ATI Exam. Document contains 199 Questions and Answers. Well Organised reading format for quick exam preparation.

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ATI Exam 199 Terms in this set A nurse is caring for a client who has severe hyperthermia. Which of the following actions should the nurse take. A. heat the clients body by using external rewa... rming devices. B. contact a specialized team to place the client on cardiopulmonary bypass. A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include. a. rinse the childs hair each day with cup of vinegar b. soak combs and brushes in hot water for 5 min c. Comb the child's hair daily with an extra fine-tooth comb A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? A. increased urination B. sweating c. dizziness a nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make? A. place child in cool bath for 20min twice a day B. avoid giving aspirin C. give 8 doses of acetaminophen in 24hrs. A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? A. bmi of 26 or above B. frequent weight bearing exercises C. hip fracture 6 months ago A nurse is caring for a client who is experiencing an asthma attack. which of the following procedures should the nurse use to assess the client's respiratory status? A. peak expiratory flow meter testing B. spirometer C. pulmonary function testing A nurse is assessing an 18- month toddler who has gastroenteritis with dehydration. The toddler is able to consume 3ml of oral rehydration solution every 5min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? A. bumetanide B. ondansetron C. Loperamide a nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend? A. one small orange B. one small apple C. one half cup of pineapples A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? A. observe the client perform the incentive spirometry B. administer the influenza vaccine C. provide teaching about antibiotic therapy. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A. brown discoloration of the lower extremities B. superficial ulcer on the medial aspect of the ankle C. dependent rubor D. telangiectasias . a nurse is assessing a client who is receiving intravenous medications. which of the following findings should the nurse identify as a manifestation of respiratory acidosis? A. confusion B. flushed, moist skin C. bounding pulses a nurse is reviewing the megastrol medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? A. megastrol B. Ondansetron C. famotidine a nurse is providing teaching c. give a second injection if the first fails to reverse to the parent of a school age your child's symptoms. child who has severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include? A. administer the medication into your abdomen B. expect your child to sleep for several hours after recieving the medication C. give a second injection if the first fails to reverse your child's symptoms. a nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? A. inhale the second puff of cromolyn 2min after the first B. use the cromolyn following exercise if shortness of breath occurs C. Use the albuterol prior to planned exercise a nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? A. cold intolerance B. diaphoresis C. weight loss A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by mRSA. which of the following client statements indicates an understanding of the teaching? A. i will soak in a bathtub one- forth full of water with one- half cup of bleach B. i will wash clothes in cold water and detergent C. i will throw away my razor after using it three times a nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse instruct the parent to report to the provider? A. swollen cervical lymph nodes B. exudate on tonsils C. onset of abdominal pain a nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? A. lithium carbonate B. escitalopram C. methylphenidate A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? A. slowly institute rewarming of the affected areas B. place the affected areas of frostbite in a warm water bath C. massage the affected areas place the affected areas of frostbite in a warm water bath a nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor. A. flushed dry skin B. seizures C. hyperreflexia A nurse is providing discharge B teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A. Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby B. dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet. a nurse is assessing a client for manifestations of left- sided heart failure. which of the following findings should the nurse expect? A. weight gain B. enlarged liver C. distended abdomen D. cool extremities cool extremities a nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect? A. pain with palpation to the substernal notch B. urinary burning C. ecchymosis over the flank a nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? A. wear open-toe shoes to allow air B. file your toenails straight across to prevent ingrown toenails C. apply a thin layer of lotion between toes twice daily a hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make? A. youre sad now, but grief will pass eventually B. you should attend a grief support group to see how others cope with loss C. what are some of the best times with your partner that you remember a