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ATI CAPSTONE MED SURG ASSESSMENT 2. LATEST 2021 100% VERIFIED VERSION GRADED A+ Work
ATI CAPSTONE MED SURG ASSESSMENT 2. LATEST 2021 100% VERIFIED VERSION GRADED A 1. a nurse is planning care for a client who has Meniere's diseas... [Show More] e and his experiencing episodes of vertical. which of Following intervention should the nurse include in the plan of care? a. Maintain strict bed rest pg 75 b. Restrict fluid intake to the morning hours. c. Administer aspirin. d. Provide a low-sodium diet. 2. a nurse is assessing a client of possible exposure of HIV . Which of the following findings should the nurse identify as an early manifestation of HIV infection? a. Stomatitis b. Fatigue c. Wasting syndrome d. Lipodystroph 3. Play nurse is teaching a client about using continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea . Which of the following information should the client include in the teaching? a. It delivers a preset amount of inspiratory pressure at the beginning of each breath pg 119?????? b. it has continuous adjustment feature that changes the airway pressure throughout thecycle c. it delivers a preset amount of airway pressure throughout the breathing cycle d. it delivers positive pressure at the end of each breath 4. A nurse is teaching a client about fecal cult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? a. "Your provider will use stool from your digital rectal examination to perform the test." b. "Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel." c. "You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old." d. "You should avoid taking corticosteroids prior to testing." 5. A nurse is preparing a client for a colonoscopy. Which of the following medication should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? a. Propofol pg 303 b. Pancuronium c. Promethazine d. Pentoxifylline 6. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as a best choice for the client to include in their diet? a. 1 packet of reconstituted dry onion soup b. 3 oz of lean cured ham c. 3 oz of chicken breast d. ½ cup of canned baked beans 7. A nurse is caring for a client who has rheumatoid arthritis and has been taking Prednisone. Which of the following finding should the nurse identify as an adverse effect of this medication? a. Weight loss b. hypoglycemia c. hypertension d. hyperkalemia 8. A nurse is caring for a client who has increased intracranial pressure (ICP ). Which of the following intervention should the nurse implement? a. Place several pillows behind the client's head b. place the client in a Sims position - per p. 83 of 2019 version, first intervention to decrease ICP is to elevate head to at least 30o c. keep the client's neck in a midline position d. maintain flexion of the client's hips at a 90 degree angle 9. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following intervention should the nurse include in the teaching? a. Keep a padded tongue blade near the bedside. b. Place a pillow under the client's head while in bed during a seizure. c. Administer diazepam orally at the onset of seizures. d. Position the client on their side during a seizure pg 36 10. A nurse is assessing a client who has meningitis the nurse should identify which of the following findings as a positive kernig's sign? a. After stroking the lateral area of the foot, the client's toes contract and draw together. b. After hip flexion, the client is unable to extend their leg completely without pain pg 31 c. The client's voluntary movement is not coordinated. d. The client reports pain and stiffness when flexing their neck. 11. A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instruction should the nurse include in the teaching? a. Monitor for increased blood pressure. b. Increase intake of high-potassium foods pg 207 c. Expect an increase in swelling in the hands and feet. d. Take the second dose at bedtime. 12. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching? a. exercise reduces the risk for hypoglycemia b. I can skip my insulin when I don't eat c. I can drink 4 ounces of soda if my blood sugar is low d. diabetic pills don't cause hypoglycemia; Only insulin does 13. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? a. Apply an ice pack directly to the affected area b. Immobilize the affected extremity with a splint - p. 9, 2019 c. Place tourniquet above and below the affected area d. Elevate the affected extremity 14. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis? a. Early menopause b. history of falls c. African American race d. obesity 15. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data). a. Breath sounds b. Temperature c. Blood pressure d. Creatine kinase 16. A nurse is providing discharge teaching to a client who is starting to take carbidopa /levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching? a. "This medication can cause your urine to turn a dark color." b. "Expect immediate relief after taking this medication." c. "Take the medication with a high-protein food." d. "Skip a dose of the medication if you experience dizziness." pg 42 17. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following day each of the nurse recommend? a. Low-potassium diet b. High-fiber diet c. Low-fat diet pg 356 d. Low-sodium diet 18. A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). which of the following statements by the client indicates an understanding of the teaching? a. I should not wash my hair prior to the procedure b. I will receive a sedated 1 hour before the procedure c. I should avoid eating prior to the procedure VERSION 19. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? a. Immunosuppressant medication needs to be taken for up to 1 year b. Shortness of breath might be an indication of transplant rejection pg 209 c. the surgical site will heal in 3 to 4 weeks after surgery d. begin 45 min of moderate aerobic exercise per day following discharge 20. A nurse is caring for a client who has been experiencing repeated tonic clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medication should the nurse administer? a. Diazepam IV pg 38 b. Lorazepam P0 c. Diltiazem IV d. Clonazepam PO 21. The nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? a. I should take my medicine with orange juice b. a bedtime snack will prevent heartburn c. I will lie down after meals d. I will limit activities that require bending at the waist 22. A nurse is caring for a client who is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet? a. Yogurt b. apples c. raisins PER NUTRITION BOOK d. cheddar cheese 23. A nurse is caring for a client who has rights sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? a. Gentle bubbling in the suction chamber PG 108 2019 VERSION b. crepitus around the insertion site osteoc. constant bubbling in the water seal chamber d. absence of breath sounds on the right side 24. A nurse is planning care for a client who has acute post streptococcal glomerulonephritis . Which of the following intervention should the nurse include in the client's plan? a. Encourage a high-protein diet for the client b. increase the client's fluid intake c. administer diuretics to the client - glomerulnophritis results in fluid retention (because kidneys can’t filter out well) (p. 402-403, 2019) d. Weigh client twice a week - wrong, should weigh daily 25. A nurse is caring for a client who has a peripheral inserted central catheter (PICC). For which of the following findings should the nurse notify the provider? a. The dressing was changed 7 days ago. b. The circumference of the client's upper arm has increased by 10% PG 175 c. The catheter has not been used in 8 hr. d. The catheter has been flushed with 10 mL of sterile saline after medication use. 26. The nurse is developing a plan of care for a client who will be placed in a Halo surgical repair cervical spine. Which of the following intervention should the nurse include in the plan? a. Inspect the pin site every 48 hr. b. Monitor the client's skin under the halo vest pg 474 c. Ensure two personnel hold the halo device when repositioning the client. d. Apply powder frequently to the client's skin under the vest to decrease itching. 