" A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. which of the following findings should the nurse expect? - ANSWER urine specific gravity 1.052 a nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. which of the following laboratory values indicates that the client needs additional nutrients added to the feedings? - ANSWER albumin 2.8g/dL should be 3.5 to 5.0 A nurse is conducting group therapy with clients who have breast cancer. the nurse should recognize which of the following statements by a client as an example of altruism? - ANSWER "I told my doctor that I would like to start a support group for other women who are sick in my community" - reaching out and helping others a nurse is providing dietary teaching to a client who has a new prescription for phenelzine. which of the following food recommendations should the nurse make? select all - ANSWER broccoli yogurt cream cheese a nurse is assessing a client for compartment syndrome. which of the following findings should the nurse expect? - ANSWER edema a nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? - ANSWER ensure that the client understands the medication regimen a nurse at an urgent care clinic assessing a client who reports impaired vision in one eye. which of the following reports by the client should indicate to the nurse that the client has a detached retina? - ANSWER floating dark spots a nurse on a medical surgical unit is assessing a client who has had a stroke. for which of the following findings should the nurse initiate a referral for occupational therapy? - ANSWER difficulty performing ADL's a nurse is assessing a client following a colonoscopy. which of the following findings should indicate to the nurse that the client is hemorrhaging? - ANSWER rapid decrease in blood pressure a nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end stage kidney disease. the donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day" which of the following responses should the nurse make? - ANSWER "You're afraid that your other kidney will fail at some point after the organ donation" a nurse is assessing a client who has pulmonary edema. which of the following findings should the nurse expect? - ANSWER pink frothy sputum A nurse administers an incorrect dose of medication to a client. the nurse recognizes the error immediately and completes an incident report. which of the following facts related to the incident should the nurse document in the client's medical record? - ANSWER time the medication was given 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? - ANSWER check the client's oxygen saturation level a nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. the nurse suspects physical abuse. which of the following actions should the nurse take? - ANSWER contact child protective services 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? - ANSWER C, the abdomen for distention and visible peristalsis a nurse is admitting a client to the psychiatric unit after attempting suicide. the client states "My family does not care whether I live or die", which of the following responses should the nurse make? - ANSWER "how does this make you feel" a nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. which of the following instructions should the nurse include in the teaching? select all - ANSWER "shake the medication bottle well before each dose is given" "store the medication in the refrigerator" "report diarrhea to the provider immediately" a nurse on a medical surgical unit is caring for a client who has a new diagnosis of terminal cancer. the client tells the nurse that they would like to go home to be with family and loved ones. which of the following actions should the nurse take? - ANSWER make a referral for social services a nurse is assessing a client who has a chest tube. which of the following findings should the nurse expect? - ANSWER occlusive dressing drainage should be less than 70 ml/hr continuous bubbling in the water seal chamber indicates an air leak a nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. the clients family tells the nurse they are concerned about the level of care the client will receive. which of the following actions should the nurse take? - ANSWER facilitate an interdisciplinary conference at the new facility for the family a nurse is assessing a client who has major depressive disorder and is taking amitriptyline. which of the following findings should the nurse identify as an adverse effect of the medication? - ANSWER blurred vision a charge nurse is providing an educational session about infection control for a group of staff nurses. which of the following statements by one of the staff nurses indicates an understandings of isolation precautions? - ANSWER "A client who requires airborne precautions should be placed in a negative pressure airflow room" a nurse is preparing to administer a blood transfusion to a client. which of the following procedures should the nurse follow to ensure proper client identification? - ANSWER verify the client and blood product information with another licensed nurse a nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. the client shows the nurse multiple superficial self inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders. - ANSWER borderline - emotionally unstable, troubled interpersonal relationships, often engage ion harmful behaviors a nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. which of the following prescriptions should the nurse clarify with the provider? - ANSWER apply a cold pack to the clients ankle for 30 min every hour - type 1 diabetes is a contraindication for cold therapy a nurse is teaching about adverse effects with a client who is starting to take captopril. which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? - ANSWER cough - due to build up of bradykinin in the lungs a nurse is reviewing the ABG values of a client. The client has a pH of 7.2, psco2 of 60 mm Hg, nd HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid base imbalances? - ANSWER respiratory acidosis a nurse in a providers office is assessing an adolescent who has been taking ibuprofen for 6 months to treatjuvenile idiopathic arthritis. which of the following questions should the nurse ask to assess for adverse effect of this medication? - ANSWER "Have you had any stomach pain or bloody stools? 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? - ANSWER a 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain a nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. which of the following actions should the nurse take? - ANSWER implement fall precautions for the client - orthostatic hypotension and dizziness a nurse is assessing a client who has decreased visual acuity due to cataracts. the nurse should identify that which of the following physiological changes is the cause for the client's visual loss? - ANSWER increased opacity of the lens a nurse is caring for a client following a vacuum assisted birth. the nurse should monitor the client for which of the following complications related to vacuum assisted birth? - ANSWER cervical laceration a nurse is updating the plan of care for a client who is 48 hr post operative following a laryngectomy and is unable to speak. which of the following actions should the nurse plan to take first? - ANSWER determine the clients reading skills a nurse is caring for a school age child who has dehydration and is receiving an oral rehydration solution. which of the following laboratory results indicates that the treatment regimen is effective - ANSWER serum sodium 138 mEq/L a school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. upon arrival at the playground, which of the following actions should the nurse take first? - ANSWER survey the scene for potential hazards to staff and children a nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. the nurse is unable to locate members of the clients family to obtain consent. which of the following actions should the nurse take? - ANSWER proceed with provision of medical care a nurse is caring for a school age child who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests? - ANSWER serum liver enzyme levels a nurse manager is preparing to teach a group of newly licensed nurses about effective time management. which of the following steps of the time management process should the nurse manager include as the priority? - ANSWER making a list of activities to complete a nurse is caring for a client who has pulmonary embolism. the client is receiving heparin via continuous IVinfusion at 1,200 units/hr and warfarin 5 mg PO daily. the morning laboratory values for the client are aPTT 98 seconds and INR 1.8. which of the following actions should the nurse take? - ANSWER withhold the heparin infusion a nurse is providing teaching to a school age child who has asthma about using albuterol metered dose inhaler. which of the following instructions should the nurse include? - ANSWER take the medication 15 min before playing sports a home health nurse is evaluating a school age child who has cystic fibrosis. the nurse should initiate a request for high frequency chest compression vest in response to which of the following parent statements? - ANSWER "my child has only a small amount of mucus after percussion therapy" a nurse is planning care for a client who is receiving chemotherapy and has neutropenia. which of the following interventions should the nurse include in the plan? - ANSWER avoid including raw fruits in the clients diet a nurse is caring for a client who is in the fourth stage of labor and is reviewing oxytocin via continuous IV infusion. which of the following assessments is the nurse's priority? - ANSWER amount of vaginal bleeding a nurse is caring for a client who is in the resuscitation phase of burn injury. which of the following findings should the nurse expect? - ANSWER hyponatremia hyperkalemia a nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. which of the following information should the nurse include in the teaching? - ANSWER "I will need to measure your weight daily" a nurse is assessing a client who has bipolar disorder. which of the following alterations in speech is the client using? - ANSWER flight of ideas - changing topics suddenly a home health nurse is caring for a group of older adult clients. the nurse should initiate a referral to the program of all inclusive care for the elderly PACE for which of the following clients? - ANSWER a client whose caregiver requests adult day care services PACE provides adult day care services along with in home assessments and supportive services 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? - ANSWER a client who was abused as a child describes the abuse as if it happened to someone else [Show More]

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