nurse is planning discharge teaching for the parent of a newborn. which of the following information should the nurse include? A. cover your newborn with a light blanket while she is sleeping B. Do not bathe your newborn immediately after she eats C. place your newborn in a crib with bumper pads a nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? a. intake of fluid is less than output over the past 2 days B. 1 kg weight gain over the past 2 days C. blood glucose 206 mg/dl a nurse is caring for a client Stay with client until manifestations subside who is experiencing a panic - ensures safety and conveys concern to the client attack. which of the following actions should the nurse take? A. distract the client by having him complete a puzzle B. encourage the client to take a deep breath every 2 seconds C. Stay with client until manifestations subside a nurse is assessing for elevated aspartate aminotransferase levels adverse medication reactions - liver injury with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? A. elevated aspartate aminotransferase (AST) levels B. decreased skin turgor C. elevated WBC count D. decreased audio acuity a nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching? A. i will drink one and a half liters of fluids every day B. I will get the pneumonia vaccine yearly C. i will wash hands whenever i come home from the grocery store a nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process. A. persistent feelings of hopelessness B. loss of self-esteem c. feeling anger toward family members a nurse is developing a plan elevate the client's arm above the heart of care for a client who is 1 hr - minimizes swelling of the surgical site and postoperative following open decreases discomfort carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan. A. elevate the client's arm above the heart B. apply heat to the clients surgical site c. instruct client to avoid moving their fingers d. monitor the clients ability to complete wrist range of motion A nurse is providing teaching I should wash my child's bed linens and clothing in home care with the parent of hot water and detergent. a child who has scabies. -very contagious from mites, rash takes 2 to 3 Which of the following weeks to heal, leave cream on child 8 to 14 hrs statements by the parent then bathe indicates an understanding of the teaching? A. i should apply the cream only to the areas where there is a rash B. i should wash my child's bed linens and clothing in hot water and detergent. C. i should expect my child rash to go away within 72hrs after starting treatment. A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. chest x ray results show increased lung space B. sputum culture show gram positive bacteria C. SPO2 level is 88% sputum culture show gram positive bacteria a nurse is assessing a client for manifestations of right- sided heart failure. which of the following findings should the nurse expect? A. jugular vein distention B. fatigue C. angina D. hacking cough jugular vein distention -fatigue, angina, hacking cough are all manifestations of left side hrt failure a nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching? A. decrease your calcium intake B. you should consume at least 2400 mg of salt per day C. limit the amount of spinach in your diet a nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching? A. a black bean burger on a whole grain bun B. oatmeal with whole milk C. a baked potato with butter A a nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching. A. i'll wash my feet every day with soap and lukewarm water B. its okay for me to go barefoot in the house, but not outside c. ill soak my feet every evening before bed a nurse is planning care for a the client reports coughing and a change of voice client following collection of whenever he eats admission date. Which of the -m following findings should the nurse identify as the priority client need? A. the client requests to see a priest for spiritual guidance B. the client reports coughing and a change of voice whenever he eats C. the client reports pain immediately following physical therapy a nurse is reviewing the lab tall t waves results of a client who is - a manifestation of hyperkalemia, effects scheduled for surgery and myocardium and impacts the client's surgical risk notes a potassium level of 6 meq/L. which of the following ECG findings should the nurse expect? A. heart rate 64/min B. tall t waves C. shortened pr interval a nurse is teaching about clonazepam with a young - suicidal thoughts adult female client who has generalized anxiety disorder. which of the following statements should the nurse include in the teaching? a. you can safely continue taking this medication if you become pregnant. b. this medication could cause you to have thoughts of self- harm c. you should take this medication 1 hour before eating a nurse is planning discharge Audi ⁹9 teaching for the guardian of a -monitor for infection, drainage, redness, and child who had a cardiac swelling catheterization. Which of the following instructions should the nurse include? A. monitor the site daily for drainage b. leave the pressure dressing on for 48 hr. C. administer aspirin if the child reports pain a nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? -abdominal distention - flank