27. A nurse is caring for a client who has syndrome of inappropriate anti diuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving? a. Urine specific gravity 1.020 pg 284 says “Urine specific gravity: Decreased (1.002 to 1.004 in sodium loss; greater than 1.012 in SIADH)” so 1.020 means not resolving b. Sodium 119 mEq/L wrong bc when have SIADH will have hyponatrmia c. BUN 8 mg/dL d. Calcium 8.7 mg/dL pg 85; I think bc its an electrolyte that is norm range-I PUT THIS 28. A nurse is caring for a client who is receiving total parenteral nutrition (TPN ). which of the following findings should the nurse identify as a possible complication of TPN administration? a. Pitting edema of bilateral lower extremities b. hypoactive bowel sounds in all four quadrants c. weight is the same as the day before d. bilateral posterior lung sounds are diminished - I think it is this. TPN can result in fluid imbalance/hypervolemia (p. 311) 29. A nurse is assessing a client who has a heart rate of 40 /min. the client is diaphoretic and as chest pain period which of the following medication should the nurse plan to administer? a. Lidocaine for tachycard b. Adenosine c. Atropine------------pg 181 chart atropine, dopamine, and epi for bradycard less 60/min d. Verapamil 30. The nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching? a. Explain procedures in full detail to a client before initiating care b. limit a client’s activities to minimize emotional outburst c. speak clearly and loudly to a client who is unable to form words or sentences d. provide supervision to prevent a client from becoming injured or lost 31. A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? a. I don't have muscle spasms as frequently PG 46 2016 VERSION b. I haven't gotten any colds, even though it is flu season c. I feel like my nerve pain has improved d. it is easier to urinate now 32. A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). which of the following referral should the nurse plan to initiate? a. Respiratory therapy b. Hospice care c. Occupational therapy d. Dietary services pg 394 14. A nurse is caring for a client who has burn injuries covering their upper body and is concern about their altered appearance. Which of the following statements should the nurse make? a. It is okay to not want to touch the burned areas of your body b. cosmetic surgery should be performed within the next year to be effective c. reconstructive surgery can completely restore your previous appearance d. injuries it could be helpful for you to attend a support group for people who have burn 4. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching? a. I can expect swelling in my hands an on my face PER ATI PRE-ASSESS STUDY GUIDE b. the amount of protein in my blood is high c. I might have some pain and gas in my stomach from this condition d. I will use a soft bristle toothbrush so my gums don't bleed 10. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following action should the nurse take first? a. Teach the client to report findings of IV extravasation b. evaluate the patency of the IV c. consult with the pharmacist about the prescription d. verify the prescription with the provider - can’t find in ATI, but google says KCl can cause vomiting/diarrhea, which you wouldn’t want if pt is already dehydrated 13. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately? a. Distended, board-like abdomen b. WBC count 15,000 /mm3 c. rebound tenderness over McBurney’s point - concur, but can’t find it in ATI on Children ATI book pg 145 2019 e d. temperature 37.3 C (99.1 F ) expected 2. A nurse in an Emergency Department is caring for a client who sustained multiple injuries. The nurse observes client’s thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries? a. Flail chest PER PG 157 2019 VERSION b. Hemothorax c. Pulmonary contusion d. Pneumothorax 20. A nurse is assessing a client who has a sodium level of 122 mEq/L. which of the following findings should the nurse expect? a. Decrease deep-tendon reflexes b. positive Trousseau’s sign c. hypoactive bowel sounds d. sticky mucus membranes • A nurse is providing teaching to a client who is scheduled for electromyography (EMG). the nurse should include which of the following information in the teaching? a. "You will receive a fixed dose of radioisotope 2 hours before the procedure." b. "Momentary flushing will occur at the beginning of the procedure." c. "You should inform your provider if you are claustrophobic." d. "You should expect insertion of small needle electrodes into the muscles." pg 448 12. The nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instruction should the nurse include? a. Eat three large meals daily b. consume high calorie foods c. limit caffeinated drinks to two per day d. drink fluids during meal time • A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following action should the nurse take first? a. Maintain IV access. b. Obtain the client's vital signs. c. Contact the provider. d. Stop the transfusion. • A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instruction should the nurse include in the teaching (select all that apply ) a. Use an electric shaver pg 615 b. Avoid crowds. c. Take temperature weekly weekly didn’t sound right d. Consume a low-residue diet pg 615; not true (low residue is veg and fiber; but in leukemia- need to restrict) e. Monitor for bruising pg 616 • A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease? o Contact precautions o Airborne precautions o Droplet precautions o Protective environment • A nurse is caring for a client who is hyperventilating and has the following abgs results PH 7.50, PACO2---29, HCO3---25. The nurse should recognize that the client has which of the following acid base imbalance? o Respiratory acidosis o Respiratory alkalosis o Metabolic acidosis o Metabolic alkalosis 5. A nurse is planning for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority? a. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10 b. administer oxygen to a client who has an oxygen saturation of 91% c. instructor client who is 1 hour postoperative about coughing and deep breathing exercises d. initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery 23. A nurse is planning care for a client who has acute pancreatitis. Which of the following intervention should the nurse include in the clients plan? (Select all that apply ) a. initiate insulin drip ??????????? Says “provide insulin as needs” b. monitor blood glucose levels pg 360 c. continue regular diet as tolerated d. maintain NPO status until pain-free e. manage acute pain 7. A nurse is caring for a client who is to undergo in liver biopsy. Which of the following instruction should the nurse provide to the client following the procedure? a. Lie on your left side b. lie on your right side PG 366 2019 VERSION c. increase your fluid intake ATI CAPSTONE MED SURG ASSESSMENT 2. LATEST 2021 100% VERIFIED VERSION GRADED A 1. a nurse is planning care for a client who has Meniere's disease and his experiencing episodes of vertical. which of Following intervention should the nurse include in the plan of care? a. Maintain strict bed rest pg 75 b. Restrict fluid intake to the morning hours. c. Administer aspirin. d. Provide a low-sodium diet. 2. a nurse is assessing a client of possible exposure of HIV . Which of the following findings should the nurse identify as an early manifestation of HIV infection? a. Stomatitis b. Fatigue c. Wasting syndrome d. Lipodystroph 3. Play nurse is teaching a client about using continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea . Which of the following information should the client include in the teaching? a. It delivers a preset amount of inspiratory pressure at the beginning of each breath pg 119?????? b. it has continuous adjustment feature that changes the airway pressure throughout thecycle c. it delivers a preset amount of airway pressure throughout the breathing cycle d. it delivers positive pressure at the end of each breath 4. A nurse is teaching a client about fecal cult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? a. "Your provider will use stool from your digital rectal examination to perform the test." b. "Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel." c. "You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old." d. "You should avoid taking corticosteroids prior to testing." 5. A nurse is preparing a client for a colonoscopy. Which of the following medication should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? a. Propofol pg 303 b. Pancuronium c. Promethazine d. Pentoxifylline 6. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as a best choice for the client to include in their diet? a. 1 packet of reconstituted dry onion soup b. 3 oz of lean cured ham c. 3 oz of chicken breast d. ½ cup of canned baked beans 7. A nurse is caring for a client who has rheumatoid arthritis and has been taking Prednisone. Which of the following finding should the nurse identify as an adverse effect of this medication? a. Weight loss b. hypoglycemia c. hypertension d. hyperkalemia 8. A nurse is caring for a client who has increased intracranial pressure (ICP ). Which of the following intervention should the nurse implement? a. Place several pillows behind the client's head b. place the client in a Sims position - per p. 83 of 2019 version, first intervention to decrease ICP is to elevate head to at least 30o c. keep the client's neck in a midline position d. maintain flexion of the client's hips at a 90 degree angle 9. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following intervention should the nurse include in the teaching? a. Keep a padded tongue blade near the bedside. b. Place a pillow under the client's head while in bed during a seizure. c. Administer diazepam orally at the onset of seizures. d. Position the client on their side during a seizure pg 36 10. A nurse is assessing a client who has meningitis the nurse should identify which of the following findings as a positive kernig's sign? a. After stroking the lateral area of the foot, the client's toes contract and draw together. b. After hip flexion, the client is unable to extend their leg completely without pain pg 31 c. The client's voluntary movement is not coordinated. d. The client reports pain and stiffness when flexing their neck. 11. A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instruction should the nurse include in the teaching? a. Monitor for increased blood pressure. b. Increase intake of high-potassium foods pg 207 c. Expect an increase in swelling in the hands and feet. d. Take the second dose at bedtime. 12. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching? a. exercise reduces the risk for hypoglycemia b. I can skip my insulin when I don't eat c. I can drink 4 ounces of soda if my blood sugar is low d. diabetic pills don't cause hypoglycemia; Only insulin does 13. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? a. Apply an ice pack directly to the affected area b. Immobilize the affected extremity with a splint - p. 9, 2019 c. Place tourniquet above and below the affected area d. Elevate the affected extremity 14. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis? a. Early menopause b. history of falls c. African American race d. obesity 15. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data). a. Breath sounds b. Temperature c. Blood pressure d. Creatine kinase 16. A nurse is providing discharge teaching to a client who is starting to take carbidopa /levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching? a. "This medication can cause your urine to turn a dark color." b. "Expect immediate relief after taking this medication." c. "Take the medication with a high-protein food." d. "Skip a dose of the medication if you experience dizziness." pg 42 17. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following day each of the nurse recommend? a. Low-potassium diet b. High-fiber diet c. Low-fat diet pg 356 d. Low-sodium diet 18. A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). which of the following statements by the client indicates an understanding of the teaching? a. I should not wash my hair prior to the procedure b. I will receive a sedated 1 hour before the procedure c. I should avoid eating prior to the procedure VERSION 19. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? a. Immunosuppressant medication needs to be taken for up to 1 year b. Shortness of breath might be an indication of transplant rejection pg 209 c. the surgical site will heal in 3 to 4 weeks after surgery d. begin 45 min of moderate aerobic exercise per day following discharge 20. A nurse is caring for a client who has been experiencing repeated tonic clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medication should the nurse administer? a. Diazepam IV pg 38 b. Lorazepam P0 c. Diltiazem IV d. Clonazepam PO 21. The nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? a. I should take my medicine with orange juice b. a bedtime snack will prevent heartburn c. I will lie down after meals d. I will limit activities that require bending at the waist 22. A nurse is caring for a client who is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet? a. Yogurt b. apples c. raisins PER NUTRITION BOOK d. cheddar cheese 23. A nurse is caring for a client who has rights sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? a. Gentle bubbling in the suction chamber PG 108 2019 VERSION b. crepitus around the insertion site osteoc. constant bubbling in the water seal chamber d. absence of breath sounds on the right side 24. A nurse is planning care for a client who has acute post streptococcal glomerulonephritis . Which of the following intervention should the nurse include in the client's plan? a. Encourage a high-protein diet for the client b. increase the client's fluid intake c. administer diuretics to the client - glomerulnophritis results in fluid retention (because kidneys can’t filter out well) (p. 402-403, 2019) d. Weigh client twice a week - wrong, should weigh daily 25. A nurse is caring for a client who has a peripheral inserted central catheter (PICC). For which of the following findings should the nurse notify the provider? a. The dressing was changed 7 days ago. b. The circumference of the client's upper arm has increased by 10% PG 175 c. The catheter has not been used in 8 hr. d. The catheter has been flushed with 10 mL of sterile saline after medication use. 26. The nurse is developing a plan of care for a client who will be placed in a Halo surgical repair cervical spine. Which of the following intervention should the nurse include in the plan? a. Inspect the pin site every 48 hr. b. Monitor the client's skin under the halo vest pg 474 c. Ensure two personnel hold the halo device when repositioning the client. d. Apply powder frequently to the client's skin under the vest to decrease itching. 27. A nurse is caring for a client who has syndrome of inappropriate anti diuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving? a. Urine specific gravity 1.020 pg 284 says “Urine specific gravity: Decreased (1.002 to 1.004 in sodium loss; greater than 1.012 in SIADH)” so 1.020 means not resolving b. Sodium 119 mEq/L wrong bc when have SIADH will have hyponatrmia c. BUN 8 mg/dL d. Calcium 8.7 mg/dL pg 85; I think bc its an electrolyte that is norm range-I PUT THIS 28. A nurse is caring for a client who is receiving total parenteral nutrition (TPN ). which of the following findings should the nurse identify as a possible complication of TPN administration? a. Pitting edema of bilateral lower extremities b. hypoactive bowel sounds in all four quadrants c. weight is the same as the day before d. bilateral posterior lung sounds are diminished - I think it is this. TPN can result in fluid imbalance/hypervolemia (p. 311) 29. A nurse is assessing a client who has a heart rate of 40 /min. the client is diaphoretic and as chest pain period which of the following medication should the nurse plan to administer? a. Lidocaine for tachycard b. Adenosine c. Atropine------------pg 181 chart atropine, dopamine, and epi for bradycard less 60/min d. Verapamil 30. The nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching? a. Explain procedures in full detail to a client before initiating care b. limit a client’s activities to minimize emotional outburst c. speak clearly and loudly to a client who is unable to form words or sentences d. provide supervision to prevent a client from becoming injured or lost 31. A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? a. I don't have muscle spasms as frequently PG 46 2016 VERSION b. I haven't gotten any colds, even though it is flu season c. I feel like my nerve pain has improved d. it is easier to urinate now 32. A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). which of the following referral should the nurse plan to initiate? a. Respiratory therapy b. Hospice care c. Occupational therapy d. Dietary services pg 394 14. A nurse is caring for a client who has burn injuries covering their upper body and is concern about their altered appearance. Which of the following statements should the nurse make? a. It is okay to not want to touch the burned areas of your body b. cosmetic surgery should be performed within the next year to be effective c. reconstructive surgery can completely restore your previous appearance d. injuries it could be helpful for you to attend a support group for people who have burn 4. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching? a. I can expect swelling in my hands an on my face PER ATI PRE-ASSESS STUDY GUIDE b. the amount of protein in my blood is high c. I might have some pain and gas in my stomach from this condition d. I will use a soft bristle toothbrush so my gums don't bleed 10. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following action should the nurse take first? a. Teach the client to report findings of IV extravasation b. evaluate the patency of the IV c. consult with the pharmacist about the prescription d. verify the prescription with the provider - can’t find in ATI, but google says KCl can cause vomiting/diarrhea, which you wouldn’t want if pt is already dehydrated 13. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately? a. Distended, board-like abdomen b. WBC count 15,000 /mm3 c. rebound tenderness over McBurney’s point - concur, but can’t find it in ATI on Children ATI book pg 145 2019 e d. temperature 37.3 C (99.1 F ) expected 2. A nurse in an Emergency Department is caring for a client who sustained multiple injuries. The nurse observes client’s thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries? a. Flail chest PER PG 157 2019 VERSION b. Hemothorax c. Pulmonary contusion d. Pneumothorax 20. A nurse is assessing a client who has a sodium level of 122 mEq/L. which of the following findings should the nurse expect? a. Decrease deep-tendon reflexes b. positive Trousseau’s sign c. hypoactive bowel sounds d. sticky mucus membranes • A nurse is providing teaching to a client who is scheduled for electromyography (EMG). the nurse should include which of the following information in the teaching? a. "You will receive a fixed dose of radioisotope 2 hours before the procedure." b. "Momentary flushing will occur at the beginning of the procedure." c. "You should inform your provider if you are claustrophobic." d. "You should expect insertion of small needle electrodes into the muscles." pg 448 12. The nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instruction should the nurse include? a. Eat three large meals daily b. consume high calorie foods c. limit caffeinated drinks to two per day d. drink fluids during meal time • A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following action should the nurse take first? a. Maintain IV access. b. Obtain the client's vital signs. c. Contact the provider. d. Stop the transfusion. • A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instruction should the nurse include in the teaching (select all that apply ) a. Use an electric shaver pg 615 b. Avoid crowds. c. Take temperature weekly weekly didn’t sound right d. Consume a low-residue diet pg 615; not true (low residue is veg and fiber; but in leukemia- need to restrict) e. Monitor for bruising pg 616 • A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease? o Contact precautions o Airborne precautions o Droplet precautions o Protective environment • A nurse is caring for a client who is hyperventilating and has the following abgs results PH 7.50, PACO2---29, HCO3---25. The nurse should recognize that the client has which of the following acid base imbalance? o Respiratory acidosis o Respiratory alkalosis o Metabolic acidosis o Metabolic alkalosis 5. A nurse is planning for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority? a. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10 b. administer oxygen to a client who has an oxygen saturation of 91% c. instructor client who is 1 hour postoperative about coughing and deep breathing exercises d. initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery 23. A nurse is planning care for a client who has acute pancreatitis. Which of the following intervention should the nurse include in the clients plan? (Select all that apply ) a. initiate insulin drip ??????????? Says “provide insulin as needs” b. monitor blood glucose levels pg 360 c. continue regular diet as tolerated d. maintain NPO status until pain-free e. manage acute pain 7. A nurse is caring for a client who is to undergo in liver biopsy. Which of the following instruction should the nurse provide to the client following the procedure? a. Lie on your left side b. lie on your right side PG 366 2019 VERSION c. increase your fluid intake d. decrease your fluid intake [Show Less]
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ATI FORM A, B & C WOMEN & NEWBORN HEALTH PRACTICE EXAM. LATEST 2021 100% VERIFIED VERSION GRADED A
ATI FORM A, B & C – WOMEN & NEWBORN HEALTH PRACTICE EXAM. LATEST 2021 100% VERIFIED VERSION GRADED A ATI –Form A 1) A client and her p... [Show More] artner ask the nurse for information about permanent contraception. Which of the following statements should the nurse include in the counseling? a. Most sterilization procedures are considered irreversible b. A woman should use contraception for 1-2 months after a tubal ligation c. A man is usually sterile immediately after a vasectomy d. The menstrual cycle is shorter after a tubal ligation 2) A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care? a. Swaddle the newborn in a flexed position b. Weigh the newborn every other day c. Increase the newborn’s visual stimulation d. Discourage parental interaction until after a social service evaluation 3) A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? a. Lentils b. Oatmeal c. Cabbage d. Asparagus 4) A nurse is teaching a client who is pregnant about a new prescription for iron supplements. Which of the following instructions should the nurse include in the teaching? a. Increase intake of foods rich in vitamin C b. Take an extra pill if you miss a dose c. Report black stools to the provider d. Drink 8 ox of milk with each pill 5) A nurse is caring for a preterm newborn immediately after delivery. Which of the following actions should the nurse take first? a. Dry the infant under the radiant warmer b. Take the infant’s temperature c. Weigh the infant d. Obtain the infant’s blood glucose 6) A nurse is discussing family planning with a client who has a history of DVT. The nurse should inform the client that this condition is a contraindication for which of the following birth control methods? a. Oral contraceptive b. Cervical cap c. Diaphragm d. Intrauterine device 7) A nurse is teaching a client who is postpartum about car seat safety. Which of the following statements indicates and understanding of the instructions? a. I will make sure the retainer clip is at the level of my baby’s abdomen b. I will position the car seat in the front passenger seat facing the font of the car c. I will adjust the angle of the car seat so that my baby sits at a 90-degre angle d. I will place the shoulder harness slightly below my baby’s shoulders 8) A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following findings indicates narcotic withdrawl? a. Excessive Crying b. Unequal pupils c. Respiratory rate of 50/min d. Hypotonia 9) A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex? a. Make a loud noise above the newborn b. Touch the newborn’s cheek with a finger c. Turn the newborn’s head to one side d. Tap the newborn’s forehead with a finger 10) A nurse is providing teaching to a client who is postpartum about her car seat safety. Which of the following statements by the client indicates an understanding of the teaching? a. I will ensure that my baby is at a 45-degree angle in the car seat b. I will put my baby facing forward in the middle of the back seat of the car c. I will fasten the harness clip 1 inch above my baby’s underarms d. I will swaddle my baby in a blanket before placing her in the car seat 11) A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following statements by the client indicates an understanding of the teaching? a. I should apply a warm compress after feeding b. I should apply lanolin to the infection site daily c. I should use a nipple shield while breastfeeding d. I should stop breastfeeding until the infection has healed 12) A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make? a. You can bathe and dress your baby if you’d like to b. You should name the baby so he can have an identity c. If you don’t hold the baby, it will make letting go much harder d. Im sure you will be able to have another baby when you’re ready 13) A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. Facial petechiae b. Erythema toxicum c. Periauricular papillomas d. Telangilectatic nevi 14) A charge nurse is discussing STIs with a newly licensed nurse. Which of the following infections should the nurse include in the teaching as an indication for a cesarean birth? a. HIV b. Chlamydia c. Gonorrhea d. Syphilis 15) A nurse is reviewing the medication prescriptions for a newborn who is 6 hours old and whose mother is HBsAg-positive. The nurse should anticipate administering which of the following medications? a. Hepatitis B Immune Globulin b. Hepatitis A immune globulin c. Haemophilus inflenzae type B vaccine d. Hepatitis A vaccine 16) A nurse is assessing a client immediately following the placement of an epidural. The nurse obtains a maternal blood pressure of 96/54 and a fetal HR of 102/min. Which of the following actions should the nurse take? a. Position the client in a lateral position b. OR administer naloxone to the client??? c. Prepare the client for an amnioinfusion d. Place the client in knee-chest position 17) A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? a. Avoid using lotion or ointment on the newborn’s skin b. Dress the newborn in lightweight clothing c. Keep the newborn supine throughout treatment d. Measure the newborn’s temperature every 8 hours 18) A nurse on the labor and delivery unit is caring for a client who is at 33 weeks of gestation and was admitted with placenta previa. Which of the following interventions should the nruse include in the client’s plan of care? a. Administration of magnesium sulfate b. Routine vaginal exams c. Ambulation as tolerated d. Nonstress test twice weekly 19) A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse should anticipate which of the following tests to assess for fetal lung maturity? a. L/S ratio b. Direct coombs test c. Biophysical prophile d. Chorionic villus sampling 20) A nurse is caring for a client who is in labor and prescribed an amnioinfusion. Which of the following findings is an indication for this? a. Variable decelerations b. Early decelerations c. Fetal macrosomia d. Increased uterine tone 21) A nurse is caring for a client who is postpartum following repair of a vaginal laceration. The client has a firm fundus, moderate lochia rubra, and reports moderate perineal discomfort and pressure. Which of the following actions should the nurse take? a. Check the perineal area b. Perform deep fundal massage c. Obtain vaginal culture d. Administer methylergonovide 0.2 mg IM 22) A nurse is assessing a full-term newborn 1 hr following a vaginal birth. Which of the following is an expected assessment finding? a. The newborn’s anterior fontanel bulges when he is quiet b. The newborn’s head circumference is greater than the chest circumference c. The newborn exhibits apneic episodes of 30 seconds d. The newborn has a heart rate of 70/min while sleeping 23) A nurse is providing discharge