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ATI PN Comprehensive Predictor Form A | RN ATI concept-based assessment,:ATI med Surd comprehensive questions and answers
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ATI_PN_Comprehensive_Predictor_Form_A___Questions_and_Answers__LATEST__2020_.pdf
1. A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following ins... [Show More] tructions should the nurse include? ANS: Use lower-body strength RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back 2. A nurse is participating in a quality improvement study about the effectiveness of client pain management in the unit. Which of the following strategies should the nurse use to collect data? ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr after administration RATIONALE: The nurse should collect data from clients' charts about pain ratings before and after pain management interventions 3. A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching? ANS: "Your HIV status will be shared with members of your health care team." RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team who provides direct care for the client, just like any other diagnoses 4. A nurse is planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the client's room? ANS: Suction catheter RATIONALE: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway 5. A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? ANS: Coronary artery disease RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension\ 6. A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider? ANS: 250 mL of sanguineous drainage over the last 3 hr RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately 7. A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. Which of the following findings should the nurse report to the provider as an indication of hyperglycemia? ANS: Polyuria RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia and report this finding to the provider 8. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? ANS: "I will dispose of my needles in a plastic laundry detergent container." RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container. 9. A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take? ANS: Encourage the client to reminisce about the past RATIONALE: The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicit feelings of happiness 10. A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider? ANS: PR interval 0.24 seconds RATIONALE: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval indicates a heart block; therefore, the nurse should report this finding provider 11. A nurse on a medical unit is reviewing a client's medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent form? ANS: Lumbar puncture RATIONALE: The nurse should identify that a client needs to provide consent for general treatment, as well as a separate written, informed consent for any treatment that has an element of risk, such as a lumbar puncture 12. A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift. Which of the following clients should the LPN ask the charge nurse to reassign to a registered nurse (RN)? ANS: A client who has a new colostomy and requires the development of a teaching plan RATIONALE: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client's need for a teaching plan regarding the new colostomy and request that this client is reassigned to an RN. The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established 13. A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to one of the following interprofessional team members? ANS: Occupational therapist RATIONALE: The nurse should identify the need for a referral to an occupational therapist to teach the client how to use special eating utensils 14. A nurse is preparing to perform blood glucose monitoring for a client who has type 1diabetes Mellitus. Which of the following actions should the nurse take first? ANS: Hold the finger for testing in a dependent position RATIONALE: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen 15. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include? ANS: Apply the stockings in the morning RATIONALE: The nurse should instruct the client to apply the elastic stockings in the morning and remove them at the end of the day before bedtime 16. A nurse in a provider's office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (Select all that apply.) ANS: Store the child's clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 min. Dry bed linens and clothing in a hot dryer for at least 20 min. RATIONALE: Transmission of lice occurs via contact with personal items. Boiling hair care items in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by washing in hot dryer for at least 20 min is an appropriate strategy 17. A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination? ANS: Use intermittent urinary catheterization for the client on at regular intervals RATIONALE: A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch. 18. A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take? ANS: Tell the client they should not experience any discomfort RATIONALE: The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort 19. A nurse is caring for a client who is crying and states that their provider informed them that they have a tumor and will need a biopsy. Which of the following responses should the nurse make? ANS: "What have you done to help yourself get through stressful situations before?" RATIONALE: This is a therapeutic response. The nurse is aware that the client is under stress and encourages comparison to investigate whether they have experience dealing with a stressful situation 20. A nurse is caring for a newborn who is 12 hr old. The nurse should expect the newborn's stool to have which of the following characteristics within the first 24 hour following birth? ANS: Dark greenish-black and viscous RATIONALE: The first stool passed by a newborn is the meconium that develops in utero. It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood 21. A licensed practical nurse is assisting with the preparation of a client for insertion of a peripherally inserted central venous catheter (PICC). Which of the following actions should the nurse take? ANS: Witness the client's signature on the informed