pain - hypervolemia - vomiting - hyperactive bowel sounds a nurse is preparing to administer medication to a client who has a hx of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? A. ginkgo biloba B. digoxin C. hydrochlorothiazide -a diuretic, and hypertension a nurse is assessing a client in the triage room of an emergency department. "reports weight loss, lethargy, and night sweats over the last 3 weeks." A. perform rapid influenza testing B. place a surgical mask on the client C. request a prescription for a single dose short-acting insulin. a nurse is assessing an infant enlarged postauricular lymph nodes whose guardian reports, "my - baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of following manifestations should the nurse expect for an infant who might have otitis media? A. enlarged postauricular lymph nodes B. Increased flatulence with constipation C. indicates a desire to suck more frequently A nurse is providing teaching i should avoid using the vacuum cleaner for for client following cataract several weeks. surgery. Which of the - following statements indicates to the nurse that the client understands the teaching? A. i will have best vision 3 weeks after my surgery b. i should report a creamy white discharge from my eye to my doctor C. i will avoid getting water in my eyes until the second day after surgery D. i should avoid using the vacuum cleaner for several weeks. a nurse is assessing a client c who has a partial obstruction - of the large bowel. Which of the following manifestations should the nurse expect? a. epigastric distention b. large amount of emesis of fecal material c. ribbon-like stools a nurse is providing discharge b teaching for a client who has a new diagnosis of COPD. which of Following client statements indicates and understanding of the teaching? A. i will quickly complete household errands in the morning before taking a break B. i will breath out slowly through pursed lips if i feel short of breath C. eat 3 large meals every day a nurse is providing discharge B teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? A. avoid lifting objects greater than 50lbs B. consume a clear liquid diet until symptoms resolve a nurse is caring for a client who has respiratory acidosis due to opioid oversedation. which of the following actions should the nurse take first. a. apply oxygen using a rebreather oxygen mask B. ensure a pt airway using chin-lift maneuver c. administer a reversal agent to the client a nurse is reviewing the lab report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? A. ldl 100mg/dl B. AST 45 unit/L b a nurse is reviewing the medical record of a client who has age related macular degeneration. which of the following findings should the nurse identify as a risk factor for this visual impairment? A. male sex B. hypertension C. osteoporosis a nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? A. restrict oral intake of clear liquids B. place a heating pad on the client's abdomen C. place the client in semi- fowler position a nurse is providing teaching to a client who has osteoporosis. which of the following information should the nurse include in the teaching? a. increase daily intake of foods containing vitamin a b. limit alcohol consumption to 10 oz daily c. perform exercises to strengthen the abdominal core d. start a jogging regimen a nurse is reviewing the b laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine. A. total bilirubin 0.8 mg/dl b. wbc count 4000/mm3 c. platelet 190,000/mm3 a nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? a. heredity b. gender c. anemia heredity -risk factors are heredity, age, hypertension, dm, retinal detachment, severe myopia a nurse is providing dietary teaching to a client who is at 13 weeks of gestation and has hyperemesis gravidarum. which of the following statements should the nurse make? a. drink fluids between, rather than with, meals b. eat foods that are served warm c. do not go more than 6hr between meals a nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect a. calcium 9.5 mg/dl b. bicarbonate 23mEq/L c. potassium 3 mEq/L a nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take? a. administer an antiviral medication to the infant b. initiate droplet precautions for the infants c. limit the infant's oral intake of fluids to 60 ml/hr. a nurse is reviewing the b laboratory results of an adult male client who has hyperlipidimia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? a. LDL 168 mg/dl b. HDL 50mg/dl c. total cholesterol 268 mg/dl a nurse is reviewing a client's home medication list during admission to a long term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? (select all that apply) A. lidocaine 5% patches B. celecoxib C. vancomycin D. cyclobenzaprine E. glucosamine a nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk for the development of pyelonephritis? A. diabetes b. radical prostatectomy 2 years ago c. cholethiasis a nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? a. focuses on the source of anxiety b. exhibit an inability to speak c. experiences auditory hallucinations a nurse is providing teaching about exercises to a client who has osteoarthritis. Which of the following information should the nurse include? A. apply heat to the joints following exercise B. avoid