teaching to the parent of a newborn about surgical site care following circumcision using a clamp technique. Which of the following statements by the parent indicates an understanding of the teaching? a. I will check the site hourly for bleeding b. I will remove the crust with each diaper change c. I will wash the penis with soap and water daily d. I will apply petroleum jelly to the area with each diaper change 24) A nurse in a provider’s office is caring for a 20-year-old client who is 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? a. You cannot have an amniocentesis until you are at least 35 year of age b. This procedure determines if your baby has genetic or congenital disorders c. Your provider will schedule a chorionic villus sampling to determine the sex of your baby d. We can schedule the procedure for later today if you’d like 25) A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. I can have a mid-day snack with soft cheese b. I can purchase a seafood salad from the grocery store c. I can still have a hot dog at the ballpark d. I can eat grilled chicken on a bun at lunch time 26) A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? a. You will lie on your side for 40 minutes after I administer the medication b. I will insert a urinary catheter before I administer the medication c. I will begin an oxytocin infusion within 2 hours of your last dose of medication d. You will receive an antacid containing magnesium before the medication 27) A nurse is reviewing the laboratory findings of a client who is 10 weeks gestation. Which of the following findings should the nurse report to the provider? a. WBC 10,000 b. Hemoglobin 12 g/dL c. Creatinine 0.5 mg/dL d. Platelets 100,000 28) A nurse on the postpartum unit is reviewing prevention of newborn diaper rash with a client. Which of the following statements indicates an understanding of the teaching? a. I will allow the diaper area to dry before applying a clean diaper b. I will wash the diaper area with an antibacterial soap with each diaper change c. I will clean the diaper area with a scented baby wipe d. I will apply a thin layer of talc to the diaper area twice a day 29) A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication? a. Respiratory rate 10/min b. Moderate fetal heart rate variability c. Urinary output 120mL in 2 hr d. Blood pressure 136/88 30) A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take? a. Have the client limit the length of breastfeeding to 5 min per breast b. Assess the newborn’s latch while breastfeeding c. Instruct the client to wait 4 hours between daytime feedings d. Offer supplemental formula between the newborn’s feedings 31) A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the client’s perineum immediately following emergence. Which of the following actions should the nurse take? a. Assess fetal position using Leopold maneuvers b. Apply pressure to the client’s suprapubic area c. Reposition the client in the left lateral position d. Empty the bladder using crede maneuver 32) A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the client is 80% and 8cm. The nurse realizes that the client is at risk for which of the following conditions a. Ectopic pregnancy b. Postpartum Hemorrhage c. Incompetent cervix d. Hyperemesis gravidarum 33) A nurse is assessing a client who is at 37 weeks gestation. Which of the following statements by the client requires immediate intervention by the nurse? a. I have been seeing spots this morning b. My feet are really swollen today c. I didn’t have lunch today, but I had breakfast this morning d. It burns when I urinate 34) A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? a. The client expels the placenta b. The client delivers the newborn c. The client begins having regular contractions d. The client experiences gradual dilation of the cervix 35. A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heart beat. Which of the following terms should the nurse use to document this finding? a. Goodell’s sign b. Funic soufflé c. Hegar’s sign d. Quickening 36. A nurse at an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first? a. A client who is at 36 weeks of gestation and reports back pain following intercourse b. A client who is at 10 weeks of gestation and reports frequent urination c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers d. A client who is at 8 weeks of gestation and reports severe vomiting 37. A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit? a. A client who has a crown-rump length of 7 weeks of gestation b. A client who has an ultrasound that confirms a molar pregnancy c. A client who has felt quickening for the first time d. A client who has a positive urine pregnancy test 1 week after missed menses 38. A nurse is assessing a newborn who is 2 hours old. Which of the following findings should the nurse report to the provider? a. Transient nystagmus b. Overlapping sutures with molding c. Single transverse palmar crease bilaterally d. Lanugo on the pinna of the ears 39. A nurse is reviewing the laboratory report of a client who is 24 hrs postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take? a. Prepare the client for a blood transfusion b. Initiate IV access for isotonic solution with an 18-gauge catheter c. Administer an iron supplement to the client d. Instruct the client that the provider will check for placental fragments 40. A nurse is caring for a client who is at 24 weeks of gestation and has a glucose screening test result of 150 mg/dL. Which of the following actions should the nurse take? a. Perform a urine screen for ketones b. Repeat the glucose screening test in 15 min to verify results c. Schedule the client for a 3 hr oral glucose tolerance test d. Determine if the client has fasted [Show Less]
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ATI PEDS/PEDIATRICS QUESTIONS AND ANSWERS LATEST 2021 100% VERIFIED VERSION – GRADED A
ATI PEDS/PEDIATRICS QUESTIONS AND ANSWERS LATEST 2021 100% VERIFIED VERSION – GRADED A A nurse is planning care for a child who has severe d... [Show More] iarrhea. which of the following actions is the nurse priority? A. Introduce a regular diet B. Rehydrate C. Maintain fluid therapy D. Assess fluid balance (Assess first the other three are interventions, before u intervene you have to assess how much fluid imbalance. Check for labs results because it will tell you what kind of fluid is to be given and how much fluid to be replaced. Priority is assessment first) A nurse is caring for a toddler who’s parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority? A. Schedule the child for an abdominal ultrasound B. Instruct the parent to avoid pressing on the abdominal area C. Determine if the child is having pain D. Obtain a urine specimen for a urinalysis A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse’s priority? A. Place the child on a no salt added diet B. Check the Childs weight daily C. Educate the parents about potential complications D. Maintain a saline lock (IV access that is attached to any fluids. For emergency) (inflammation of the kidneys caused by group A beta hemolytic streptococcus, infection. Fluid or fluid retention. Patient with kidney problems affect blood pressure -> High blood pressure because of fluid retention. Salt increases high blood pressure. Lower the salt intake of this patient) A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following is the nurse’s priority? A. Administer antibiotics when available B. Reduce environmental stimuli (because of increase of ICP and can cause seizures) C. Document intake and output D. Maintain seizure precautions A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide? A. Availability of firearms B. Family conflict C. Homosexuality D. Active psychiatric disorder (Mark, mental problems, patients mind is unstable) A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse should expect which of the following findings? A. Tugging on the affected ear lobe B. Bluish green discharge from the ear canal (there’s usually no discharge, discharge only comes out if there’s opening in the ear drum) C. Increase in appetite (decrease in appetite) D. Erythema and edema of the affected auricle (usually no redness in the affected auricle) (otitis externa: infection of the outer ear) A nurse is reinforcing reaching with a parent of a 1 month old infant who is to undergo the initial surgery to treat Hirschsprung’s disease (a ganglionic megacolon, part of the colon isn’t connected to the nerves or not functioning, so there will be an increase size of the colon and stool gets stuck in there). Which of the following statements should indicate to the nurse that the parent understanding the goal of surgery? A. “I’m glad that the ostomy is only temporary “ (1st there going to cut the nonfunctioning of the colon, and then apply temporary colostomy, after a couple of months they will suture it together) B. “I’m glad my child will have normal bowel movements now” C. “I want to learn how to use the feeding tube as soon as possible” D. “the operation will straighten out the kink in the intestine” A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Apply an antibiotic ointment to the suture site B. Clear oral secretions using a