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NURSING 493 Priority 1 VERSION 2. Exam 180 Q&A Rated 100%. West Coast University, Los Angeles.

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VERSION 2 - 2020 1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care... ? a. Give acetaminophen to control the child’s fever b. Monitor the client’s cardiac status (PEDS p120) c. Administer antibiotics via intermittent IV bolus for 24 hrs. d. Provide stimulation with children of the same age in the play room 2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? a. “Do you recognize the voices as belonging to anyone you know?” b. “I understand the voices are frightening you, but I do not hear any voices.” c. “That can’t be true. The only voices in this room are yours and mine.” d. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” 3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an understanding of advance directives? (Select all that apply.) a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnesses it) b. “I have the right to refuse treatment.” (Leadership p38) c. “My doctor will need to approve my advance directives.” (just needs to write a prescription) d. “My health care proxy can make medical decisions for me.” (Leadership p38) e. “I can’t change my advance directives once submitted.” (yes, you can) 4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrives. Which of the following statements by the nurse is appropriate? a. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give the sibling) b. “Teach your son to change the baby’s diapers.” (Allow older siblings to help in providing care for the infant) c. “Tell your son to kiss the baby.” (Maternity p126: Let the sibling be one of the first to see the infant) d. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s arrival) 5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should the nurse include in the teaching? a. Limit total daily sodium intake to 4 to 5 grams B. Obtain most calories from complex carbohydrates (for CKD) c. Consume a high-protein diet (High protein, high potassium, low sodium) d. Avoid intake of soy products. 6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse? a. “Did you think about removing yourself from the situation when you became angry?” b. “Why do you get angry when things don’t go your way?” c. “How do you think others feel when you express anger?” D. “What are you thinking about when you express anger?” (assessing the underlying issue of aggression) 7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a. Wear a dosimeter film badge while in the client’s room. (Med Surg p583) b. Ensure family members remain at least 3 feet from the client (should be at least 6ft) c. Limit each of the client’s visitors to 1 hrs. per day. (should be 30 minutes) d. Remove dirty linens from the room after double bagging. 8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Sit at or below the client’s eye level during feedings (Funds p215: Observe for aspiration and pocketing of food in the cheeks or other areas of the mouth) b. Talk with the client during her feeding c. Discourage the client from coughing during feedings (encourage pt. to cough to prevent aspiration) d. Instruct the client to lift her chin when swallowing (tuck chin) 9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates moderate dehydration? a. Bradypnea B. Oliguria (Funds p343) c. Diaphoresis d. Excessive tears 10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? a. “Your child can return to school after a negative titer result.” b. “Your child can return to school 24 hours after beginning antibiotics.” c. “Your child can return to school once the lesions have crusted over.” REPEAT 2016 d. “Your child can return to school once the fever has subsided.” 11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Muscle weakness- rhabdomyolysis b. Edema c. Weight loss d. Fever 12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is receiving warfarin and has an INR of 3.3 b. A client who had an NG tube inserted 6 hrs. ago and has abdominal distention c. A client who is 4 hrs. postoperative following a thyroidectomy and reports fullness in the back of the throat (edema can lead to resp. distress) d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL 13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports changing her perineal pad every 2 hrs. b. A client who reports abdominal pain during breastfeeding c. A client who has a urine output of 250 mL in 6 hrs. d. A client who has hyporeflexia while receiving magnesium sulfate REPEAT 14. A nurse is providing nutritional teaching regarding appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following should the nurse include in the teaching? a. Roast beef b. Chicken breast c. Low-fat yogurt (avoid purine foods [organ meats & shellfish] & poultry) d. Tuna fish 15. A nurse in the emergency department is caring for a client who has a full-thickness burn of the thorax and upper torso. After securing the client’s airway, which of the following is the nurse’s priority intervention? a. Preventing infection b. Offering emotional support c. Providing pain management d. Initiating IV fluid resuscitation - REPEAT 16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to discuss the results with her partner. Which of the following is an appropriate response for the nurse to make? REPEAT a. “The provider will be tactful when talking to your partner.” b. “You have the right to decide who receives information.” c. “Is there a reason you don’t want your partner to know about your procedure?” d. “Your partner can be a great source of support for you at this time.” 17. A nurse is providing teaching about dietary recommendations to the parents of a school-age child who has acute kidney injury. Which of the following recommendations should the nurse include in the teaching? a. Provide low-calcium foods b. Provide high-phosphorus foods c. Provide low-potassium foods d. Provide high-sodium foods 18. A nurse is planning care for a school-age child who is 4 hrs. postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? REPEAT a. Apply a warm compress to the operative site every 4 hrs. b. Offer small amounts of clear liquids 6 hrs. following surgery c. Give cromolyn nebulized solution every 8 hrs. d. Administer analgesics on a scheduled basis for the first 24 hrs. 19. A nurse is assessing a client who is 8 hrs. postpartum and has been unable to void. Which of the following actions should the nurse take first? a. Pour warm water over the client’s perineum b. Offer the client a Sitz-bath c. Insert a sterile catheter d. Administer an analgesic 20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin. Which of the following statements by the nurse is appropriate? a. “Limit foods that contain folic acid while taking this medication.” b. “You should expect a change in the color of your stool while taking this medication.” c. “Increase your intake of vitamin D while taking this medication.” - phenytoin complication (bone pain and weakness) d. “Plan to take this medication with antacids.” 21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash. Which of the following findings indicates the client is experiencing a fat embolism? b. Decreased pedal pulses c. Pain unrelieved by opioid analgesics d. Crepitus at the knee joint 22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching? b. “You should massage one of your nipples to stimulate contractions of your uterus.” c. “You will need blood work before and after the test.” d. “You should avoid eating or drinking for 4 hrs. before the test.” 23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? a. Changes in appetite b. Daily fluid intake d. Prescribed medications 24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the following statements should the nurse include in the teaching? a. “Eat a diet rich in fresh fruits and vegetables.” c. “Children may visit as long as they’ve recently received a live influenza vaccination.” d. “Check your temperature weekly.” BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID 25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? REPEAT a. Maintain the client in supine position for the first 24 hrs. b. Secure the drain to the bedding d. Position the affected extremity below the level of the client’s heart 26. A nurse is providing discharge instructions to a client who is 1-day postoperative vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding for the dietary teaching? b. “I will be limited to pureed foods for the next 6 months.” (weeks) c. “I should eat three meals per day.” d. “Vomiting is common and I will have to learn to live with it.” SERVE TO RESTRICT AND DECREASE FOOD INTAKE HELPS TO PROMOTE WT LOSS 27. A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide? a. “Respite care offers financial resources to help care for your husband.” b. “Respite care includes volunteers who will perform household tasks.” c. “Respite care provides clinicians to work with you in caring for your husband.” 28. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Obtain the urinalysis specimen before the culture specimen. b. Collect 2 mL or urine for each specimen. c. Drain the specimen from the drainage bag. 29. A nurse is caring for four clients. Which of the following clients should the nurse care for first? b. A client who has a burn requiring a sterile dressing change c. A client who received a chemotherapy treatment and reports nausea d. A client who had an appendectomy 2 days ago and has diminished bowel sounds 30. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication to using lavender? a. The client has a history of alcohol use disorder b. The client has a history of asthma c. The client takes Vitamin C daily 31. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? b. “I don’t need to use a walker when walking around my house.” c. “I will stay in bed for 3 days after returning home before starting leg exercises.” d. “I will bend over at my hips to tie my shoes.” bend at your knees 32. A nurse is assessing a client who is experiencing a pulmonary embolism. Which of the following manifestations should the nurse expect? a. Hypertension c. Bradycardia d. Frothy sputum 33. A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse determines that cranial nerve XI is intact when the client performs which of the following actions? b. Frowns symmetrically c. Sticks his tongue out d. Identifies a sour taste cra 34. A nurse is preparing to administer lactated Ringer’s 500 mL IV to infuse over 4 hrs. 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 the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.) ! 31 gtt/min 4x60= 240mins 500/240 = 2.08 x 15 gtt = 31.25 or 31 35. A nurse is teaching an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? a. HbA1c level greater than 8% c. Blood glucose level less than 60 mg/dL before breakfast d. Blood glucose level greater than 200 mg/dL at bedtime 36. A nurse is caring for a client who develops a lower left leg deep-vein thrombosis following surgery. Which of the following actions should the nurse take? b. Check for the presence of a Homan’s sign c. Form a 5 cm (2 in) cuff at the top of the ant embolism stocking d. Massage the left lower extremity 37. A nurse working in an acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. Euphoric mood b. All-or-nothing thinking c. Hypochondriasis 38. A nurse is developing a nutritional care plan for a client who has COPD with severe dyspnea. To promote intake, which of the following instructions is appropriate to include in the plan of care? a. Administer a bronchodilator after meals b. Ambulate the client before each meal c. Offer the client three large meals each day 39. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? a. WBC 9,800/mm3 b. Creatinine 0.9 mg/dL < 1.0 is normal c. Fasting blood glucose 108 mg/dL 40. A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Respiratory therapist d. Occupational therapist 41. A nurse in an oncology clinic receives a call from the partner of a client who has pancreatic cancer. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make? b. Respite care c. Skilled nursing facility d. Restorative care 42. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Click on the “Exhibit” button below for additional client information. There are three tabs that contain separate categories of data.) a. Massage the affected extremity every 4 hrs. b. Administer acetaminophen d. Position the client with the affected extremity lower than the heart 43. A nurse preceptor is working with a newly licensed nurse to care for a client who has vancomycin-resistant enterococci (VRE). Which of the following actions by the newly licensed nurse requires the nurse preceptor to intervene? b. Cleaning her hands with alcohol-based antiseptic after delivering a meal to the client c. Instructing the client to dispose of soiled facial tissues in the wastebasket in his room d. Wiping a client’s over bed table with hydrogen peroxide following a dressing change 44. A nurse in a health clinic is developing written material to teach adult clients how to manage their blood pressure. Which of the following strategies should the nurse use in creating the material? a. Create material using a 12-point font size b. Type information in capital letters c. Use words with one or two syllables 45. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? b. Place the client in a side-lying position prior to assessing the fetal heart rate c. Perform Leopold maneuvers prior to auscultating the fetal heart rate d. Measure the fundal height to determine the placement of the ultrasound stethoscope 46. A nurse in a mental health facility received change-of-shift report on four clients. Which of the following clients should the nurse plan to assess first? b. A client who received a PRN dose of haloperidol 2 hrs. ago for increased anxiety c. A newly admitted client who has a history of 4.5 (10 lbs.) weight loss in the past 2 months d. A client who will be receiving his first ECT treatment today 47. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should recognize that atrial fibrillation places the client at risk for which of the following? b. Cardiac tamponade c. Hemothorax d. Widened pulse pressure 48. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Iron b. Calcium d. Zinc 49. A nurse is caring for a client who is not ambulatory. Which of the following interventions is appropriate to prevent contracture? a. Place a towel roll under the client’s neck b. Align a trochanter wedge between the client’s legs c. Apply an orthotic to the client’s foot- REPEAT d. Position a pillow under the client’s knees 50. A nurse is caring for a client who has a thoracic spine injury. Which of the following actions is appropriate for the nurse to take when turning the client? b. Instruct the client to keep his arms at his side when altering positions c. Place a pillow under the client’s knees when changing positions d. Use a sheet when repositioning the client onto his side 51. A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate? b. “Imagine a situation that has been stimulating for you when practicing guided imagery.” c. “Talk to someone who you admire as the first step in using mindfulness techniques to relax.” d. “Breathe in through your mouth and out through your nose when using deep breathing exercises.” 52. A nurse is caring for a client who is incontinent and has a stage II pressure ulcer on her coccyx. Which of the following interventions should the nurse implement? a. Reposition the client every 3 hrs. b. Use two facility personnel to slide the client up in bed d. Apply lotion to the skin every 4 hrs. 53. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who is at 36 weeks of gestation with a biophysical profile score of 8 54. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (Select all that apply) d. Aspirate the blood sample with large bore needle e. Apply a tourniquet above the catheter insertion site 55. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate? a. “I don’t understand why I am getting this antibiotic.” b. “My arm burns each time that medication is running.” d. “This medication bag is still full.” 56. A nurse is caring for a client who has schizoaffective disorder and tells the nurse, “I’m the prince of peace and my enemies are coming to take me to another world.” Which of the following responses should the nurse make? a. “Why do you think people will come for you?” b. “Let’s take a walk around the unit together.” c. “The staff and I will protect you from them.” 57. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Perform range-of-motion exercises to the client’s extremities b. Place the client’s right hand in a supination position d. Change the client’s position every 2 hrs. 58. A charge nurse is providing information to a group of nurses on the unit about risk factor for hypoglycemia in newborns. Which of the following risk factors should the charge nurse include in the information? (Select all that apply) a. Anemia b. Infection c. Maternal diabetes d. Prematurity e. Polycythemia 59. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balance suspension traction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearing aid d. A client who is ambulatory and receiving oxygen 60. A nurse is providing discharge instructions for a client who has a new prescription for clopidogrel following a cardiac catheterization. Which of the following instructions should the nurse include? a. “Your stools will become black and tarry” b. “Take NSAIDs for pain every 6 hours” d. “Take medication twice daily with acetaminophen.” 61. A nurse is an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram.” b. “I will avoid foods containing tyramine while taking fluoxetine.” c. “I will take my lithium on an empty stomach.” d. “I will take the sustained-release methylphenidate every morning.” 62. A nurse is planning care for a client who has stage II Parkinson’s disease. Which of the following actions should the nurse include in the plan of care? a. Offer clear liquids with in between meals b. Offer high-calorie nutrition supplements c. Encourage the client to concentrate on looking at his feet while walking d. Encourage the client to participate in small muscle dexterity activities 63. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication to the use of metformin? b. Gluten intolerance c. Seizure disorder d. Polycystic ovary syndrome 64. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Obtain a 12 F catheter b. Apply EMLA cream prior to the procedure c. Discard the first 10 mL of urine d. Don sterile gloves prior to the procedure- REPEAT 65. A charge nurse is teaching a newly licensed nurse about clients designating a healthcare proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include? a. “The proxy should make healthcare decisions for the client regardless of the client’s ability to do so.” b. “The proxy can make treatment decisions if the client is under anesthesia.” c. “The proxy can make financial decisions if the need arises.” d. “The proxy should manage legal issues for the client.” 66. A nurse is providing teaching to a client who is receiving misoprostol for induction of labor. Which of the following statements hould the nurse include in the teaching? a. “You will have oxytocin initiated within 3 hours of administration of the medication.” b. “You will have intermittent fetal monitoring while you receive the medication.” c. “You will lie on your side for 30 minutes after the medication is inserted.” d. “You will have a urinary catheter inserted prior to the placement of the medication.” 67. A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings hould the nurse report to the provider? a. Bleeding gums b. White vaginal discharge c. Fundal height of 26 cm d. Periorbital edema 68. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply) b. Limit visitors to 30 minutes per day c. Wear a lead apron when providing care d. Place the client in a semi-private room " private e. Instruct visitors who are pregnant to remain 3 feet from the client " 6 feet 69. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the ollowing interventions should the nurse include in the plan of care? a. Perform neurological checks every 4 hrs. b. Perform active range-of-motion exercises d. Suction the airway frequently 70. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the following should the charge nurse identify as he purpose of telemetry monitoring? a. To measure cardiac perfusion b. To identify valve insufficiency c. To measure cardiac output d. To identify dysrhythmias 71. At her first prenatal visit a client asks the nurse when she will most likely deliver. If her last menstrual period began on March 31, when is the estimated date of delivery (EDD)? a. December 24 b. January 7 - 3 month + 7 days c. December 31 d. January 3 72. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Focus on how the conflict occurred b. Attempt to understand both sides of the issue c. Identify solutions prior to negotiation d. Personalize the conflict 73. A public health nurse is managing four projects for the community. Which of the following activities should the nurse identify as a primary prevention strategy? a. Providing crisis intervention through a mobile counseling unit b. Conducting mental health screenings at the local community center d. Referring individuals who have mental health disorders to day treatment programs 74. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? a. Return unopened equipment to the supply center b. Stock the room with a 2-day supply of disposable diapers c. Bring in formula as needed d. Leave the unused infusion pump in the room until discharge 75. A nurse in a provider’s office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. Herpes zoster b. Hypertension c. Obesity d. Hypothyroidism 76. A nurse manager observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following actions should the nurse manager take first? b. Request the nurses present an in-service on client confidentiality c. Place documentation of the nurses’ actions in the personnel file d. Advise the nurses to read the facility’s confidentiality policy 77. A nurse is teaching a client who is to start a new prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? a. Monitor for hyperglycemia b. Take with a protein snack c. Change positions slowly - orthostatic hypotension d. Report dark-colored urine 78. A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? a. Wipe the stethoscope with alcohol after leaving the client’s room b. Place the client in a room with negative airflow c. Wear a gown while providing personal hygiene d. Apply a mask when providing care 79. A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about using saw palmetto to relieve the symptoms of BPH. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto? a. Metoprolol b. Clopidogrel - saw palmetto interacts with antiplatelet/anticoagulant medications c. Ipratropium d. Zolpidem 80. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care? a. Weight loss of 5% in 10 days " Risk for development of pressure ulcer: Recent weight loss- lost 5% of total body weight or 4.5 kg (10lb) practice ass b. Appearance of pink tissue under eschar c. Hgb 15 g/dL d. Albumin level 4.0 g/dL a. Soy 81. A nurse is providing preoperative teaching to an older adult female client who is scheduled for a laminectomy and uses supplements. Which of the following supplements should the nurse identify as increasing the client’s risk for hypotension during surgery? c. Probiotics d. Flaxseed 82. A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? b. Schedule an MRI post procedure to verify placement c. Administer sedation for the procedure d. Use gauze to secure an arm board to the involved extremity 83. A nurse is assessing a client who has fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? b. Hyperparathyroidism c. Hypoparathyroidism d. Hypothyroidism 84. A nurse is providing discharge teaching for a client who has a prescription for captopril. Which of the following adverse effects should the nurse instruct the client to report to the provider? a. Alopecia b. Headache d. Hypoglycemia 85. A nurse is receiving report on four clients. Which of the following clients should the nurse assess first? b. A client who has an ilial conduit and mucus in the pouch c. A client who had a transurethral resection of the prostate with red-tinged urine in the bag d. A client who has an arteriovenous fistula that vibrates when palpated 86. A nurse is caring for a group of clients. Which of the following clients should the nurse assess first? a. A client who has heart failure and reports shortness of breath while ambulating b. A client who had an open cholecystectomy and has green drainage from the T-tube c. A client who has benign prostatic hyperplasia and is unable to urinate 87. A nurse is caring for a client who has Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? b. D-dimer test c. Oral glucose tolerance test d. Thyroid scan 88. A nurse is reviewing the medical record of a client who has tuberculosis and a new prescription for rifampin. The nurse should notify the provider for which of the following findings? a. Irregular heart rate b. Elevated blood glucose level d. Allergy to cephalosporins 89. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the selected order of performance) 1) Turn on the suction and set the pressure 2) Don sterile gloves 3) Insert the catheter during the client’s inspiration 4) Apply suction while rotating the catheter 5) Rinse the catheter to remove secretions 90. A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid. Which of the following actions should the nurse take? a. Ensure the client has a full bladder just prior to the procedure b. Weigh the client before and after the procedure c. Administer a low-volume hypertonic enema the night before the procedure d. Place the client in a side-lying position for the procedure 91. A nurse is caring for a child who has sickle cell anemia and is experiencing vaso-occlusive crisis. Which of the following actions should the nurse include in the place of care? a. Give aspirin to reduce pain b. Start a 24-hr urine collection c. Encourage ambulation d. Initiate IV fluid replacement - REPEAT 92. A nurse manager is planning an in-service program for newly licensed nurses. The nurse manager should instruct to perform medication reconciliation in which of the following situations? a. When a client has a new prescription for an enteral feeding b. When a client is referred to physical therapy c. When a client returns to the unit after surgery d. When a client has completed hemodialysis treatment 93. A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (Select all that apply) a. Honoring family requests to withhold medical information b. Addressing client needs when providing resources c. Encouraging clients to seek further information from the provider d. Promoting health care access e. Making decisions about health care on clients’ behalf 94. A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? a. Decrease the maintenance infusion rate of IV fluid b. Have protamine sulfate available at the bed ide c. Monitor the client for hypertension D. Reposition the client side-to-side each hour 95. A nurse is caring for a client who has a new prescription for clozapine. Which of the following should the nurse recognize as an adverse effect of this medication? a. Hypoglycemia b. Diarrhea c. Agranulocytosis- REPEAT d. Urinary frequency 96. A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first? a. Determine the client’s current anxiety level b. Report the client’s assault to the authorities c. Initiate a referral for client counseling d. Request the client’s permission to contact a family member 97. A charge nurse is teaching a newly licensed nurse regarding herpes simplex virus (HSV) during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “The laboratory will test the cord blood to determine if the newborn has contracted HSV.” b. “The client should avoid acyclovir during pregnancy due to risk to the fetus.” c. “The client should have a cesarean birth if any active lesions are present.” d. “The client should avoid breastfeeding until the lesions are healed.” 98. A nurse is providing instruction to a client who is to start therapy with acarbose(anti-diabetic). Which of the following statements by the client indicates an understanding of the teaching? a. “I should take this medication even if I miss a meal.” b. “I may experience insomnia while taking this medication.” c. “I may lose weight while taking this medication.” d. “I should take this medication with the first bite of each meal.” 99. A charge nurse is admitting four clients to an acute care unit. Which of the following clients should the nurse place near the nurses’ station? a. A client who has an open wound b. A client who has orthostatic hypotension- risk for falls patient = put them in sight of the nurses for OTC monitoring c. A client who is on fluid restriction d. A client who is in Buck’s traction 100. A nurse is preparing information about skin care for a client who has cancer of the prostate and is receiving radiation therapy. Which of the following should the nurse include in the information? a. Clean the perineal area using a washcloth b. Dry the perineal area by using a patting motion c. Wear snug-fitting underwear d. Apply heat packs to the affected area as needed 101. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Schedule daily activities b. Develop an hourly time frame for tasks c. Determine goals of the day d. Delegate tasks to the AP 102. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider? a. A client who is 4 hrs. postoperative and has a heart rate of 98/min b. A client who has a total of 110mL of serosanguineous fluid from a Jackson-Pratt drain within the first 24 hrs. following surgery c. A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm - immunosuppressed d. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing 103. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? a. Advance the catheter into the vein b. Flush the catheter with saline c. Retract the stylet d. Release the tourniquet 104. A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings? a. Three uterine contractions within 10 min b. Baseline FHR 115/min c. Prolonged decelerations- ABSENT or LATE DECELS are always priority - this may lead to c section emergency d. Moderate variability in the FHR 105. A nurse is providing discharge instructions to the parents of a child who is postoperative following a tonsillectomy. Which of the following instructions should the nurse include in the teaching? a. “You should use a warm-moist vaporizer.” b. “Encourage your child to eat ice cream to promote comfort for his throat.” c. “You should call your provider if your child has an increase in swallowing.” - bleeding d. “Encourage your child to blow his nose frequently to clear secretions.” 106. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take? a. Recommend to the provider specific acute care clients for discharge b. Determine the medical needs of incoming clients through the emergency department c. Act as a liaison between the facility and the media d. Call in additional medical-surgical unit nursing care staff 107. A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? a. Ensure the state health department has been notified - national notifiable disease b. Administer antitoxin c. Educate the family to avoid sharing personal belongings d. Assess for skin necrosis 108. A surgeon is obtaining informed consent from a client. When a nurse witnesses the client sign the consent form, which of the following legal requirements is the nurse confirming? a. The client knows he may no longer refuse the procedure b. The client agreed to the procedure voluntarily c. The nurse explained the risks and benefits of the surgery d. The nurse explained the surgical procedure in detail 109. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? REPEAT a. Heightened perceptual field- REPEAT b. Rapid speech c. Purposeless activity d. Feelings of dread 110. A nurse in the emergency department is caring for an adolescent who has acute appendicitis and reports pain at McBurney’s point. The nurse should identify which of the following areas as McBurney’s point? (You will find “Hot Spots” to select in the artwork below. Select only the hot spot that corresponds to your answer.) This was on ATI Practice Assessment A 111. A nurse working with the state health department is reviewing medical records for four clients. Which of the following infectious diseases is a national notifiable disease? a. Hepatitis B b. Human papillomavirus c. Molluscum contagiosum d. Bacterial vaginosis 112. A nurse is verifying informed consent for surgery from a client who does not speak the same language as the nurse. Which of the following resources should the nurse use to facilitate communication? a. The client’s family member b. A language application on an electronic device c. A bilingual staff member D. A medical interpreter 113. A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take? a. Have the AP check the medical record for prior blood glucose test results b. Determine if the AP has the skills to perform the test c. Help the AP perform the blood glucose test d. Assign the AP to ask the client if he has taken his antidiabetic medication today 114. A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take? a. Store the oxygen tank wrench in a locked cabinet b. Have the client store smaller tanks under his bed c. Ensure that the client is checking the gauge weekly d. Place the oxygen tank away from curtains or drapes 115. A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first? a. “Do the voices cause you to feel anxious?” b. “Can you tune out the voices by listening to music?” c. “What are the voices telling you to do?” d. “Are you also seeing unusual persons or things? 116. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. “You should not have this procedure if you have a tattoo.” b. “The nurse will ask you to remove any transdermal patches prior to the procedure.” c. “You should not have this procedure if you are allergic to iodine.” - contrast media may be used d. “The nurse will ask you to wear protective eyewear during this procedure.” 117. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to an AP? REPEAT a. Administering oral fluids to a client who has dysphagia b. Documenting the report of pain for a client who is postoperative c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercises with a client who had a stroke 118. A client who is having suicidal thoughts tells the nurse, “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate? a. “You can trust me and tell me what you are thinking.” b. “I need to know what you mean by misery.” c. “Why do you think your life is not worth it anymore?” d. “Do you have a plan to end your life?” - SAFETY 119. A nurse is providing teaching to a client who has a new prescription for omeprazole. Which of the following adverse effects should the nurse include as a possible risk of long-term therapy? a. Constipation b. Lung cancer c. Tinnitus d. Osteoporosis 120. A mental health nurse is caring for a client who recently attempted suicide. The client states, “I wish I was dead.” Which of the following is an appropriate response by the nurse? a. “Suicide is not the answer to your problems.” b. “Don’t worry. Everything will be just fine.” c. “You seem like you’re feeling hopeless.” d. “Did you take your medications today?” 121. A charge nurse is concerned about a recent increase in facility-acquired infections. Which of the following actions should the nurse take first? a. Schedule nursing staff training for infection control procedures b. Revise the current policy for catheter care c. Identify possible precipitating factors related to the infections d. Meet with providers to discuss measures to decrease the infections Rationale: Assess first by Identifying. 122. A nurse receives change-of-shift report on four clients. Based on the shift information, which of the following clients should the nurse plan to assess first? a. A client who had a hip arthroplasty reports pain and erythema in his calf b. A client who had a barium enema 2 days ago and reports constipation c. A client who has anorexia and peripheral edema d. A client who had Addison’s disease with a blood glucose level of 75 mg/dL (low sugar level expected for Addison’s) Rationale: Clinical Manifestation of Postthrombotic Syndrome, specially seen after surgery such as Arthroplasty. 123. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum creatinine c. Serum potassium D. Liver function test Rationale: Valproic Acid risk for Hepatotoxicity on Practice Q 124. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? a. Replace the NG tube B. Evaluate functioning of the suction device c. Provide oral hygiene care d. Administer an antiemetic medication Rationale: Page 302 of Med/Surg book. Assess and maintain function of NG tube 125. A nurse in a clinic is reviewing the health history of a client during her first prenatal visit. Which of the following findings indicates a risk for diabetes mellitus? a. Delivery of a low birth-weight infant b. Previous miscarriage C. BMI of 28 d. 1-hr oral glucose tolerance test of 132 mg/dL (140 mg/dL is considered DM per OB ATI Book) Rationale: Page 527 of Med/Surg ATI Book. Risk factor of DM is Obesity. 126. A nurse is preparing to administer medications to a group of clients using a portable medication cart. Which of the following actions should the nurse take? a. Lock the medication cart prior to entering each client’s room b. Place controlled substances in the client’s drawers of the medication cart before leaving the medication room (they can take it from the drawer) c. Prepare each client’s medications and place in client drawers prior to beginning medication administration d. Contact the pharmacy to restock the medication cart when the cart if empty Rationale: To prevent loss of medication patient might take it if they have access to it. 127. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a 90 second duration and the fetal heart rate is 170 to 180/min. Which of the following actions should the nurse take? a. Discontinue the oxytocin infusion b. Increase the oxytocin infusion c. Maintain the oxytocin infusion d. Decrease the oxytocin infusion Rationale: Discontinue if uterine hyper stimulation occurs with contraction frequency more often than every 2 min, contraction duration longer than 90 seconds, contraction intensity results with pressures greater than 90 mm Hg as shown by IUPC, uterine resting tone greater than 20 mm Hg between contractions showing no relaxation of uterus between contractions. 128. A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis? a. Limited range-of-motion of hips b. Exaggerated curvature of sacrum c. Mild pain in the hip region D. Uneven shoulder and pelvic heights Rationale: Scoliosis is Lateral Curvature of the Spine which can be seen as uneven shoulder and pelvic heights. 129. A nurse is reviewing laboratory results for a client prior to administering zidovudine. Which of the following laboratory values should the nurse monitor? a. Serum potassium B. WBC count c. Blood glucose d. Serum albumin Rationale: Page 384 of ATI PHARM. Zidovudine is a NRTI which causes suppress bone marrow. 130. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? a. Maintenance of NPO status until therapy is complete b. Removal of vaginal packing c. Ambulation four times daily (Activity is Restricted to prevent dislodgement) d. Insertion of an indwelling urinary catheter Rationale: The client who has cervical cancer will have a vaginal radiation implant. A catheter is needed to prevent displacement of the implant during ambulation. 131. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a. Malpractice b. Battery d. Negligence 132. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first? a. Ensure the device inspection sticker is current b. Report the defect to the equipment maintenance staff d. Initiate a requisition for a replacement CPM device 133. A nurse is planning to teach a client about ways to prevent recurrent urinary tract infections. Which of the following instructions should the nurse plan to include? b. Drink orange juice c. Soak in a hot tub d. Wear nylon underwear 134. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? a. Second-degree heart block b. Ventricular asystole d. Sinus tachycardia 135. A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse take? a. Keep calcium gluconate at the bedside b. Monitor blood pressure every hour d. Use an in-line filter 136. A nurse is teaching a parent of a child about pediculosis capitis. Which of the following should be included in the teaching? a. “Lice can be transmitted by pets.” b. “The eggs live off the host’s blood supply.” d. “Applying mayonnaise on your child’s head will remove the lice.”- avoid home remedies 137. A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? (direct thrombin inhibitor, for stroke clients who have atrial fibrillation, DVT) a. “I can crush the medication and mix with applesauce.”- must be taken whole b. “I can store the medication in the refrigerator.” c. “I should replace any unused medication every 6 months.”- container should be used in 30 days 138. A charge nurse is selecting clients for discharge to prepare to receive victims from a local disaster. Which of the following clients should the nurse recommend for discharge? b. A client who has a BUN 105 mg/dL following a CT scan with contrast c. A client who reports vomiting and is under observation following a head injury d. A client who has shortness of breath and a B-type natriuretic peptide 230 mg/mL 139. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? b. Contact the family regarding the client’s condition c. Inform the transferring agency of the client’s condition d. Notify risk management 140. A nurse in the emergency department is admitting a client who reports ingesting 30 diazepam tablets 20 minutes ago. The client has a respiratory rate of 10/min and is lethargic. After securing the client’s airway, which of the following actions should the nurse take next? a. Evaluate the client for potential suicidal ideation c. Assist the client with ingestion of activated charcoal d. Perform gastric lavage for the client 141. A nurse is providing teaching to a client who has a new prescription for methotrexate. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider? a. Muscle pain b. Pedal edema c. Insomnia 142. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? a. Using effleurage on a client’s lower abdomen c. Instructing a client’s partner how to apply counter pressure to the client’s sacral spine for 30 minutes d. Encouraging a client to use jet hydrotherapy on her lower back for 1 hrs. 143. A nurse is performing assessments on infants in the newborn nursery. Which of the following findings should the nurse report to the provider? a. A 16-hr-old infant whose blood glucose is 45 mg/dL b. A 2-day-old infant who has a small amount of blood-tinged vaginal discharge c. A 16-hr-old infant who has yet to pass a meconium stool 144. A nurse is verifying a record of informed consent for a client who is scheduled for surgery. Which of the following actions should the nurse take? a. Explain the procedure to the client before verifying informed consent b. Inform the client about the condition that requires treatment d. Provide information on the informed consent form about the benefits of the surgery 145. A nurse is providing teaching for a child prescribed ferrous sulfate. Which of the following instructions should the nurse include? a. Take at bedtime c. Take with a glass of milk d. Take with meals 146. A nurse is teaching a client about taking omeprazole. Which of the following statements by the client indicates an understanding of the teaching? a. “I will open the capsule and mix the medication with applesauce.” b. “I will take a laxative if I become constipated.” d. “I will take it as needed for ulcer pain every 4 hours.” 