aerobic exercises such as biking c. perform exercises even on days when the joints are painful a nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression? A. i teach my kids about children eating because my anxiety makes me want to overeat B. i started taking kickboxing classes to release the stress i feel from work C. i avoid thinking about the problem that worry me until i have time to focus on a solution a nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? a. hypertension b. somnolence c. oliguria a nurse is assessing client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. which of the following manifestations should the nurse expect? a. orthostatic hypotension b. hoarse voice c. neck vein distention a nurse is assessing a client for manifestations of GERD. which of the following findings indicates to the nurse that the client might have GERD? a. decreased salivation b. diarrhea c. globus a nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition? A. wbc count B. albumin level c. CD4 T cell count a nurse is providing teaching c to a client who has mrsa skin infection. which of the following client statements indicates an understanding of the management of antibiotic resistant infections? A. i will keep the infected area open to air to help it heal b. i can sleep in the same bed as my partner after i have been taking antibiotics for 24 hrs c. i will wash all uninfected skin areas with a fresh washcloth. a nurse is assessing a 6-moth c old infant who has bacterial pnuemonia. which of the following manifestations should the nurse expect? a. protruding tongue b. facial flushing c. nasal flaring a nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? a. fruity-scented breath b. serum glucose 350 mg/dl c. hypotension a nurse in an emergency respiratory alkalosis department is reviewing the - caused by hyperventilation as an excess loss of laboratory report of a client co2. youll have elevated PH and decreased pa who has hyperventilation. the co2 client's ABG's results are pH 7.50, paCO2 29mmhg, HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid base imbalances? a. metabolic alkalosis b. metabolic acidosis c. respiratory alkalosis d. respiratory acidosis a nurse is assessing a client a, b, e who has acute cholecystitis. -pain radiates to right shoulder, fever, clay Which of the following colored stool, eructation or belching findings should the nurse expect a. fever b. dyspepsia c. pain radiating to the left should d. blood tinged stool e. eructation a nurse is caring for a client b who has developed cellulitis -promote venous return and decrease edema in a lower extremity. Which of the following actions should the nurse take? a. apply warm dry packs initially then apply cool moist packs to the lower extremity. b. elevate the extremity 7.6 to 15.2 cm (3 to 6 in) above heart level. c. gently massage the affected extremity for 10-15 min every shift. a nurse is caring for a school b age child who was admitted - opens airway to the emergency department -a is incorrect/correct because its not the first for acute asthma step exacerbation. Which of the following actions should the nurse take first? a. encourage the child to take frequent sips of cool fluids b. apply humidified oxygen with a simple mask c. start a peripheral access iv a nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which of the following actions should the nurse include? A. limit the amount of time the client spends with the newborn after birth. B. discourage the client from having other family members see the newborn C. bathe, diaper, and dress the child before bringing the newborn to the client. a nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? a. flank pain with radiation toward the scrotum b. 150 ml emesis c. oliguria with bladder distention a home health nurse is a. assessing a client who has -according to evidenced based practice, high COPD. The client has a fowler position facilitate ease of breathing respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first? a. place the client in high- fowler's position b. encourage the client to perform diaphragmatic breathing c. instruct the client to perform a huff-coughing technique a nurse is assessing a client c who has hypermagnesemia. - a manifestation of hypermagnesmia, as well as Which of the following peripheral vasodilation and hypotension due to manifestations should the reduced membrane excitabillity nurse expect? -a,b,d are all signs of hypomagnesmia a. hyperactive deep tendon reflexes b. abdominal distention c. bradycardia d. positive trousseau's sign a nurse is assessing a client c who has external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? a. flushing of the skin on the right arm b. bounding pulse palpated in the radial artery c. numbness to the fingers on the right arm a nurse is assessing a client b who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate a. holding on to the left arm while ambulating b. stand on the right side and hold on the gait belt c. stand in front of the client walker a nurse in a provider's office is a assessing a client who is - black tarry stool is a sign of bleeding in the gi taking warfarin to treat atrial and should be reported immediately fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider a. black tarry b. ringing in the ears