consent form. RATIONALE: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse should witness the client's signature on the consent form after ensuring the client has an understanding of the procedure, including its risks and benefits 22. A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client's meal tray? ANS: Spaghetti noodles with red sauce RATIONALE: The nurse should identify that spaghetti noodles with red sauce is appropriate for a client who adheres to a kosher diet. 23. A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color RATIONALE: The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding 24. A nurse is assisting with the care of a client who is postpartum and has a deep-vein thrombosis. The client has been receiving heparin IV infusion. Which of the following medications should the nurse ensure is readily available? ANS: Protamine sulfate RATIONALE: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin 25. A nurse is reinforcing teaching with a client about how to replace their two piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest? ANS: Hold the skin taut while removing the barrier RATIONALE: Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin 26. A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following responses should the nurse make? ANS: "What is your current understanding about the purpose of AA?" RATIONALE: The nurse should identify the client's understanding about the purpose ofAA to provide further information about the program and meetings and to facilitate a referral if needed. For treatment to be successful, the nurse should involve the client in the care decision-making process. This ensures the treatment program meets the client's individual needs and demonstrates caring by the nurse 27. A nurse is performing a dressing change for a client who is 3 days postoperative. Which Of the following findings should the nurse report to the provider? ANS: Yellow-green drainage at the incision line RATIONALE: Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the Provider 28. A nurse is providing comfort to the partner of a client who has died. Which of the following statements should the nurse make? ANS: "Journaling about your relationship might help with the grieving process." RATIONALE: Journaling provides a means for the client to identify thoughts and feelings and to recognize and come to terms with the positive and negative aspects the client's relationship with their partner 29. A nurse is assisting with an educational session for newly licensed nurses about partner violence. Which of the following characteristics should the Nurse included as placing a vulnerable person at risk for partner violence? ANS: Recent confirmation of pregnancy RATIONALE: The nurse should include pregnancy as a characteristic placing a vulnerable person at risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship due to the attention the child receives 30. A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury. Which of the following instructions for safe lifting technique should the nurse include? ANS: "You should hold a box close to your body when lifting it up." RATIONALE: The client should hold the box as close to their body as possible to maintain balance and prevent injury 31. A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include? ANS: "Apply a water-based lubricant around the nostrils to prevent irritation." RATIONALE: The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy 32. A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect? ANS: The client calls their partner to ask what they should wear each day RATIONALE: Clients who have dependent personality disorder have problems making everyday decisions without input from others 33. A nurse is caring for a client who is scheduled for a mastectomy the following day. The client is tearful and tells the nurse that they are not ready to have this procedure done at this time. Which of the following responses should the nurse make? ANS: "Would you like for me to talk to the surgeon with you?" RATIONALE: The nurse should advocate for the client's needs by offering to talk to the surgeon with the client. The nurse should also offer moral support and encourage the client to express their concerns and make a more informed decision 34. A nurse is documenting client care in the medical record. Which of the following entries should the nurse make? ANS: "Client remains NPO until x-ray procedure is complete." RATIONALE: The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation "NPO", which is an accepted abbreviation for "nothing by mouth." 35. A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? ANS: Observe the client's facial expressions during communication RATIONALE: The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying 36. A nurse is collecting data from a client who reports recent methamphetamine use. Which Of the following manifestations should the nurse expect? ANS: Dilated pupils RATIONALE: The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance 37. A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend to the charge nurse for discharge? ANS: A client who has pneumonia and is currently receiving oral antibiotics RATIONALE: The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation 38. A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client? ANS: Walking outside with a staff member RATIONALE: During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the one-on-one nature of the activity provides the client with a sense of security 39. A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first? ANS: Gloves RATIONALE: The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE. 40. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching? ANS: Strain the urine to collect stone fragments RATIONALE: The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation 41. A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider? ANS: Muscle pain RATIONALE: The nurse should instruct the client to report findings of muscle pain or tenderness to the provider. These findings can be manifestations of myopathy, or muscle injury, which is a potential serious adverse effect of atorvastatin 42. A nurse is caring for a client who is recovering from a motor vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make? ANS: "I cannot give you this information. You will need to speak with your employee." RATIONALE: Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclosed in a health care setting. The nurse should inform the employer they will need to speak with the client directly 43. A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take? ANS: Provide the client with a handheld event marker to record fetal activity RATIONALE: The nurse will provide the client with a handheld event marker for use in documenting fetal movement. The client will press the button every time they feel the fetus move throughout the test, which is then logged on the paper tracing recording the heart rate and activity of the Fetus 44. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching? ANS: "I should wear a soft scarf around my neck when I am outside." RATIONALE: A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun Exposure 45. A nurse is reinforcing teaching with an older adult client who has severe left-sided heart failure. Which of the following statements should the nurse make? ANS: "Rest for 15 minutes between activities." RATIONALE: The nurse should instruct the client to increase activity gradually and tourist for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardiac Workload. 46. A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following positions should the nurse plan to place the client during the procedure? ANS: Upright with arms resting on the overbed table RATIONALE: The nurse should position the client upright with arms resting on the overbed table to widen the intercostal spaces and improve access to the pleural fluid 47. A nurse is talking with a client who says the provider agreed to initiate a do-not- resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first? ANS: Check for documentation that the provider spoke with the client about theDNR RATIONALE: The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements 48. A nurse is observing a client who is in the first stage of labor. Which of the following interventions should the nurse recommend for this client? (Select all that apply.) ANS: Squatting using an exercise ball. Counterpressure to the sacral area. Pelvic rocking. RATIONALE: Squatting using an exercise ball can help relax the pelvis and perineal area and can relieve pain during contractions.Counterpressure to the sacral area can help decrease pain by relieving pressure on the spinal nerves caused by the fetus's occiput.Pelvic rocking can relieve backache during the first stage of labor. To perform this action, the client hollows their back and then arches it to relieve back pain. 49. A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? ANS: A visitor who develops a bruise on their head following a syncopal episode RATIONALE: The nurse should complete an incident report for an injury involving a client or visitor 50. A client is requesting information from a nurse about creating a health care proxy. Which Of the following statements should the nurse make? ANS: "The person you appoint will make healthcare decisions for you if you cannot do so yourself." RATIONALE: The nurse should instruct the client that a health care proxy designates a surrogate to make health care decisions when the client is no longer able to make decisions for themselves. 51. A client in a mental health facility unjustly accuses a nurse of stealing money from their room. Which of the following therapeutic responses Should the nurse make? ANS: "Tell me how you decided who took your money." RATIONALE: This response by the nurse is an example of therapeutic communication,in which the nurse validates the client's concern by encouraging them to describe their perception 52. A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take? ANS: Flush the feeding tube with water before and after administering the medication RATIONALE: To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration 53. A nurse is planning care for a 5-year-old child who is 8 hr postoperative following a tonsillectomy. Which of the following interventions should the nurse include in the plan of care? ANS: Administer PRN analgesics regularly for the first 24 hr. RATIONALE: The nurse should administer analgesics for the first 24 hr even if they are ordered on an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics regularly provides a steady state of analgesia. With pain being managed, children are more likely to consume fluids, remain hydrated, and avoid delayed discharge or readmissions for fluid volume deficit. 54. A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include? ANS: "You should increase your fluid intake while receiving this medication through the PCA pump." RATIONALE: The client should increase their fluid intake to prevent or relieve the adverse effect of constipation while receiving morphine through the PCA pump 55. A nurse is using the FLACC scale to determine the pain level of an 11-month-old infant who is postoperative. Which of the following factors should the nurse consider when using this pain scale? ANS: Level of activity RATIONALE: The nurse should consider the infant's activity level when using the FLACC pain scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolability (C). 56. A nurse is receiving a change-of-shift report for four clients. The nurse should plan to collect data from which of the following clients first? ANS: A client who has asthma and had frequent exacerbations on the previous shift RATIONALE: When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experienced several exacerbations of asthma on the previous shift, which can result in an obstruction of the client's airway [Show Less]
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ATI RN CONCEPT-BASED ASSESSMENT LEVEL 1