147. A nurse is preparing to administer heparin IV bolus to a client. The prescription is for 175 units/kg. The client weighs 167.2 lbs. How many units should the nurse plan to administer? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.) ! 13,300 units 167.2 / 2.2 = 76 kg 175 units x 76kg = 13,300 units 148. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Notify security to monitor the facility’s exits c. Call the provider for a discharge prescription d. Place the client in seclusion 149. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client? a. Canned barley soup b. Wheat crackers d. White flour tortillas 150. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? a. Assess the client’s behavior once every hour c. Discuss with the client his inappropriate behavior prior to seclusion d. Offer fluids every 2 hrs. 151. A nurse is providing teaching for a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching? a. “I should limit my intake of dairy products to prevent nausea.” c. “I should moisten my lips with lemon-glycerin swabs.” d. “I should gargle with an alcohol-based mouthwash to kill germs.” 152. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which o the following actions should the nurse take? a. Withhold the medication if the client does not appear to be in pain b. Withhold the medication if the client has a fever d. Document administration of the medication upon removal from the medication dispensing system 153. A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel? b. Check the client’s pedal pulse on the right leg ASSESS c. Ask the client to describe her pain ASSESS d. Observe the position of the suspended weight ASSESS 154. A wound care nurse is planning care for an older adult client who has a pressure ulcer on his coccyx. Which of the following resources should the nurse reference when including evidence-based practices in the treatment plan? a. A diagnosis-related group (DRG) b. The State Nurse Practice Act d. The current Institute of Medicine (IOM) report 155. A nurse on an inpatient mental health unit is leading a group session and a member of the group is dominating the discussion. Which of the following actions should the nurse take? a. Ask the client why he is being disruptive b. Request that the client leave the group session d. Encourage other group members to ignore the client’s behavior 156. A nurse is reviewing the laboratory results of a client who has severe malnutrition and is receiving total enteral nutrition. Which of the following results should the nurse report to the provider? a. Serum phosphorus 3.3 mg/dL c. Serum calcium 9.2 mg/dL d. Serum potassium 3.9 mEq/L 157. A nurse is caring for an adolescent who has hyperthermia. Which of the following is an appropriate action for the nurse to take? a. Cover the adolescent with a thermal blanket b. Initiate seizure precautions c. Administer oral acetaminophen B na yan kalerki. d. Submerge the adolescent’s feet in ice water 158. A nurse is caring for a female client who tells the nurse she is taking valerian to relieve her menstrual cramps. The nurse should instruct the client to avoid the use of this herbal product due to which of the following client’s medications? b. Oral contraceptives c. Levothyroxine d. Calcium carbonate 159. A nurse is reviewing laboratory findings of a client who is to receive a dose of enoxaparin. For which of the following laboratory values should the nurse withhold the dose and notify the provider? a. BUN 25 mg/dL b. Urine specific gravity 1.035 d. WBC 15,000/mm3 160. A nurse is providing prenatal teaching about iron to a client who follows a vegetarian diet. The nurse should recommend that the client consume which of the following foods to enhance the absorption of nonheme iron? b. Boiled eggs c. Mixed nuts d. Cheddar cheese 161. A nurse is admitting a client who is 1 week postpartum with excessive vaginal bleeding. The nurse does not speak the same language as the client. The client’s partner and 1-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s admission data? a. Ask a nursing student who speaks the same language as the client to translate c. Have the client’s child translate d. Allow the client’s partner to translate 162. A nurse is preparing to apply a transdermal nicotine patch on a client. Which of the following actions should the nurse take? a. Remove the previous patch and place it in a tissue b. Shave hairy areas of skin prior to application c. Apply the patch within 1 hrs. of removing it from the protective pouch d. Wear gloves to apply the patch to the client’s skin REPEAT Q. 163. A nurse is reviewing a client’s laboratory values. Which of the following should the nurse review to evaluate the client’s nutritional status? a. Serum sodium c. Troponin level " heart stroke d. Erythrocyte sedimentation rate 164. A nurse is assessing the pupils of a client who has a head injury. Which of the following images indicates that the client has increased intracranial pressure? P. 1359 LEWIS sxs increased ICP = uncal herniation = UNILATERAL DILATED PUPIL BOTTOM LEFT 165. A nurse is assessing a client who is 2 hrs. postpartum for uterine atony. Which of the following actions should the nurse take? a. Evaluate the client’s pain level b. Monitor the client’s urinary output d. Check the client’s vital signs 166. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? a. “The cord stump will fall off in 5 days.” b. “Contact the provider if the cord stump turns black.” d. “Clean the base of the cord with hydrogen peroxide daily.” 167. A nurse is teaching an adolescent who has type 1 diabetes mellitus and his parents how to dispose of his insulin syringes and needles at home. Which of the following instructions is appropriate? a. Recap the needles and wrap them and the syringes in paper towels b. Seal the needles in zipper-lock plastic bags and place them in a metal trash can d. Place the needles in a plastic container and then pour alcohol into the container 168. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing? a. Digoxin c. Morphine d. Omeprazole 169. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first? a. Instruct the client about the steps of the procedure b. Document the sequence of events as they occur d. Provide nonpharmacological pain management interventions 170. A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor? b. Bradycardia c. Bulging fontanel d. Distended jugular vein 171. A nurse is assessing a client who has antisocial personality disorder. Which of the following characteristics should the nurse expect? b. Needs continued reassurance c. Sensitive to criticism d. Exaggerated expression of emotion 172. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following strategies is appropriate for this client? a. Schedule the client as the last surgery of the day c. Tape stockinet over monitoring devices and cords d. Disinfect and powder any latex products before use 173. A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client’s plan of care? a. Provide 60 mL (2 oz.) of fluid intake every 5 min c. Ambulate the client 48 hrs. after the procedure d. Provide a soft diet on the first postoperative day 174. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag 2016 practice comp c. A client who is scheduled for chemotherapy and has an RBC of 4 million/mm3 d. A client who is 24 hrs. postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing 175. A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider? a. Breast tenderness b. Frequent nausea - migraine headaches; report to MD d. Weight gain 2.3 (5 lbs.) 176. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? a. Numbness and tingling of the extremities b. Increased salivation c. Headache - dye is injected 177. A nurse is caring for a client who has AIDS and is receiving antiretroviral treatment. Which of the following laboratory findings indicates that the client is responding to the treatment? b. Negative ELISA test c. Decreased CD4+ cell count - should increase when responding to TX d. Positive Western blot test 178. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. The lung has re-expanded b. There is a loop of tubing below the drainage system d. The tubing is partially obstructed by clots 179. A nurse is caring for a client who has a new diagnosis of diabetes mellitus and states, “I will never be able to give myself insulin shots.” Which of the following is an appropriate response by the nurse? a. “Don’t you think you will change your mind about the injections?” b. “Many people give themselves injections every day.” c. “Would you tell me more about how you are feeling?” d. “Let’s talk about the changes you will need to make in your lifestyle.” 180. A nurse is caring for a client recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, “I am sick of being in here, and I want to go home.” Which of the following is an appropriate therapeutic response? a. “You should call your partner to discuss this.” b. “You are making progress in your treatment plan.”. c “It must be very frustrating for you to be here.” d. “Maybe you should discuss your discharge plans with your provider.” d. Exaggerated expression of emotion 58. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag c. A client who is scheduled for chemotherapy and has an RBC of 4 million/mm3 d. A client who is 24 hrs. postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing 59. A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider? REPEAT a. Breast tenderness b. Frequent nausea d. Weight gain 2.3 (5 lbs.) 60. 44. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform? A. a. Position the head of bed at 30° during feeding PREVENT ASPIRATION b. Mix the client’s medications with the tube feedings c. Give 100 mL of water with every feeding d. Obtain gastric residuals every 24 hrs. 61. 37. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication b. Provide discharge instructions c. Perform chest compressions during cardiac resuscitation REPEAT d. Perform a dressing change for a new amputee 62. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia which of the following is the nurse’s priority? a. Urinary output 35 ml/hrs. at least 30 ml b. 2+ deep tendon reflexes - normal c. 3+ pedal edema d. Respiratory rate 63. A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac disease. Into which of the following positions should the nurse place the client to best promote optimal cardiac output? a. High fowlers b. Standing c. Left-lateral d. Supine 64. A nurse is assessing a client who has type 1 diabetes Mellitus and a blood glucose level of 32mg/dl. Which of the following should the nurse expect? a. Blurred vision b. Hot, dry skin c. Deep respirations d. Bradycardia 65. A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying? a. Atrial fibrillation b. Complete heart lock c. First degree atrioventricular block d. Premature atrial complexes 66. A nurse is providing discharge teaching to a client who has hyperlipidemia and is to start treatment with atorvastatin. The nurse should instruct the client to avoid taking the medication with which of the following? Pg. 184 pharm a. Caffeinated beverages b. Green leafy vegetables c. Aged cheese d. Grape fruit. 67. A nurse is evaluating a client’s understanding of food nutrition labels. Which of the following statements by the client indicate an understanding of the teaching? a. The ingredient with the greatest weight appears first b. Food manufacturers provide nutrition information voluntarily c. Item serving size is consistent from one manufacturer to the next d. The daily values relate to a 1,500-calorie diet 68. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following interventions should the nurse include in the plan? a. Screen the child’s visitors for active infections = correct b. Initiate a low protein diet for the child c. Prepare the child for a platelet transfusion d. Monitor the child for indications of active bleeding 69. The nurse is reviewing laboratory values for a client who has bipolar disorder and takes lithium carbonate. Which of the following values should the nurse report to the provider? a. Thyroxine tT4 2.8 mcg/dl b. Sodium 137 c. Lithium 1.0 d. WBC 5,600 70. A nurse is preparing to administer cefpodoxime 10 mg/kg/day PO divided equally every 12 hrs. to a child who 66lbs. available is cefpodoxime 20 mg/ml oral solution. How many ml should the nurse administer per dose? 66lbs/2.2= 30kg; 300mg/day PO. 300/20 = 15mL oral solution per day Q is bid so 15ml/2 = 7.5mL 71. A nurse is caring for a client who has a prescription for lactated ringers IV 4080 ml/24 hr. the nurse should set the IV infusion pump to deliver many ml/hrs. to administer half the total volume in the first 8hr? 255 72. A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter? a. Speak in a normal voice at a natural pace - correct b. Direct statements to the interpreter - put this send it before changing c. Use gestures when speaking with the client d. Pause in the middle of sentence. MAIN VERSION PRIORITY ONE 1. Missing 2. A nursing planning care for a school-age child who is 4 hrs. postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hrs. following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hrs. (for asthma) c. Apply a warm compress to the operative site every 4 hrs. d. Administer analgesics on a scheduled basis for the first 24 hrs. Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short term (24 to 48 hrs.) around the clock administration of opioids is preferable to following a PRN schedule. ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated on ATI. 3. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR, decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress, tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur after injury usually within 12-48 hrs. 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) b. Wear gloves to apply the patch to the client’s skin c. Apply the patch within 1 hrs. of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) Rationale https://medlineplus.gov/druginfo/meds/a601084.html: How to apply patch Rationale ATI Skills Module Medication Administration: Topical medications include lotions, creams, ointments, patches, and paste. Because topical medications are absorbed by the skin, wear gloves when applying them to protect yourself against accidental exposure Shaving may cause skin irritation and change the absorption of the drug. 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hrs. (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain Rationale Med Surg ATI PDF p529: assess for improvement or worsening of hypoglycemia. Repeat the administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens. 6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial Rationale ATI MS p309: Complications: Aspiration of gastric secretion, causes: Reflux of gastric fluids into the esophagus can be aspirated into the trachea. 