c. urinary retention d. recent hallucinations A nurse is reviewing the c laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? a. wbc count 10000/mm3 b. magnesium 2 meq/l c. creatinine 2.5 mg/dl a nurse is caring for a client b protamine sulfate who has deep-vein -it reverses the anticoagulant effects of heparin thrombosis and is receiving - vitamin k is prescribed for pts. receiving warfarin heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescriptions should the nurse expect the provider to prescribe? a. vitamin k b. protamine sulfate c. flumazenil a nurse is caring for a client d who has renal calculi and is taking oxybutynin for pain. which of the following findings should the nurse identify as an adverse effect of this medication a. increased salivation b. bradycardia c. tinnitus d. distended bladder a nurse is assessing a 6-month old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? a. absence of tear when crying b. loss of 6% body weight c. capillary refill greater than 2 seconds a nurse is assessing a school age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? a. inaudible lung sounds b. yellow zone peak flow meter reading c. prolonged expiration phase a a nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? a. i should avoid taking this medication with milk b. i will return to have my cholesterol levels checked in 2 weeks c. i understand that muscle tenderness is an expected result of this medication a nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess? a. right upper quadrant b. right lower quadrant c. left lower quadrant a nurse is assessing a client who has DVT in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? a. swelling b. coolness c. distended, tortuous veins a nurse is planning discharge a for a postpartum client. The client tells the nurse she is having a subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? a. irregular bleeding b. fatigue c. shoulder pain a nurse is caring for group of clients. which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? a. a client who is anxious b. a client who has fever c. a client who has abdominal ascites a nurse is admitting a client who has peptic ulcer disease and upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? select all that apply. a. dark, tarry stool b. bright red emesis c. increased heart rate d. increased bp e. bounding peripheral pulses a nurse on a pediatric unit is c preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? a. congenital hypothyroidism b. meconium staining at birth c. congenital heart disease a nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching? a. bacterial infection with e. coli b. Long-term use of NSAIDS c. Frequent use of proton pump inhibitor a nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication? a. the client's skin is warm and moist b. the client reports sleeping longer during the night c. the client is experiencing increased bowel movements a nurse is assessing a client whose parent recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? a. the client lost his house in a house fire 1 month ago b. client retired 30 years ago c. the client's parent was an older adult a nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse a. gonorrhea b. herpes genitalis c. hpv d. bacterial vaginosis A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? a. prothrombin time 12 seconds b. history of sinusitis several times yearly each year c. report of urinating small amounts twice daily c a nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? a. palpate the left lower quadrant of the abdomen to check for rebound pain b. start IV fluid replacement c. treat the client's pain with oral opioids with food a nurse is providing dietary teaching for a client who has GERD. the nurse should instruct the client to avoid which of the following items? a. caffeinated coffee b. shell fish c. apple juice a nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. arrange the following steps. 1. withdraw the prescribed volume of NPH insulin into the syringe. 2. withdraw the prescribed volume of insulin aspart into the syringe 3. inject air into the vial equal to the amount of insulin aspart prescribed 4. inject air into the vial equal to the amount of NPH insulin prescribed a nurse is assessing a newly c admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? a. agorphobia b. xenophobia c. acrophobia a nurse is providing teaching b for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? a. i should wash my feet with soap before i try to treat my calluses b. i should limit wearing the same shoes 2 days in a row c. i should use home remedies to treat any blisters or sores on my feet a nurse is assessing a client a who has developed C. diff. as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. diff? a. vancomycin b. magnesium hydroxide c. rifampin A nurse is providing teaching a to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? a. keep mouth open when sneezing b. block one nostril when blowing your nose c. use an ear wick candle to remove excess cerumen from the canal a nurse is assessing a client who musculoskeletal trauma following motor-vehicle crash 2 days ago. which of the following findings should the nurse report to the provider? *pt. has a cast. a. blood pressure b. pain report (8 out of 10 