bulb syringe C. Feed the infant using a spoon D. Position the infant on her abdomen A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching? A. “I will make sure my child washes her hands before eating” B. “I will restrict the amount of salt in my child’s meal” C. “I will put my child in daycare to ensure that she socializes with other children” D. “I will provide low fat meals for my child A nurse working at a clinic speaks on the telephone with a parent of a 2-month- old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following response by the nurse is appropriate? A. “Bring your infant into the clinic today to be seen” B. “Burp your child more frequently during feedings” C. “Give your infant an oral rehydrating solution” D. “You might want to try switching to different formula” A nurse is caring for a 4 year old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority . (causes icp hydrocephalus) A. lethargy (high pitched cry, respiratory changes, bradycardia, wide pulse pressure, irritability) B. lying flat on the unaffected side C. respiratory rate 20/min D. urine output 50 mL in 2hr a nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A. Remove the window and view the incision B. Turn the client so the cast will dry on all sides C. Medicate the client for pain D. Perform neurovascular checks of the affected extremity (check for infection, color, capillary refill, redness) A nurse is an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler? A. Activated charcoal (can work with toxin, poison. Given through ng tube absorbs toxins) B. Acetylcysteine (antidote for acetaminophen) C. A chelating agent (usually used for iron) D. Digoxin immune FAB A nurse is caring for a 3 year old client who has persistent otitis media. To help identify contributing factors, the nurse should ask the parents which of the following questions? A. Has your daughter been drinking 6 glasses of water a day B. Does anyone smoke in the same house as your daughter? (smoking can cause irritation, cause mucus in respiratory and causes otitis media?) (otitis media is purulent color) C. Does your daughter get water in her ears when you bathe her? (otitis externa, bluish green color) D. Has your daughter had a lot of earwax in her ears over the last month? A nurse is collecting data from a 2 year old toddler who has AIDS. The nurse should inspect inside the toddler mouth for which of the following opportunistic infections (fungus infections is usually opportunistic infections)? A. Candidiasis (also called oral thrush) B. Gingivitis C. Canker sores D. Koplik spots (measles, rubella) A nurse is caring for a 4 year old child who has dehydration. Which of the following findings should the nurse identify as the priority? A. Blood glucose 110 mg/dL B. Potassium 2.5 mEq/L C. Sodium 142 mEq/L D. Urine specific gravity 1.025 A nurse is caring for a child who Is postoperative following the insertion of a ventriculorperitoneal shunt. The nurse should place the child in which of the following positions? A. On the nonoperative side B. A 45 deg head elevation C. Prone D. Supine A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant response to therapy by performing which of the following actions? A. weighing the infants at the same time everyday B. Taking the infants vital signs every 2 hr. C. Measuring the infants head circumference twice per day D. Counting the number of wet diapers every shift A nurse is caring for a preschool age child who has croup. Which of the following findings should the nurse report to the provider? A. Barky cough B. Paroxysmal attacks of laryngeal spasm at night C. Hoarseness D. Drooling (that could mean it can mean there’s an epiglottitis causes obstruction of the airway) A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? A. Projectile vomiting B. Bile colored vomit C. Absent bowel sounds D. Fever A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination? A. Lie prone on the examination table B. Touch your chin to your chest and then look up at the ceiling C. Turn to the side and remain in a relaxed position D. Bend forward from the waist with your head and arms downward A nurse is collecting data from an infact. Which of the following sites is the most reliable location to check the infats pulse ? A. Carotid B. Apical C. Dorsalis pedis D. Temporal A nurse is reinforcing teaching with a parent of a child who has eczema. Which of th following instructions should the nurse include in the teaching A. Apply a cool wet compress to the affected area B. Launder clothing with fabric softener C. Give bubble baths every day D. Use a wool gloves in the winter time A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take? A. Administer opioids on a schedule (Nsaids) B. Encourage the child to take daytime naps C. Apply cool compresses for 20 mins every hour D. Maintain night splints to the affected joint A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching. A. Fractures in a child take longer to heal than fractures in an adult B. Normal bone growth can be affected by the fracture C. Bone marrow can be lost through the fracture D. Your child will need to increase his calcium intake to 3,000 milligrams daily A nurse is collecting data from an 8 month old infant who has increased intracranial pressure (ICP) which of the following manifestations should the nurse expect? A. Insomnia (tired sleepy) B. Bulging fontanel C. Low pitched cry (high pitched) D. Positive babinski reflex A nurse is caring for a school age child who has a fracture to the right femur. Which of the following findings is the nurse priority? A. 2+ right pedal pulse B. respiratory rate 24/min C. capillary refill less than 2 seconds D. tingling in the right foot A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect? A. Nonpruritic erythematous papulse B. Rash with thick skin C. Maculopapular lesions between fingers and toes D. Inflamed area with white exudate A nurse is assisting with the care of a school age child who has respiratory failure due to pneumonia. Which of the following positons should the nurse encourage to allow maximal lung expansions? A. Prone B. Supine C. Side lying D. Upright (orthopnic positon, semi fowler, high fowler) A nurse in a provider’s office is reinforcing teaching with a parent of a school age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Wash all bed linens and dry them in a dryer for at least 20 min B. Apply permethrin cream twice daily C. Apply an antifungal treatment ointment once every day D. Ensure that family pets are treated within 10 days A nurse is reinforcing teaching with the mother of an infant who has oral candidiasis and is breastfeeding which of the following instructions should the nurse include in the teaching? A. Wash hands prior to each breastfeeding B. Swab the infants mouth with salt water twice daily C. Change to formula feeding with a bottle D. Hand wash pacifier in warm soapy water each day A nurse is caring for a school age child who has mild persistent asthma. Which of the following findings should the nurse expect? (select all the apply) A. Symptoms are continual throughout the day B. Daytime symtoms occur more than twice per week C. Nighttime symptoms occur approximately twice per month D. Minor limitations occur with normal activity E. Peak expiratory fow (PEF) is greater than or equal to 80% of the predicted value A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect? A. WBC 17,000/mm3 B. Left lower quadrant abdominal pain C. Hyperactive bowel sounds D. Bradycardia (tachycardia) A nurse is caring for a toddler who has a cast applied 2 hr ago due to multiple fractures of the right hand of the following findings should the nurse report immediately to the charge nurse? A. The fingers on the right hand have a capillary refill of 4 seconds B. The fingertips of the right hand are swollen and bruised C. The child is not attempting to move her right arm or fingers D. The parents report the child will not keep the arm elevated on the pillow A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Heart rate 130/min B. respiratory 24/min C. urine specific gravity 1.015 (1.010-1.015) higher urine specific gravity is dehydration D. Capillary refill greater than 3 seconds A nrse is caring for a school age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take? A. Position the casted arm in a dependent position (worsen the edema. Elevate it so there wont be edema, elevate it on a pillow ) B. Place a warm moist heat pack on the cast C. Administer diphenhydramine to relieve itching D. Move the casted arm with a firm grip A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first? A. Administer albuterol by nebulizer (open the airway, and loosen the secretions it will be more effective to loosen it up) B. Percuss the upper posterior chest C. Perform vibration while the client exhales slowly through the nose D. Instruct the client to cough A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take? A. Feed the infant through an BG tube B. Place the infant in prone position C. Cover the infants lesion with a dry cloth (cover infant with moist sterile cloth) D. Perform range of motion exercises to the infant’s hips A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? A. Obtain a throat