7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an INCREASED in which of the following laboratory values? a. Serum glucose level- increased b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased Rationale ATI MS PDF p518: Cushing disease" everything is UP except Potassium & Calcium: DECREASED. 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? Pg. 235 pharm Ch. 30 a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. 9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison Rationale ATI MH p185: Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Rationale ATI COMMUNITY p50: Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body" flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field " 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level" it says BELOW waist level; should be ABOVE waist level Rationale POTTER & PERRY SKILLS & TECH p187: Remove sterile seal and cap from bottle in upward motion. 11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hrs. if unable to fall asleep c. Take a 1 hrs. nap during the day d. Perform exercises prior to bedtime 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. 13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. “Can you tell me who visited you today?” b. “What high school did you graduate from?” c. “Can you list your current medications?” d. “What did you have for breakfast yesterday?” Rationale ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g. birthdate). OR ask the client to state a fact from their past that is verifiable. Memory of events that occurred in the distant past. 14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? P .528 med surg Ch. 82 a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON-COMPLIANT b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% 15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive impairment (http://emedicine.medscape.com/article/816447-clinical#b4 also states that this is an indication of phenytoin toxicity); According to my Davis Drug Guide book, progressive s/s of phenytoin toxicity include ataxia, nystagmus, confusion, nausea, slurred speech & dizziness. 16. A nurse is caring for a client who is 1 hrs. postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing" may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face" side effect d. Absent gag reflex" possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC 17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hrs. b. Monitor the child’s cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hrs. d. Provide stimulation with children of the same age in the playroom Rationale ATI PDF p: PEDS p. 120 Monitor VS, cardiac status. Maintain cardiac monitoring. Assess for HF (decrease urine output, gallop heart rhythm, tachycardia, respiratory distress) Kawasaki disease cause inflammation in the walls of medium-sized arteries throughout the body. It primarily affects children. The inflammation tends to affect the coronary arteries, which supply blood to the heart muscle. 18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction Rationale ATI PDF p:33 PEDS Age appropriate activities for high school students: sports, video games, music, social events. 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? Pg. 146 Ch. 19 CONFIRMED a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia 20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. “I will let the client know that I am available as the interpreter.” b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m available today, but when I’m not, you can use a family member.” d. “I will let the client know that an interpreter is unavailable during the night shift.” Rationale ATI PDF p: Makes most sense (best rationale yet) 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? Pg. 156 Ch. 23 MATERNITY PDF a. A two-day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal they can be is RESPIRATORY DISTRESS b. A 16-hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool c. A 2-day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hrs. old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal 22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hrs. postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity c. A client who had a cardiac catheterization 3 hrs. ago and has 3+ pedal pulses d. A client who has an elevated AST level following administration of azithromycin Rationale: circulation is affected; ABCs 23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? a. Dry mouth" anticholinergic effects b. Sedation " c. Shuffling gait !A/E EPS: is an indication of parkinsonism and should be reported to the provider. ATI PHARM 110 Rationale: e book pg. 69 Ch. 10 24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? Pg. 177 Ch. 26 a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths b. The cord stump will fall off in 5 days- about 10 - 14 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry. 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas b. Potato pancakes c. Wheat crackers d. Canned barley soup Rationale: no wheat, flour, or barley 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech ! alterations in speech d. Hypochondriasis (anxiety disorder) pg. 108 eBook Ch. 20 Rationale: e book pg. 79 under expected findings Ch. 15 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the client’s legs b. Place a towel roll under the client’s neck c. Apply an orthotic to the client’s foot d. Position a pillow under the client's knees Rationale: Casting or splinting techniques are used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint from prolonged immobilization. It is also popular for treating contractures resulting from an increase in muscle tone from nerve injury. After an initial holding cast is applied for seven to 10 days, a series of positional casts are applied at weekly intervals. Before the application of each new cast, the joint is moved as much as can be tolerated by the patient, and measured by a goniometer. When as much motion as possible is obtained after stretching, another final cast is applied to maintain the newly acquired motion. 28. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution ATI COMMUNITY: Providing education to achieve community health goals is a component of identifying and intervening to meet health needs of the local community, which is responsibility to local health departments. 29. A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation " ESI Level 1 b. 10cm (4 in) laceration " ESI Level 4 c. Fractured tibia " ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn " ESI Level 2 required immediate pain control per Triage, hypotension with signs of hypoperfusion. -Patients with signs and symptoms of compartment syndrome are at high risk for extremity loss and should be assigned ESI level 2. Other patients with high-risk orthopedic injuries include any extremity injury with compromised neurovascular function, partial or complete amputations, or trauma mechanisms identified as having a high risk of injury such as serious acceleration, deceleration, pedestrian struck by a car, and gunshot or stab wound victims. Patients with possible fractures of the pelvis, femur, or hip and other extremity dislocations should be carefully evaluated and vital signs considered. These fractures can be associated with significant blood loss. Again, hemodynamically unstable patients who need immediate life-saving intervention such as high-level amputations meet ESI level-1 criteria. High level amputations meet ESI level 1. -Patients with inhalation injuries from closed space smoke inhalation or chemical exposure should be considered high-risk for potential airway compromise. If the patient presents with significant airway distress and requires immediate intervention, they meet level-1 criteria. Patients with third-degree burns should also be considered high-risk and be assigned ESI level 2. It is possible that they will require transfer to a burn center for definitive care. 30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED a. Hgb 12.8 g/dl - 12- 16 b. Potassium 4.2 mEq/l 3.5 - 5.0 mEq c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding Rationale: all other options are okay; except the platelets which is in an abnormal range. 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl (normal: 16-40) c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl Rationale: Prealbumin is low (normal is 18-36). Prealbumin = nutritional status ATI MH 111 Hypoalbuminemia 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? a. A client who is postoperative following a bowel resection with an NGT set to continuous suction b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs 33. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor. Which of the following nursing actions should the nurse take? pg. 88 Ch. 13 maternity a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMED b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the client’s current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 35. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range b. Fasting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. Rationale: CDC states that: There is no documented evidence that breastfeeding spreads HCV. Therefore, having HCV- infection is not a contraindication to breastfeed. HCV is transmitted by infected blood, not by human breast milk. There are no current data to suggest that HCV is transmitted by human breast milk. However, HCV is spread by infected blood. Therefore, if the HCV-positive mother’s nipples and/or surrounding areola are cracked and bleeding, she should stop nursing temporarily. Instead, she should consider expressing and discarding her breast milk until her nipples are healed. Once her breasts are no longer cracked or bleeding, the HCV-positive mother may fully resume breastfeeding. 37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the client’s information? Exhibit. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain? b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds 38. A nurse is caring for a client who has hyperthermia. Which of the following actions for the nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket " if hypothermia. c. d. Initiate seizure precautions Seems like the safest intervention Rationale: Hyperthermia occurs when a person's body temperature rises and remains above the normal; 98.6°F Most frequently, this occurs during the heat of summer and among the elderly. However, it may also be triggered by other medical conditions or certain medications. Rapid cooling may be the single most important action to prevent death or permanent disability. To mitigate organ damage, the goal should be to reduce rectal temperature to below 40°C within 30 minutes of beginning cooling therapy. The question does not indicate whether it is malignant hyperthermia which could have been caused by a medication. The question simply asks that the person has hyperthermia. 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include? a. Document the client's conditions every 15 minutes b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? P. 482 Ch. 75 CONFIRMED a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have questions about your mom dying. Let’s talk about it. Rationale: Therapeutic communication 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who received a Mantoux test 48 hours ago and has induration c. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) Rationale: The skin test (Mantoux tuberculin skin test) should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will probably need to be rescheduled for another skin test. 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone Rationale: Clarify! 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information - HIPAA rules b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner Rationale: HIPAA (Patient has the right to make their own health decisions and also decide who they want the information to be shared with.) 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lbs.). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3% Rationale: 15lb/200lb = 0.075 x 100 = 7.5% weight loss percentage 46. A nurse is caring for a client who is 4 hrs. postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage (massage if fundus is boggy) b. Pour water from a squeeze bottle over the client’s perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client’s perineal area. (warm) 47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hrs. transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. Rationale: According to manufacturer, do not expose the site to heat sources such as heating pad, electric blanket, sauna, hot tub, heated waterbed, excessive sun exposure, or hot climate. The body absorbs too much medicine with excessive heat. *48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? Ch 55 p. 333 a. Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) b. Place the client upright on a donut-shaped cushion- Upright causes increased pressure on the sacrum c. Assess pressure points every 24 hr.- must assess FREQUENTLY so I would rule out b then yeah it does. d. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in chair. Rationale: impairment or loss of motor or sensory function in areas of the body served by the thoracic, lumbar, or sacral neurological segments owing to damage of neural elements in those parts of the spinal column. It spares the upper limbs but, depending on the level, may involve the trunk, pelvic organs, or lower limbs. 49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress d. We should establish our roles in the initial session. Rationale: Orientation Phase: ! The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship). ! Trust, respect, honesty and effective communication are key principles in establishing a relationship. ! The expectations the nurse and the client have of each other and of their relationship are discussed and clarified ! The nurse gathers information and ensures that priority issues are appropriately addressed. ! Consistency and listening are considered by clients to be critical at the beginning of the relationship ! The nurse assists in promoting client comfort that may include reducing anxiety or tension. 50. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon Rationale: MAOIs = antidepressants; avoid foods with high tyramine content (egg, aged cheeses, sour cream, red wines, beer, bologna, pepperoni, salami, summer sausage, pickled herring, liver, meat prepared with tenderizers, canned figs, raisins, bananas, avocados, soy sauce, fava beans, yeast extracts), drink alcohol, or consume large quantities of caffeine (coffee, tea, chocolate, or cola) 51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit (1) b. Activate the facility’s fire alarm system (2) c. Close all nearby windows and doors (3) d. Use the unit’s fire extinguisher to attempt to put out the fire (4) Rationale: RACE *52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? Ch 4 p. 23 funds a. Heightened perceptual field b. Rapid speech -severe c. Feelings of dread d. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) CONFIRMED a. Tremors b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis e. Inability to concentrate 54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension (Upper HYPERtension) b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses Rationale: Pg.112 (Pediatrics) A narrowing of the major artery (the aorta) that carries blood to the body. This narrowing affects blood flow where the arteries branch out to carry blood along separate vessels to the upper and lower parts of the body. CoA can cause high blood pressure or heart damage. *55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd) Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: # legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) # education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) # immunization against infectious diseases. 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative = ASSESSMENT= RN b. Administering oral fluids to a client who has dysphagia- RN- complex patient who is also UNSTABLE + basic nursing skills c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke- Assessment = RN 57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” : Pg. 315 (Med/surg) Drink alcohol in moderation. Stop smoking. Avoid NSAIDs. Limit Caffeine-containing. 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech Rationale: dry mouth 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? CONFIRMED a. Assess effectiveness of antiemetic medication- ASSESS = RN b. Perform chest compressions during cardiac resuscitation- BASIC LIFE SUPPORT- CNA can do c. Perform a dressing change for a new amputee- BASIC NURSING SKILLS= LVN d. Apply a transdermal nicotine patch- BASIC NURSING SKILLS =LVN *60. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily 61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? P. 57 pharm a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss c. Urinary retention- ANTICHOLINERGIC EFFECTS- dry dry dry. Also, tachycardia, blurred vision, constipation d. Hypertension- orthostatic hypotension it will cause instead 62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. Hypertension: p g. 245 Ch. 31 pharm c. Fibromyalgia d. Fibrocystic breast condition 63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure Rationale: fund ati pg. 27 64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. “You should not have this procedure if you are allergic to iodine.” b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” Rationale: med-surg ati pg. 39. Nursing actions: assess for allergy to shellfish or iodine, which would require the use of a different contrast media 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, Hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? Pg. 125 Ch. 21 a. Initiate IV fluid replacement- BLOOD IS TOO VISCOUS = obstruction = tissue hypoxia. CONFIRMED b. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to Reye’s disease. d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? !"##$%& (.*+ Babies are cuties~ a. b. C and D not shown From the two pictures shown I think it is B. Rationale: https://www.whattoexpect.com/first-year/infant-car-seat-safety Dress baby comfortably, set the seat at 45 degrees, rear facing until 2 years old, make sure baby’s head is secure (usually with special cushioned inserts), the straps on a rear facing safety seat should be at or below baby’s shoulders, strap and fasten them at armpit level, straps should lie flat and untwisted; tight enough so that you get fit two fingers between harness and baby’s collarbone 68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion- assess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hrs.- 2- 4 hours for blood transfusion pg. 250 c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- prime blood administration set with NS only d. Administer the blood via a 21-gauge IV needle- page 249 says 18 -20 gauge 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? CONFIRMED a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: fund ati pg. 17 - When a client decides to leave the facility against medical advice (without a discharge prescription), the nurse notifies the provider and discusses with the client the risks to expect when leaving the facility prior to discharge. *70. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. “I try to respond to the baby quickly so she doesn’t cry very long.” b. “I think the baby should be sleeping through the night by now.”??????? c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.” 71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? Pg. 180 Ch. 26 maternity a. Temperature 38 C (100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability !"##$%& (1*+ Leaning more towards D or B. A/C both sound more like it's about TLC for the baby. Why D? Sounds like they could be distressed or worn out, so they can't deal with the situation as they look for other answers. B sounds like they -kind of- know their baby's schedule and perks and can further manage their behavior well enough, but it can also mean something in a more sinister way, if you think about it. TBC c. Pale and 24-hour fluid deficit of 30 mL - pale= Respiratory distress????? d. Sunken fontanels and dry mucous membranes 72. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, the nurse does not speak the same language as the client. The client partner and a 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s information? a. Request a female translator interpreter through the facility b. Ask a student nurse who speaks the same language to translate c. Have the child translate d. Allow the clients partner to translate 73. A nurse is caring for a client who has pernicious anemia. Which of the following laboratory values should the nurse evaluate effectiveness of the treatment? p. 253 Ch. 41 med surg pdf A. Folate level B. INR level C. Vitamin b12 level CONFIRMED D. Creatinine level 74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device 75. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mLs b. Fundus 2 fingerbreadths above the umbilicus (needs to be below or at the umbilicus) c. Uterine atony (fundus not firm which means possible hemorrhage) d. Fundus firm and to the right of the abdominal midline (fundus not midline, bladder may cause shifting if patient not voiding properly) 76. A nurse is caring for a client who has acute glomerulonephritis. Which of the following should the nurse expect? p. 391 Ch. 60 med surg pdf a. Polyuria- oliguria b. Hypotension- hypertension c. Hematuria - urinalysis will show red blood cells and protein, also reddish-brown col colored urine d. Weight loss - weight gain 77. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include? p. 50 Ch. 7 pharm pdf SSRI for social anxiety, PTSD, A. Excessive sweating - diaphoresis, nausea, fatigue, drowsiness (early adverse) B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 78. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? a. your baby will be given 2 ounces of water to drink prior to the test b. this test will be repeated when your baby is 2 months old c. a nurse will draw blood from your baby’s inner elbow d. this test should be performed after you baby is 24 hours old ATI MATERNITY 281■ Newborn genetic screening is mandated in all states. A capillary heel stick should be done 24 hrs. following birth. For results to be accurate, the newborn must have received formula or breast milk for at least 24 hr. If the newborn is discharged before 24 hrs. of age, the test should be repeated in 1 to 2 weeks. 79. a nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? Pg. 106 Ch. 10 pediatrics a. perform the procedure prior to meals: AVOID Before or AFTER meals b. perform the procedure twice a day c. administer a bronchodilator after the procedure- must be given BEFORE d. hold hand flat to perform percussions on the child- NO has to be CUPPED!!! 80. a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls" correct approach; yellow bracelet indicates fall risk b. administering potassium via IV bolus ! incomplete info; I don't see anything wrong with administering K+ IV bolus? - IV bolus Vit. K Push has been used to murder patients, should be diluted or pushed very slowly c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication " If they’re conscious and can swallow and the NGT is clamped, OK! However, Malpractice (Professional Negligence) A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. 81. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness. R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? P. 106 CH 19 PEDS a. Take pancrelipase b. Complete oral hygiene c. Eat a meal d. Use an albuterol inhaler ATI PEDS 85 Administer a bronchodilator medication or nebulizer treatment prior to postural drainage if prescribed. 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P. 164 Ch. 27 med/surge a. Monitor the dorsalis pedis pulse every 15 minutes ! circulation b. Maintain strict bedrest for first 12 hrs.- only for prescribed time, older adults usually are up to 4 hours. c. Keep the client NPO for 24 hrs.- doesn’t say anything about restrictions AFTER the procedure, and NPO b4 the procedure is up to 8 hours. d. Place the client in Fowler’s position- supine they must be http://micunursing.com/cardiaccathpreandpostcare.htm ! Generally, the nurse should monitor vital signs, and distal pulses every 15 minutes X 4, every 30 minutes X 2, then every hour X 2, then routine. If there is any change in the patient's neurovascular status for physician should be notified immediately. 84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? a. Offer high-calorie, high protein snacks to the client b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing? a. Non-maleficence b. Veracity c. Autonomy d. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first? p. 287 Ch. 43 A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. 87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor? CONFIRMED a. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow b. Hyperkalemia- LESS c. Hypercalcemia d. hypoglycemia ATI PHARM 237 A/E Hyponatremia, dehydration, and hypochloremia 88. a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 Cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) 140??(not sure) _ pounds 1 lbs. per week x 25 week= 25 lbs. 75 x 2.2= 165 lbs. 165 lbs-25 lbs.=140 lbs. or 63.6 kg (64 kg) 89. a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will change my baby’s diaper at least every 4 hours b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change R: p178 Maternal newborn Teach the parents to keep the area clean. Change the newborn’s diaper at least every 4 hrs., and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hrs. after the circumcision to keep the diaper from adhering to the penis. 90. a home health nurse is caring for an adult client who reports, “I keep coughing when I try to swallow my food, but not at other times.” Which of the following actions should the nurse take? a. encourage the client to increase fluid intake b. initiate a consultation with a speech! language pathologist; swallow eval c. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. 91. A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% Glycosylated hemoglobin (HbA1c): best indicator of an average blood glucose level for the past 120 days 92. A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication? A. BUN B. Blood pressure C. Respiratory rate D. aPTT Beta blocker - blood pressure medication. 93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? A. Encouraging the client to use jet therapy on her lower back for 1 hrs. - (as long as a patient in active labor has no contraindications, she can generally stay in the bath for 30-60 mins) B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen (some therapies vary - such as TENS may require trained practitioners and sometimes specialized equipment) C. Using effleurage on a client’s lower abdomen - (light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions) D. Instructing a client’s partner how to apply counter pressure to the client’s sacral spine for 30 min - (consistent pressure is applied using the heel of the hand/fist against the client’s sacral area to counteract pain in the lower back) 94. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 D. Evaluate the APs’ performance of each task 4 95. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I should take antibiotics when I have a virus.” (antibiotics doesn’t fight viral infections) B. “I should wash my hands for 10 seconds with hot water after working in the garden.” (ok burn your hands) C. “I can clean my cat’s litter box during my pregnancy.” Toxoplasmosis D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” Contagious from the beginning of the illness (up to 2 days before the spots appear) until about 5 days after the first spots appear. So long as there are no new blisters or moist crusts on spots, person will not be contagious even if there are still crusts on the skin. 96. A nurse is caring for a school-age child who is 2 hrs. postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take? A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site. B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site. C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site. to localize pressure over the vessel puncture D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. 97. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? A. Phlebitis B. Abdominal aortic aneurysm C. Osteoarthritis D. Peripheral neuropathy Contraindications include acute inflammatory diseases, skin lesions, and peripheral neuropathy because of the risk of BURNS...has loss of sensation 98. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? A. Sensation of skin warmth Feeling of warmth and fluttering of heart is felt as catheter is passed B. Headache C. Increased salivation D. Numbness and tingling of the extremities 99. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? A. Lorazepam .5 mg PO one tablet daily (needs a preceding zero - “0.5”) B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 100. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face Preeclampsia B. Urinary frequency Pressure on bladder from enlarging uterus C. Faintness upon rising D. Bleeding gums Caused by increase of blood flow to gums, normal 101. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? !" #$%&'()*(&+ &- *./ 01(+ &+ *./ +/%1 )+2 %./0* !"