from pain medications c. ecg results (tachycardia) pain report - indicates compartment syndrome with cast a nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4 year old son is expected to react to the death of his partner. which of the following information should the nurse include in the teaching? a. a preschooler has no concept of death b. a preschooler is often interested in what happens to the body after death c. a preschooler often believes that death is reversible A nurse is providing teaching an adolescent client who mRSA. which of the following instructions should the nurse provide to prevent the spread of this infection? a. bath in a tub of warm water using mild soap twice daily b. place soiled dressing bandages in a red biohazard bag for disposal C. do not return to football practice until the infection has healed A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A: Presence of a transparent cornea B: Presence of strabismus C: Pinna moderately extends outward from the skull D: Walls of peripheral aspect of auditory canal are pink A nurse in an emergency department is caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit? a. the sibling believes the client will wake up in few hours b. the sibling is curious about what happen to the client's body. a nurse is providing teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? a) notify your provider if you notice small pieces of tissue in your urine B) expect to see an increase in the amount of semen produced C) perform kegal exercises several times throughout the day . A nurse is assessing a school- age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect?A: Hyperreflexia B: Fruity breath odor C: Sweating D: Shallow respirations A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection?? A: "I will apply the lotion once a day for 1 week." B: "I will rub in the lotion thoroughly from my face to my toes." C: "I will wash the lotion off 12 hours after I apply it." D: "I should avoid bathing for 6 hours prior to applying the lotion." A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right kidney. Which of the following findings should the nurse instruct the client to report to the provider? A: Bruising over the right flank area B: Blood-tinged urine C: Urine pH 6.0 D: Painful urination A nurse is teaching a client who is at moderate risk for osteoporosis about ways to help prevent this chronic disease. Which of the following instructions should the nurse include? (Select all that apply.) A: Avoid sun exposure. B: Increase dairy product intake. C: Engage in weight-bearing exercises regularly. D: Increase phosphate intake. E: Reduce excessive caffeine intake A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include? A: Wash bedding, clothes, and towels in hot water in a washing machine. B: Rinse the child's hair with vinegar three times a day. C: Seal items that are not machine washable in plastic bags for 1 week. A nurse is assessing an older D adult client who is experiencing malnutrition. Which of the following findings should the nurse expect? B: Diaphoretic skin C: Clubbing of fingers D: Brittle hair A nurse is assessing a client C who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider? A: Urine color is light pink. B: The suprapubic area is soft to palpation. C: The catheter tubing has multiple red clots. A nurse is assessing a school- age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? A: Abdominal distention B: Bradycardia C: Hyperactive bowel sounds A nurse is assessing a client who reports a new onset of joint pain and stiffness. Which of the following findings should the nurse identify as an indication of osteoarthritis? A: Joint pain improves with rest. B: Joint pain is in both arms and shoulders bilaterally. C: Emotional upset exacerbates joint pain. D: Client is 35 years old. A school nurse is assessing a C school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect? A: Otitis media B: Parotitis C: Facial eruption D: Lymphadenopathy A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis A nurse in an emergency A department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? A: Apply ice packs to the client's axillae, neck, groin, and chest. B: Administer aspirin to the client C: Initially offer the client cool, oral fluids. D: Continue cooling measures until the client's rectal temperature is 37.2º C (99º F). A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.) A: Apply cold packs to the affected area. B: Treat the affected area with propranolol. C: Elevate the affected area 15.24 cm (6 in) above the heart. D: Place a dry heating pad over the affected area. E: Administer cefazolin intermittent IV bolus A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings should the nurse expect? A: Circumoral tingling B: Hypoactive reflexes C: Fatigue D: Anorexia A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? A: WBC 16,000/mm³ B: Board-like abdomen C: Nausea and vomiting D: Temperature of 38° C (100.4° A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the teaching? A: "I should drink 1.5 liters of water daily to keep hydrated." B: "I should make my abdomen rise with each inhalation." C: "I should inhale through my mouth and exhale through my nose." D: "I should limit walks to 10 minutes daily in order to conserve my