culture B. prepare the child for a neck radiograph C. initiate airborne precaution (droplet) D. visualize the epiglottitis using a tongue depressor (it can stimulate spasm and cause airway obstruction) (manifestation of epiglottitis the patient has drooling) A nurse is caring for a child who is experiencing a seizure. Which of the following Actions should the nurse take? A. Elevate the childs legs on a pillow B. Restrain the childs arm C. Insert a padded tongue blade into the child’s mouth D. Place the child in a side lying position(for aspiration) A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding? A. Prone (fundamentals) B. Upright (ATI) C. Left side D. Right side A nurse is contributing to the plan of care for a 2month old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the clients plan of care? A. Feed the infant half strength formula for the first 48 hr. (NPO, start with clear liquids not half strength formula) B. Remove elbow restraints while the infant is sleeping (do not remove the restraint unattended because when they sleep they can still touch the operative site, u can remove it for a short period of time to just monitor) C. Keep the infant in a side lying position D. Administer pain medication PRN for the first 48 hr. (it should not be PRN it should be scheduled) A nurse is receiving hand off report for a toddler who has a fractured right femur and is in 90 degree /90 degree traction. The nurse should expect to observe which of the following? A. Skin straps maintaining the affected leg in an extended positon B. A skeletal pin in the distal end of the femur C. A padded sling under the knee of the affected leg D. The buttocks elevated slightly off of the bed A nurse is caring for a child who is having a tonic clonic seizure and vomiting. Which of th following action the nurse priority A. Place a pillow under the childs head B. Move the child into a side lying position C. Remove the childs eyeglasses D. Time the seizure A nurse is caring for a child who has tinea pedis. The childs parents ask the nurse what this infection is commonly called. The nurse should respond with which of the following common names A. Shingles B. Athletic foot C. Fever blisters D. Pinworms A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infants pain level? A. FLACC B. Oucher C. FACES D. Visual analog scale A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect? A. Hip dislocation B. Flaccid paralysis of lower extremities C. Hydrocephalus D. Dimple in sacral area A nurse is caring for a 2 week old infant who’s mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make? A. You should place your baby on her back when sleeping to decrease the risk of SIDS B. SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines C. SIDS rates have been rising over the last 1- years D. Sleep apnea is the main cause of SIDS A nurse is caring for a newly admitted adolescents who has anorexia nervosa. Which of the findings should the nurse expect A. Diarrhea B. Hypertension C. Tachycardia D. Lanugo A nurse is collecting data from a child who has (beta) B-thalassemia. Which of the following findings should the nurse expect? A. Hyperactivity (hypoactivity) B. Increased appetite (decreased appetite) C. Fever D. Flushed of skin (pale skin) A nurse in a clinic is preparing to administer pre-k-kindergarten vaccines to a 5 year old child whose medical record indicates that his immunization are up to date which of the following vaccines should the nurse plan to adminiser A. Mealsles, mumps, rubella (MMR) B. Haemophilus influenza type B HIB C. Pneumococcal conjugate vaccine (PCV) D. Heptatits B (HBV) A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actoons should the nurse take? A. Ask another nurse to assist with holding the toddler in a prone position B. Restrain the toddler for 1 hr after the procedure C. Place the toddler in a side lying knee chest position D. Swaddle the toddler in a warm blanket A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS) the nurse include that TSS is a commonly assoiciated with which of the folloqing? A. High absorbency tampons B. Mosquito bites C. International travel D. Multiple sexual partners A nurse is talking with a 13 year old female clients who is having her annual health screening visit. Which of the following comments by the client should concern the nurse? A My parents treat me like a baby sometimes B I start taking ibuprofen a few days before my period starts C None of the kids at my school like me and I don’t like them either D Theres a pimple on my face and iw orry that everyone will notice it A nurse is caring for a 6 month old child. The childs provider has ordered a diphtheria, tetanus, and pertussis (DTAP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine? A. Febrile otitis media B. Evidence of sensitivity to egg atigens C. Temp of 40.5 C (104.9F) after last DTAP D. New onset of seizurs disorder in the childs sibling A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks? A. Building a sense of trust (infant)trust vs mistrust B. Learning to use creative energies (school aged) C. Learning to perform tasks independently (toddler)autonomy vs shame and doubt D. Defining a sense of self (Adolescence) A nurse is selecting a toy for a 7 month old infant. Which of the following toys should the nurse choose? A. A set of blocks to build a block tower B. A colorful crib mobile that plays music C. A soft toy that squeaks or crackles when squeezed D. A wooden farm animal puzzle with large pieces A nurse is reinforcing teaching with the parents of an 8 month old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching? A. You will need to go home when it is not visiting hours B. You should bring the infants favorite blanket to the hospital C. You should begin to manipulate the infants bedtime based on the hospital visitng hours D. You should read the childs a story about hospitalization A nurse is collecting data regarding the pain level of a 3 year old child on the second postoperative day following an appendectomy. Which of the following actions should the nurse take? A. Use a numeric scale to assess the childs pain level B. Use the FACES scale to assess the childs pain level C. Use a color tool to assess the childs pain level D. Use the visual analog scale to assess the childs pain level A nurse in a pediatric clinic is collecting data from a preschool age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection? A. Scaly patches that have clear centers (ring worm) B. Red macule with honey colored crusts C. Firm brown papules with a roughened, finely papillomatous texture D. Reddened areas with white exudate A nurse is reinforcing teaching with an adolescent regarding administration of the Gardasil vaccine. The vaccine provides Immunity against which of the following sexually transmitted infections? A. Human papillomavirus (HPS) B. Herpes simplex virus ( HSV-2) C. Chlamydia trachomatis D. Gonorrhea A nurse is collecting data from a 7 month old infant which of the following findings should indicate to the nurse a need for further evaluation? A. Usees a unidextrous grasp B. Has a fear of strangers C. Sits leaning forward on both hands D. Babbles one syllable sounds A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of hemorrhage? A. Increased pain B. Poor fluid intake C. Drooling D. Continuous swallowing A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take? A. Initiate a protective environment B. Initiate airborne precautuons C. Initiate droplet precautions D. Initiate contact precautions A nurse is caring for a child who has erythema infectiousm. Which of the following findings should the nurse expect? A. Facial erythema B. Koplik spots (measles) C. Parotitis (mumps) D. Pruritus (itchiness. Chicken pox) A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH) which of the following findings should the nurse expect? A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Inwardly turned foot on the affected side D. Asymmetric thigh folds A nurse is caring for a child who has nosebleed. Which of the following actions should the nurse take? A. Place the child in a sitting position and tilt her head back B. Apply ice at the opening of the nares for 5 min and then recheck for bleeding C. Place the child In a supine position with a pillow under her head D. Have the child sit with her head tilted forward and hold pressure on her nose for 10 mins (use ur fingers pinching the nose) A nurse is collecting data from a 1 year old child who has Wilms tumor. Which of the following findings should the nurse expect? A. Jaundice B. Swollen joints C. Abdominal mass D. Diarrhea A nurse is caring for a school age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35mL of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe? A. Low sodium, fluid restricted B. Regular diet no added salt C. Low carbohydrate, low protein diet D. Low protein. Low potassium diet A nurse is preparing to administer vaccines to a 4 month old infant. Which of the following vaccines should the nurse to administer? A. Rotavirus B. Influenza C. MMR (measles, mumps, rubella) D. Varicella (VAR) A nurse is collecting data from an infant at well-child visit. The nurse should expect the infant to double his birth