#$ &'()#*#+,-'* ./,01&,-/,0+ 3" !"#$%&'(& 4" 45(/+* '/6&'*0 ) 6)(+ 5/7/5 &- 8 &+ 0%)5/ -'&9 :;<: 23+'4 56(-) =" >/'&0*&9() 7"8 $#9() 102. A nurse is assessing a client who is 2 hrs. postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus 103. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? !" *+%(# ,"$- ./ #-(012- 3&4 5- 6(#,&7-4 /.2 8&"82-&6(4'9 ?%)+ @/ @'(/- *.)* 0&9/*(9/0 *./A )'/ 9(0*)1/+ -&' 2)A2'/)9(+B )+2 9)A +&* @/ 2/*/%*/2 -&' 9&+*.0C 3" DE./ %.(52 F0F)55A .)0 )+ )F') 6'(&' *& &+0/*G 4" E.(0 *A6/ &- 0/(HF'/ 5)0* I:;8: 0/%G ?@/B(+ )+2 /+2 )@'F6*5AC =" DE.(0 *A6/ &- 0/(HF'/ .)0 ) B')2F)5 &+0/*G ?B/+/')5(H/2 &+0/*C 104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? !" =(0(+-/%* )+2 6&J2/' )+A 5)*/$ 6'&2F%*0 @/-&'/ F0/ ?0F665A ) 5)*/$;-'// %)'*C 3" +&$- #,.37(4-, .:-2 6.4(,.2(4' 8-:(3- &48 3.28# ?65)%/ )55 9&+(*&'(+B 2/7(%/0K %&'20L*F@/0 (+ 0*&%1(+/* )+2 0/%F'/ J(*. *)6/ *& 6'/7/+* 2('/%* 01(+ %&+*)%*C Our group answered B on this one. Double Check. 4" M%./2F5/ *./ %5(/+* )0 *./ 5)0* 0F'B/'A &- *./ 2)A ?)55/'B/+ -'&9 5)*/$ %)+ %('%F5)*/ (+ *./ )(' -&' )+ .&F' )-*/' 6'&%/2F'/ J./'/ 5)*/$ J)0 F0/2 ; 0%./2F5/ 0F'B/'A ;<=>+ %)0/ &- *./ 2)AC =" N/9&7/ 0*&6%&%10 -'&9 OP *F@(+B ?Q0/ OP *F@(+B 6&'*0 J(*.&F* 5)*/$ 6&'*0 ; F*(5(H/ MERS4R4TM (- )7)(5)@5/C .**6ULL5)*/$)55/'BA'/0&F'%/0"&'BL)'*(%5/0L))+);5)*/$;6'&*&%&5 105. A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication? (there is an exhibit. The answer the person picked was A) A. Dumping syndrome B. Ketoacidosis C. Hepatotoxicity D. Thyroid storm 106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room (private room) B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft. from the client (6ft for reg visitors, no preggerz allowed) E. Close the door to the client's room 107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem 108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one Don’t just offer, prepare gifts ahead of time so the sibling doesn’t feel left out. Provide a gift from the infant to give to sibling B. Move your son to a toddler bed when the baby arrives 2 months before C. Tell your son to kiss the baby Don’t force interactions b/t child and the baby =" Teach your son to change the baby diapers - allow older siblings to help in providing care for the infant 109. A nurse is obtaining a nutritional health Hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics- this would cause diarrhea C. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen Peritonitis D. Bounding pulse A condition in which the normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left to right shunt) "" Murmur (machine hum) "" Wide pulse pressure "" Bounding pulses "" Asymptomatic (possibly) "" Heart failure 111. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occurs. Rationale: OB ati book. Page 66. Monitor for magnesium sulfate toxicity, and discontinue for any of the following adverse effects: loss of deep tendon re exes, urinary output less than 30 mL/hrs., respiratory depression (less than 12/min), pulmonary edema, and chest pain. 112. A nurse is caring for a client who has end stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension (96)('0 1(2+/A -F+%*(&+ b. Primary glaucoma c. Osteoarthritis d. Amputation Rationale: pretty sure it’s A. Page 373. Age younger than 2 years • Age older than 70 years: Older adult clients are at risk for developing advanced heart disease and malignancies, which increases the risk for complications with kidney transplantation surgery. • Advanced, untreatable cardiac disease • Active cancer • Chemical dependency • Chronic infections or systemic disease (HIV, hepatitis B or C) • Coagulopathies and certain immune disorders • Morbid obesity • Diabetes mellitus • Chronic pulmonary disease 113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. BEFORE MEALS b. Request non-gas forming foods from the dietary department :'. 4#"$,0+ 4##3. 5*#'( ()6 '53; $'/,0+ 5"6'(),0+ 3,44,-9*( c. Limit the client’s food consumption between meals. SMALL FREQUENT MEALS d. Arrange for a low protein diet. HIGH PROTEIN. 114. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department? https://medlineplus.gov/ency/article/001929.htm a. Candidiasis b. Herpes simplex virus c. Human papillomavirus d. Chlamydia .**60ULLJJJ+"%2%"B&7L++200L%&+2(*(&+0L+&*(-()@5/LV:<8L 115. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? a. Place a cardiac monitor on the client CONFIRMED b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hrs. urine collection Rationale: potassium level is too high so yeah place a cardiac monitor on the client b/c hyperkalemia can lead to dysrhythmias. 116. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks. -Avoid vigorous activities. b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds. c. I can resume activities, such as sewing. <'8 "6.9$6 $#.( "#9(,06 -)#"6.='-(,>,(,6. '"#903 ()6 )#9.6 d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level. Rationale: http://wps.prenhall.com/wps/media/objects/737/755395/eye_surgery.pdf 117. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min (# '>#,3 ,049.,#0 "6'-(,#0. .9-) '. ?63 <'0 .803"#$6@ "'.)6.; 4*9.),0+; ('-)8-'"3,'; '03 )8&#(60.,#0 1 '3$,0,.(6" .*#A*8 #>6" BC $,0 b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose Rationale: page 597. PHARM ati book. 118. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Take magnesium hydroxide for indigestion -not for pts with CKD or dialysis. b. Eat 1g/kg of protein per day - e'-) 6D-)'0+6 39",0+ 3,'*8.,. 36&*6(6. &"#(6,0; "6E9,",0+ ()6 -*,60( (# ,0-"6'.6 &"#(6,0 ,0('/6 #>6" &"63,'*8.,. *,$,('(,#0.; 59( ,( .(,** $,+)( "6E9,"6 .#$6 "6.(",-(,#0F c. Drink at least 3L of fluid daily -too much fluid d. Consume foods high in potassium -low potassium diet Rationale: http://www.nutritionmd.org/health_care_providers/renal/renal_nutrition.html https://www.gicare.com/medication/mylanta-liquid/ 119. A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology- b. Take the vital signs of the clients on the side of the unit c. Tell me the standing weight of the client in room 102 before breakfast d. The client in room 109 has spilled his water pitcher Rationale: right direction/communication. Leadership. 120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site 06-"#.,. A,() 6D("'>'.'(,#0 1 3,.-#0(,096 2G b. Blood pressure 92/68 mm Hg - 20-"6'.6. A#"/*#'3 #4 ()6 )6'"(; A#"/. (# ,0-"6'.6 HI=J? c. Urine output 35mL/hrs. d. Pedal pulse of +1 bilaterally Rationale: Page 277. PHARM ATI. ADVERSE EFFECT: Necrosis. 121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward first (Both crutches ONLY forward first) Rationale: CRUTCH INSTRUCTIONS # Do not alter crutches after fitting. # Follow the prescribed crutch gait. # Support body weight at the hand grips with elbows flexed at 30°. # Position the crutches on the unaffected side when sitting or rising from a chair. 122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? !" W&6 &+ &+/ -&&* KL 86'". #*3M ?@ A(37 & 5&BB /.2C&28 4" 45(9@ M*)('0 J(*. )5*/'+)*/ -//* N 86'". #*3 O P 86'". #*3 -*,$5. .(',". 58 &*'-,0+ 5#() 466( #0 6'-) .(6& =" N(2/ ) *'(%A%5/ KN1B 86'". #*3M 123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. I’m sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. Rationale: Case Manager Role: Also, D is the most therapeutic. • Coordinating care, particularly for clients who have complex health care needs • Faci I i tating continuity of care • Improving efficiency of care and utilization of resources 124. A nurse is assessing a client following an ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures Rationale: COMPLICATIONS WITH ISCHEMIC STROKE . Dysphagia and aspiration . # Dysphagia can result from neurological involvement of the cranial nerves that innervate the face, tongue, soft palate, and throat. As a result, the client’s risk of aspiration is great. . # Not all clients who have experienced a stroke have dysphagia, but all should be evaluated prior to reestablishing oral nutrition and hydration. 125. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedural weight. B. Check the client's serum albumin levels (Check possible albumin for possible complication not for effectiveness) C. Examine for leakage at the site of the procedure D. Confirm that the client is able to urinate (To check for complication not effectiveness) Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and remove ascites fluid in the abdominal wall. 126. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with this leg extended. (With leg Flexed) 3" X)(+*)(+ /A/ %&+*)%* J(*. *./ +/J@&'+ 2F'(+B -//2(+B0" !7&(2 /A/ %&+*)%* D@ E(4(6(0- 4.(#- (4 ,%- 4-C5.24 -4:(2.46-4, 2/%'/)0/ /+7('&+9/+*)5 0*(9F5( =" !29(+(0*/' +)5&$&+/ *& *./ +/J@&'+ F0/ 9&'6.(+/K +)5&$&+/ 9)A 6'/%(6(*)*/ 0/(HF'/0 Rationale: Nursing care for maternal substance use and neonatal effects or withdrawal include the following in addition to normal newborn care. # Monitor the newborn’s ability to feed and digest intake. Offer small frequent feedings. # Offer non-nutritive sucking. # Monitor the newborn’s fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, and I&O. # Reduce environmental stimuli (decrease lights, lower noise level). 127. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? !" F&2,(3($&,- (4 3.6614(," 82(BB# &48 6.37 -:-4,#" YF0* *.(+1 )@&F* (*Z" B(7/ (* ) J.(5/ [R[ UCCCCC 3" P)%%(+)*/ 0F0%/6*(@5/ %.(52'/+ )+2 )2F5*0 )B)(+0* 09)556&$ D@ G##-## ,"$-#H B-:-B# &48 #3.$-# ./ 8(#&#,-2#@ X/)+J.(5/ ./'/ %&9/0 ) 2(0)0*/' )+2 A&F\'/ 0*(55 )00/00(+B [R["""3RRX]] =" X)1/ ^F)')+*(+/ 6'/6)')*(&+0 -&' *.&0/ /$6&0/2 *& )+*.')$ N)*(&+)5/U !00/00 _('0* `F'0/0 )+2 &*./' 9/9@/'0 &- *./ ./)5*.%)'/ */)9 0.&F52 @/ (+7&57/2 (+ *./ 2/7/5&69/+* &- )+ #RS -&' 0F%. /9/'B/+%(/0" 128. A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect? A. Ritualistic behavior (OCD) B. Exhibits separation anxiety (Dependent) C. Preoccupied with aging D. Suspicious of others. (Paranoid) Rationale: Narcissistic: Characterized by arrogance, grandiose views of self-importance, the need for consistent admiration, and a lack of empathy for others that strains most relationships; often sensitive to criticism 129. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Withdraw the client's TV privileges if he does not attend group therapy F0/ *./')6/F*(% %&99F+(%)*(&+ */%.+(^F/0K )7&(2 6&J/' 0*'FBB5/0 B. Place the client in seclusion when exhibits signs of anxiety (Seclusion when on Acute Manic Episode) C. Encourage the client to take frequent rest periods. D. Encourage the client to spend time in the day room. X)A /0%)5)*/ @/.)7(&' @/%)F0/ &- 0*(9F5)*(&+ Rationale: Page 76 of Mental Health Book. NURSING CARE involves implement frequent rest period. 130. A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. (Stage IV Kidney Disease) B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. 131. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area 132. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet - People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato 133. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Seizure disorder b. Polycystic ovary syndrome c. Renal insufficiency- due to the increase of lactic acidosis '*-#)#* J(55 (+%'/)0/ '(01 &- 5)%*(% )%(2&0(0 J(*. %&+%F''/+* F0/ &- 9/*-&'9(+a '/+)5 (+0F--(%(/+%A J(55 '/0F5* (+ )%%F9F5)*(&+ &- 9/2(%)*(&+ (+ *./ @&2A )+2 '/0F5*(+B (+ .A6&B5A%/9() d. Gluten intolerance 134. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? )" D.4,2&3,(.4# ; !27(0/ *./ %5(/+* *& '/6&'* *& ./' 6'&7(2/' (- 0./ /$6/'(/+%/0 -/7/'K %.(550K 5/)1)B/ &- -5F(2K &' @5//2(+B -'&9 *./ (+0/'*(&+ 0(*/K 2/%'/)0/2 -/*)5 9&7/9/+*K 7)B(+)5 @5//2(+BK &' 1,-2(4- 3.4,2&3,(.4# )-*/' *./ 6'&%/2F'/ @" P&9(*(+B %" WA6/'*/+0(&+ 8@ I$('&#,2(3 $&(4 J'..'B- - Amniocentesis -performed at 14 weeks. Finds out abnormalities, lung maturity. Empty bladder before procedure. complications: fluid emboli, hemorrhage, fetal death, premature rupture of membranes, leakage of amniotic fluid (Epigastric pain is mostly heartburn and other digestive complications, would not make sense to report this problem. 4&965(%)*(&+U 9(0%)''()B/ &' 6'/*/'9 5)@&'a !EO X!E#N`OEb 6B" Ic 135. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? a. A 15-year-old who is 6 hrs. postop following a herniorrhaphy and reports pain at the IV site b. 3-month-old who is 1-day postop following cleft lip repair and has a pulse of 120 c. 12-year-old who is 2 days postop following an appendectomy and is refusing to ambulate d. 8-year-old client who is 12 hrs. postop following a tonsillectomy and is experiencing frequent swallowing - @5//2(+B 136. A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after I first feel the urge to urinate d. I will determine which muscles to contract by stopping and starting my stream of urine 137. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? a. I need to have an enema before the test b. I should urinate before the test c. I will lie on my left side during the test 0F6(+/ 6&0(*(&+ J(*. J/2B/ F+2/' '(B.* .(6 d. I will drink an oral glucose solution during the test O+0*'F%* 6*" *& -6$," 5B&88-2 6'(&' *& 6'&%/2F'/ *& '/2F%/ 0(H/ d '/2F%/ '(01 &- (+)27/'*/+* 6F+%*F'/ 138. A nurse in an emergency department is caring for a client who reports cocaine use 1 hrs. ago. Which of the following findings should the nurse expect? a. Memory loss b. Slurred speech c. Elevated temperature d. hypotension - Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension 4&%)(+/ ?MEOXQ[!`EC ; 2(HH(+/00K (''(*)@(5(*AK *'/9&'K @5F''/2 7(0(&+K .)55F%(+)*(&+0K 0/(HF'/0K -K,2-6- /-:-2K *)%.A%)'2()K WE`K %./0* 6)(+K 6&00(@5/ 4P %&55)60/K 2/)*. 139. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules S/'(%)'2(*(0U (+-5)99)*(&+ &- *./ 6/'(%)'2(F9 *.)* %&99&+5A -&55&J0 ) '/06(')*&'A (+-/%*(&+" 4)+ @/ 2F/ *& ) 9A&%)'2()5 (+-)'%*(&+" _(+2(+B0 (+%5F2/ %./0* 6'/00F'/L6)(+ )BB')7)*/2 @A @'/)*.(+B ?9)(+5A (+06(')*(&+CK %&FB.(+BK )+2 0J)55&J(+Ba $-2(3&28(&B /2(3,(.4 215 )F0%F5*)*/2 )* 5/-* 5&J/' 0*/'+)5 @&'2/'a MR3a )+2 '/5(/- &- 6)(+ J./+ 0(**(+B )+2 5/)+(+B -&'J)'2 140. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Consume food high in bran fiber c. Sweeten foods with fructose corn syrup d. Increase intake of milk product - Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids 141.A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client’s condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client’s condition. Rationale: Assess the situation by interviewing the client alone so they will speak freely. Need to find out who caused the abuse and neglect. Don’t contact family until you confirm from the client that the family is not responsible. 