energy." A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? A: Drink tomato juice with the breakfast meal. B: Suck on peppermint when having indigestion. C: Elevate the head of the bed 10 cm (4 in) using wooden blocks. D: Plan to finish eating at least 3 hr before bedtime A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions should the nurse include in the client's plan of care? A: Give the client detailed instructions. B: Reframe situations in a positive manner for the client. C: Speak in a brisk manner to the client. D: Avoid involving the client in problem solving A nurse is providing dietary A teaching for a client who has hyperlipidemia due to nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A: Less than 30% of daily calories should come from fat. B: Decrease caloric intake to less than 25 cal/kg/day. C: Increase sodium intake. D: Limit daily intake of foods high in carbohydrates A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? A: Diminished peripheral pulsations in the right lower leg B: Discoloration and edema of the right ankle C: Atrophy of the skin and hair loss on the right leg D: Dependent rubor in the right leg A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect?A: Increased deep tendon reflexesB: Hypoactive bowel soundsC: Decreased level of consciousnessD: Bradycardia A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? A: Hallucinations B: Vomiting C: Bradycardia D: Seizures A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching? A: "I will blow out as hard as I can before I use the peak flow meter." B: "I will not take my controller medication if my peak flow meter scores in the yellow zone." C: "I will base my peak flow meter score on the best of three attempts." D: "I will go to the emergency room if my peak flow meter is in the green zone. A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make? A: "You'll need to take this medication once a day at bedtime." B: "This medication causes adverse effects if the dosage is too high or too low." C: "Continuing this medication therapy long-term will eventually cure your hypothyroidism." D: "Potassium supplements can reduce the effectiveness of this medication." A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection? A: Negative nitrites B: RBCs < 2 C: Positive leukocyte esterase D: Amber-colored urine A nurse in an emergency department is assessing a client who reports severe constipation. The nurse should identify which of the following findings as an indication that the client might have a small-bowel obstruction?A: Peripheral edema B: Minimal vomiting C: Intermittent cramping in the lower abdomen D: Visible peristaltic waves in the upper abdomen A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care? A: Position the affected leg flat when sitting up in bed. B: Instruct the client to perform weight-bearing activities on the affected leg. C: Check for paresthesia of the affected leg. D: Apply heat to the surgical incision area of the affected leg. A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? A: Becomes angry when it is time to perform colostomy care B: Touches the colostomy stoma when the bag is changed C: Looks away as the nurse empties the colostomy bag D: Tells others that it will be nice to have a normal bowel movement again A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management? A: "Wash your child's exposed clothing in cold water using powder detergent." B: "Keep your child away from other children for 10 days after lesions appear." C: "Scrub your child's affected areas with an antibacterial soap every other day." D: "Place your child in an oatmeal bath using tepid water for 15 minutes." A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect? A: Progressive loss of peripheral vision B: Opacity of the lens of the client's eye C: Impaired central vision D: Report of seeing floating dark spots A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record? A: Pyrophobia B; Agoraphobia C: Monophobia D: Astraphobia A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi? A: Maintain bedrest until calculi are expelled. B: Withhold thiazide diuretics. C: Encourage intake of at least 3 L of fluid each day. D: Collect all urine for 24 hr in a collection containe A nurse is developing an in- service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death? A: Adolescents cope with death better than children of other ages. B: Adolescents view funeral services as an opportunity for closure. C: Adolescents are more concerned with the past than the present or future. D: Adolescents often alienate themselves from their peers when grieving. A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A: Numbness of hands B: Gingival hyperplasia C: Clay-colored stools D: Carotid bruits A nurse is providing home C care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include? A: Apply heat for the first 48 hr. B: Wear a sling when resting in bed. C: Elevate the wrist above heart level. D: Use a soft-bristle toothbrush to relieve itching under the cast. A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for the client? A: Apply oxygen therapy to the client. B: Administer an anti- inflammatory medication. C: Check the client's nail beds. D: Initiate IV fluid therapy. A [Show More]

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