weight by which of the following ages? 3 months 6 months 9 months 12 months NURSE IS CARING for a child who reports being physically abused by a family member. Which of the following statements should the nurse make? A. I promise I wont tell anyone about this B. Lets discuss what you have told me with your family members C. Your family is bad for doing this to you, D. IT is not your fault that this happened A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child? Birtth Cherry Gelain Apple juice Pedialyte A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations ? A Influenza (TIV) B Inactivated poliovirus (IPV) C Haemophilus Influenza tybe B (HiB) D Hepatitis B (Hep B) A NURSE on e medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse tha one of the children is a potential victim of abuse? A. A toddler who has multiple Bruises on the sins of both legs and his parents report that he is clumsy. B. A preschooler who has a BMI indicating Obesitiy. C. A school age child who cries when the nurse is giving him an injection D. An adolescent who asks to stay in the hospital because he likes the room A nurse is prepeating to administer IM injection to a preschool-age child. Which of the following actions should the nurse take? A. Ask the parents to hold the child B. Allow the child to hold a favorite toy. C. Administer the medication in the child’s room D. Tell the child the medicine will make him feel better. A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non corrosive substance that has no recommended antitode. The nurse should recommend to perform gastric lavage with which of the following substances? A. 0.9% sodium chloride B. Syrup of Ipecac C. Osmotic Diarrheal agents D. Activated Charcoal (absorbs toxins in the stomach , Mixed with Saline for aspiration via NG tube ) A nurse is reinforcing teaching about preventing disease tansmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include? A. Ill continue to encourage him to drink lots of fluids.” B. Ill take his temp. Q 4 hours” C. Ill give him acetaminophen for the pain D. Ill discard his toothbrush and buy another “ A nurse on a pedicatric unit is caring for a client who has brain tumor. To help ensure the lcients safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. B. Limit contact with other pediatric clients. C. Initiate Seizure precautions for the child D. Have the child use a wheelchair for all out-of-bed activities A nurse is caring for a child who is having seizure. Which of the following actions should the nurse take? ( select all that apply ) A. Elbow B. Mummy C. Wrist D. Jacket A nurse is caring for a child who is having seizure. Which of the following actions should the nurse take ( SELECT ALL THAT APPLY) A loosen restrictive clothing B place a tongue depressor in the child’s mouth C clear the area of hard objects D Place the child in prone positions E Restrain the child 83?...A nurse enters a school age child’s room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor Lateral position A nurse is assiting with the care of a child with spina bifida. Which of the folloing precations should nurse take while caring for this child? Precautions for Spina Bifida -- Latex Precautions A nurse is assisting with the admission of an infant who has resp. Syncytial Virus (RSV) which of the following rooms should the nurse assign the infant? A. A semi-private room with an infant who has a croup B. A semi-private room with a toddler who has pneumonia C. A private room with contact/droplet precautions D. A private room with protective isolation A nurse is reinforcing teaching with new parents about risk factors for the sudden infant death syndrome (SIDS). Which of the following statements by a parent indicates an understanding of the teaching? A. “Our baby will sleep in my bed because I am breastfeeding.” B. I do not plan to offer my baby a pacifier during naps or at bedtime C. My baby will be placed on her back when sleeping D. We will place an antique quilt in out baby’s crib.” A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the adolescent parent is the priority for the nurse to addresss?” A. He only sleeps 5 hours each night B. HE takes his medication between meals with water C. He seems to be getting a lot more bumps and bruises lately D. HE has not been eating as much lately” A nurse is caring for a toddler who has laryngotrachobronchitis ( LTB ) For which of the following findings should the nurse monitor to detect airway ob struction? A. Decreased Stridor (increase airway becomes more obstructive) B. Decreased Restlessness ( increase ) C. Increased Heart rate ( in order to deliver more blood pump more oxygen) D. Decreased Temperature ( Increased Temperature ) A nurse is reinforcing teaching with the mother of a 2-month old infant whose provider applied a Paylik Harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements. Which of the following statements by the mother indicates an understanding of the teaching? A. I will adjust the harness straps every day.” B. I will place the diaper over the harness.” ( Under the Harness ) C. I will check my baby’s skin three times each day. D. I will gently massage lotion on his skin around the harness clasps.” (Build up in skin and cause irritation ) A nurse reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? A administer a bronchodilator to the child after chest percussion therapy .” ( B. a pigeon- shaped chase might become evident as the disease progressing. “ C. Bradycardia is an early indicator of pneumothorax.” D. Engage the child in daily aerobic exercise. “(help promote erection of the mucus. Endorphine will Rise. YEEEE) A nurse is a collecting data from an infant which of the following is a clinical manifestation of pyloric stenosis?” A. Absent Bowel sounds (appendeictis and hirchsprung disease) B. Increased Sodium Level (decrease because of vomiting) C. Projectile Vomiting after feedings D. Golf- ball size over the left quadrant (olive shaped mass) (On the right of Umbilicus ) A nurse is planning meals for a 2-year child who has a fractured jaw and is having difficult swallowing. The surgeon has prescribed a pureed diet. Which of the following food selections should the nurse make? A. scrambled egg (Pureed) B. Cottage Cheese (mechanical diet) C. Dried fruit D. Peas A nurse reincofrcing teaching the parents of a pre schooler who has a atopic dermatitis. Which of the following information should the nurse include? You’ll need to take the entire prescription of antibiotics even if your symptoms improved. The doctors may recommend anti-histamines to help control symptoms. You can relieve your child’s iscomfort by applying warm compression of the lesion The doctor will remove the lesions with the liquid nitrogen A nurse is contributing to the plan of care of a 14-month old toddler who is 24 hour post-OP following a cleft palate repair. Which of the following interventions should the nurse include in the plan? A. Provide soft foods for the toddler. B. Suction the toddler nose and mouth every hour C. Maintain elbow restraints on the toddler D. Give the toddler a hard – tipped sippy cup to drink liquids. A nurse is collecting data from an infant who has Gastroesophageal reflux (GERD) . Which of the following findings should the nurse expect? ( select all that apply) A. Vomiting B. Weight Loss C. Rigid Abdomen ( for Appendecitis ) D. Wheezing E. Pallor A nurse is caring for a toddlet who has intusussepction. Which of the following manifestations should the nurse expect? A. Drooping B. Increased Appetite C. Jaundice D. Mucus in Stools A nurse is caring for a 4-year old child who refuses to take his medication because of the bad taste. Which of the following strategies should the nurse use to medication A. Offer the child an ice pop prior to administering the medication ( numb the tongue …Nerves ) B. Tell the child the medicine tastes like candy C. Hide the medication in apple slices. D. Inform the child that if he does not take the medication he will need a shot. A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.5 mEq/L Which of the following findings should the nurse expect? ( 9- 10.5 = Normal Calcium level ) A. Diarrhea B. Muscle Hypotonicity C. Tachycardia ( HypoCalcemia ) D. Positive Chvostek’s sign ( HypoCalcemia) (Face twitching after a tap ) tappity tap A nurse is planning care for a 4-year old child who has been admitted to the hospital. Which of the following toys. Should the nurse plan to provide the child? A. Modeling Clay B. Brightly Colored mobile ( INFANTS ) C. 100- piece jigsaw puzzle ( TOO MUCH APPARENTLY ) D. Checkerboard and Checkers ( SCHOOL AGE 6-12 Y/O ) A nurse is reincofrcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching ? A. “ I need to catheterize myself twice a day. “ ( Catheterize every 4-6 Hours ) B. I carry a water bottle with me because I drink a lot of water.” C. I used a suppository every night to have a bowel movements .” D. I do my wheelchair exercises sitting in my chair A parent asks a nurse about toys to provide for a 10-month old infant. Which of the following toys should suggest? A. Push- Pull Toy ( B. Crib Gym C. Large-Piece puzzles D. Coloring book with crayons [Show Less]
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