142.A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client’s extremities. d. Place the clients right hand in supination position. Rationale: Med-surg eBook pg. 84, Assess for swallowing and gag reflex, may cause aspiration if client has difficulty swallowing, keep NPO until cleared. B and C are also nursing actions but not priority. 143. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. “I will decrease my protein intake during the third trimester” (increase protein for basic growth) b. “I will need to increase my insulin doses later in my pregnancy” c. “I will increase my carbs at breakfast and limit them the rest of the day” d. “I will decrease my calorie consumption during the first trimester” (increase calorie) Rationale: OB eBook pg. 26, monitor and limit intake of carbs which include sweets and desserts, due control blood glucose levels. !"#$ ()6 .6-#03 (",$6.(6" #4 &"6+0'0-8; 6.&6-,'**8 '4(6" QR A66/. 8#9" ,0.9*,0 "6E9,"6$60(. A,** 9.9'**8 .('"( (# ",.6F H8 '"#903 NC A66/. 8#9 $'8 0663 '. $9-) '. (A# #" ()"66 (,$6. 8#9" 3',*8 &"61 &"6+0'0-8 ,0.9*,0 3#.6F S),. ,. 56-'9.6 ()6 )#"$#06. $'36 58 ()6 &*'-60(' ,0(6"46"6 A,() ()6 A'8 8#9" ,0.9*,0 0#"$'**8 A#"/. 1 '. ()6 &"6+0'0-8 )#"$#06. ",.6; .# 3#6. 8#9" 0663 4#" ,0.9*,0F T,0/@ )((&@==&"6+0'0-8'033,'56(6.F-#$F'9=60=4#"1A#$601A,()13,'56(6.=-#0("'-6&(,#0=3,'56(6.139",0+1&"6+0'0-8=,0.9*,01 -)'0+6.139",0+1&"6+0'0-8= 144. A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau’s sign b. Assess the client’s skin turgor c. Check the client’s motor strength d. Measure the client’s pupil size Rationale: Med/surg PDF pg. 277 Sign for hypocalcemia, tetany. Early sign of hypocalcemia and paresthesia of fingers and lips. 145. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. “I should clean my stoma with warm water” (can use low pH soap and water) b. “My stoma should be bright pink or red” (pink, red and moist) c. “I should change the stoma pouch every day” d. “I should cut my pouch opening inch larger than my stoma” (allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ! or " full. 146.A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea (bradypnea, less than 12/min) c. Pruritus (sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hrs.) Rationale: OB PDF pg.61, decreased or absent DTRs. 147.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg (9.5 lbs.). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 148.A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “Your desire to be an organ donor must be documented in writing” b. “I cannot be a witness for your consent to donate” (nurses can witness consent to donate) c. “You must be at least 21 years of age to become an organ donor” (no age limit) d. “Your name cannot be removed once you are listed on the organ donor list” (can remove whenever they want, it's a choice by the client not forced once it's signed) Rationale: Leadership PDF pg. 37 advance directives and will are all written and documented 149.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hrs. while awake(bedrest) c. Provide the client with 4 g sodium diet d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr. (fluid restriction, monitor fluid intake and I/O, may overload the patient since they are already in HF they will have edema) Rationale: Med-surg PDF pg. 199 medication for HF, ACE to help pump blood easily, afterload reducing agents. 150.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag (not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen U$T .8",0+6 d. Obtain the urinalysis specimen before the culture specimen Rationale: Urine collection ATI video, clamp for collection of urine, allows urine collection to be easier with urine in the tube. 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension Rationale: Pg. 474 in Chapter 43 Fluid Imbalances. Diarrhea falls under risk factors of fluid imbalances. Orthostatic hypotension is one of the manifestation to assess for. 152. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively. - histrionic Rationale: Pg. 129 in ATI Chapter 15 Personality Disorders. BPD falls under Cluster B and is characterized by “instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often tries self-injury and may be suicidal.” 153. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension Rationale: 154. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure. Rationale: Pg. 194 in ATI book Chapter 18 Under Chest Tube Removal. “Provide pain medication 30 min before removing chest tubes.” 155. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. Rationale: I could not find a rationale but it is the most critical piece of information that the med-surg nurse would need to know. 156. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. “You can add the medication to a half-cup of your child’s favorite juice.” B. “Repeat the dose if your child vomits within 1 hour after taking the medication.” C. “Limit your child’s potassium intake while she is taking this medication.” D. “Have your child drink a small glass of water after swallowing the medication.” Rationale: Pg. 117 in ATI Nursing Care of children. “Give water following administration to prevent tooth decay if the child has teeth.” 157. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension Rationale: Pg. 298 in Med Surg ATI just says Left Heart- PAWP with no specific information. On www.austincc.edu I found, “PAWP, it measures pressure generated by the left ventricle. It is used to assess left ventricular function.” 158. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation treatment. C. A client who is 1 day postoperative following a vertebroplasty.????? 1528 of Lewis book says ppl who do this procedure can be discharged as soon as they learn how to perform care, and that this procedure is very minimal -- Procedure healing time is also 1-2 hours to recover D. A client who is receiving heparin for deep vein thrombosis. - Repeated below Heparin for Hospital coumadin for home. Rationale: I could not find a specific rationale but this patient is the least urgent. 159. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl (WNL) B. WBC 9,800/mm (WNL) C. Creatinine 0.9 mg/dl (WNL) D. Potassium 5.2 mEq/L Rationale: All other lab values are within normal range. Potassium is elevated. This can cause dysrhythmias and even sudden death. 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? Paul for 158 would u pick D? A. Engage the client in activities that increase sensory stimulation. R7/'0*(9F5)*(&+ e O+%'/)0/2 %&+-F0(&+ B. Discourage physical activity during the day. C. Establish a toileting schedule for the client. Maximizes the ability to learn, less confusion D. Use clothing with buttons and zippers. Aspiration risk (repeated) 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? pg. 343 Ch. 57 fundamentals pdf a. Orthostatic hypotension - d/t fluid volume deficit b. Dependent Edema- fluid volume excess c. Decreased Hematocrit - fluid volume excess d/t super dilation d. Neck vein distention - fluid volume excess 152. A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder? p .76 Ch. 14 mental health a. The client is overly concerned about minor details b. The client exhibits impulsive behavior - spending money giving away money or possessions. c. The client is exceptionally clingy to others d. The client might act seductively 153. A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider? 3+ deep tendon reflexes -preeclampsia a. Protruding hemorrhoids b. Urinary frequency Ch. 4 p. 21 maternal- c. Supine hypotension - teach them side lying position. - COMMON 154. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first? a. Inform the provider of the time of the last does of pain medication????????? - chest tubes may be painful so knowing when pain med was given can help lower the pain threshold during the procedure??????? b. Document the sequence of events as they occur c. Provide non-pharmacological pain management interventions d. Instruct the client about the steps of the procedure 155. A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report? a. The client was intubated without complication b. The estimated blood loss was 250 milliliters - out of the four, it sounds like the most vital, crucial, descriptive information you can give. c. There was a total of 10 sponges used during the procedure - what kind d. The client is a member of the board of directors 157. A nurse is assessing a client’s PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? P. 199 Ch. 32 MED/SURGE a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension 158. A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range b. A client who has cancer with a sealed implant for radiation therapy - an implant is inside them, and its active c. A client who is 1 day postoperative following a vertebroplasty - 1 day seems to soon - p. 1528 of Lewis, vertebroplasty patients can be discharge as soon as they learn the home care. this procedure is not major. d. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for Hospital and that other Coumadin for home 159. A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? a. Fasting blood glucose 108 mg/ dL b. WBC 9,800 mm3 > 4,800 is normal c. Creatinine 0.9 mg/dL, < 1.0 is normal d. Potassium 5.2 mEq /L 3.5 - 5.0 = imbalance = CARDIAC DYSRHYTHMIAS !"##$%& ()4*+ I think the answer is C. I found that the procedure is done and a few hours after they can leave. it’s not a patient who is critical like the DVT with heparin patient. !"##$%& ())*+ https://familydoctor.org/vert ebroplasty-for-spine-fracture-pain/ !"##$%& (),*+ 158. DVT with heparin patient seems like the most stable out of the 4 tbc Rationale: Med Surg ATI page 382: Avoid NA, K, Mg, Phosphorus. Imbalances before surgery 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? a. Engage the client in activities that increase sensory stimulation. b. Discourage physical activity during the day c. Establish a toileting schedule for the client d. Use clothing with buttons and zippers 161. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred Assess the situation first prior to trying to solve it. 162. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. 163. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding - not without crushing them first b. Dissolve the medications together- some medications can mix others can’t c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water- 10ml VS2 !903'$60('*. 1 W9.6 .8",0+6 X '**#A $63 (# 4*#A ,0 58 +"'>,(8 #" &9.) ,( ,0 A= ()6 &*90+6" #4 ()6 .8",0+6Y &F PBL 164. The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor c. Seductive Behavior d. Lack of remorse They want attention !EO X/+*)5 W/)5*. ; W(0*'(&+(%U /9&*(&+)5K )**/+*(&+ 0//1(+Ba %/+*/' &- )**/+*(&+a 0/2F%*(7/ d -5('*)*(&F0 165. A nurse in a prenatal Clinic is teaching a client about non-pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt. and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. I can use my ultrasound picture as a focal point during contractions- Distraction 166. A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute - WNL b. ST segment elevations_ Remember this could possibly lead to infarctions c. 2 PVCs per minute d. Widened P wave ME /5/7)*(&+ e (+-)'%*(&+ &' (+fF'A 167. A nurse is observing a newly licensed nurse who is administering Total Parenteral Nutrition TPN to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the TPN IV tubing to administer the clients next dose of antibiotics- start another IV/lock for antibiotic, can’t use with TPN d. Increases the TPN infusion rate each hour until the prescribed rate is achieved 168. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? a. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your responsibility to contain it b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - no comparison 169. A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations -either or is fine b. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the right way c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear d. Count respirations for 1 minute if the rhythm is irregular 170. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the client’s biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff c. contact the laboratory manager regarding the situation - you are not high enough up the chain to do that d. Notify the facilities legal department - no need to go that far 171. A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infections d. Migraines with aura Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease. 172. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 (Normal 8-10) b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache 173. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure. b. Position the client over an overbed table prior to the procedure. c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hrs. prior to the procedure. Rationale: MS RM 10.0 Ch.47 p.299; Preprocedural nursing actions: Have the client void, or insert an indwelling urinary catheter. 174. A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia @" 4.&'(&)9+(&+(*(0 -/*)5 *)%.A%)'2() %" _/*)5 )+/9() -/*)5 *)%.A%)'2() 2" X)*/'+)5 -/7/' -/*)5 *)%.A%)'2() Rationale: MN RM 10.0 Ch.13 p.87; FHR <110/min; complications: Uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, prolonged umbilical cord compression, fetal congenital heart block, anesthetic medications, viral infection, maternal hypoglycemia, fetal heart failure, maternal hypothermia 175. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic? a. “You should make sure your partner takes the prescribed medication.” b. “Why do you think your partner’s symptoms are progressing so quickly?” c. “You did the right thing by bringing your partner in for treatment.” d. “Can you talk about what was happening with your partner at home?” 176. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver function test d. Serum creatinine Rationale: MH RM 10.0 Ch.23 p.124; Hepatotoxicity !EO S.)'9)%&5&BA ; %&965(%)*(&+ ./6)*&*&$(%(*A g )00/00 @)0/5(+/ 5(7/' -F+%*(&+ d 9&+(*&' 5(7/' -F+%*(&+ '/BF5)'5A 177. A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” b. “The PCA will deliver a double dose of medication when you push the button twice.” c. “You should push the button before physical activity to allow maximum pain control.” d. “You can adjust the amount of pain medication you receive by pushing on the keypad.” 178. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure. 179. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Potassium 3.2 mEq/L 3.5 - 5.0 is normal b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? a. “How long have you been hearing the voices?” b. “What are the voices telling you?” c. “Have you taken your medication today?” d. “I realize the voices are real to you, but I don’t hear anything.”- [Show More]

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