1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission-based precautions should the nurse initiate? • Airb... [Show More] orne • Rationale: Pulmonary tuberculosis is an infection that is transmitted by airborne droplets smaller than 5 microns in diameter. Therefore, this client requires airborne precautions to prevent communicating this infection to others 2. A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse plan to include? • An adult client may be in a mechanical restraint for up to 4 hours • Rational: The nurse should specify that a client who is 18 years or older may be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are limited to 2 hr and children who are younger than 9 years old are limited to 1 hr 3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make? • Exercise in the morning after arising • Rationale: Daily exercise has many benefits, including enhancing cardiovascular, psychological, and musculoskeletal health. The nurse should recommend that the client avoid exercising within 2 hr of bedtime to limit stimulation and enhance sleep 4. A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask? • Remove the mask by securely holding the ties and moving it away from the face • Rationale: The nurse should untie the bottom strings and then the top strings. Finally, while still holding the strings, the nurse should remove the mask from her face. This action prevents the nurse from touching the front of the mask, which is contaminated 5. A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the parent? • Inform the parent that anger is a natural response when dealing with loss • Rationale: The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings 6. A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk of developing hypertension? • African Americans • Rationale: Evidence-based practice indicates that individuals of African- American ethnicity have the highest prevalence of hypertension. Therefore, the nurse should identify community members of this ethnicity are at greatest risk of developing hypertension. 7. A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. Which of the following actions should the nurse plan to take first? • Determine the level of health equity among groups in the community • Rationale: Health equity among all groups in the community is a Healthy People 2020 initiative. Using the nursing process, the first action the nurse should take is to assess the needs of the community. By identifying disparities in community health, the nurse can develop interventions targeted at the community's specific needs. 8. A nurse is reviewing a client's new prescriptions that were just documented in the client's medical record by the provider. Which of the following abbreviations should the nurse clarify with the provider? • Enoxaparin 40 mg SQ QD • Rationale: The nurse should clarify this prescription with the provider. The abbreviations "SQ" and "QD" are considered error-prone and should not be used in documentation. The nurse should clarify that the provider intends the prescription to be administered subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ" and "daily" should be used instead of "QD." 9. A nurse is talking with a client who has major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse take? • It sounds as though you’re feeling hopeless • Rationale: This statement by the nurse is an example of restating, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding. 10. A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals regarding blood administration, which of the following actions should the nurse plan to take? • Verify the client and blood component using a two-person process • Rationale: The Joint Commission National Patient Safety Goals regarding blood transfusions includes improving the accuracy of client identification. The nurse should eliminate transfusion errors related to client misidentification by using a two-person verification process to identify the client and the blood component. 11. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflex urinary incontinence? • A client who has a T12 spinal cord injury • Rationale: The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization. 12. A nurse is documenting an assessment in a client's electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take? • Request that the AP use another computer to enter the data • Rationale: The nurse should request that the AP to go to another computer that is not in use to enter the morning blood glucose from the client. This is time- sensitive data that needs to be entered in the computer as soon as possible. 13. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) • 1.2 mL • Rationale: Ratio and Proportion • STEP 1: What is the unit of measurement the nurse should calculate? mL • STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg • STEP 3: What is the dose available? Dose available = Have 80 mg • STEP 4: Should the nurse convert the units of measurement? No • STEP 5: What is the quantity of the dose available? 0.8 mL • STEP 6: Set up an equation and solve for X. • Have/Quantity = Desired/X • 80 mg/0.8 mL = 120 mg/X mL • X = 1.2 • STEP 7: Round if necessary. • STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Desired Over Have • STEP 1: What is the unit of measurement the nurse should calculate? mL • STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg • STEP 3: What is the dose available? Dose available = Have 80 mg • STEP 4: Should the nurse convert the units of measurement? No • STEP 5: What is the quantity of the dose available? 0.8 mL • STEP 6: Set up an equation and solve for X. • Desired x Quantity/Have = X • 120 mg x 0.8 mL/80 mg = X mL • 1.2 = X • STEP 7: Round if necessary. • STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Dimensional Analysis • STEP 1: What is the unit of measurement the nurse should calculate? mL • STEP 2: What is the quantity of the dose available? 0.8 mL • STEP 3: What is the dose available? Dose available = Have 80 mg • STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 120 mg • STEP 5: Should the nurse convert the units of measurement? No • STEP 6: Set up an equation and solve for X. • X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ • X mL = 0.8 mL/80 mg x 120 mg/ • X = 1.2 • STEP 7: Round if necessary. • STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO 14. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) • 125 mL/hr • Rationale: • Follow these steps to calculate the infusion rate: • STEP 1: What is the unit of measurement the nurse should calculate? mL/hr • STEP 2: What is the volume the nurse should infuse? 1,000 mL • STEP 3: What is the total infusion time? 8 hr • STEP 4: Should the nurse convert the units of measurement? No • STEP 5: Set up an equation and solve for X. • Volume (mL)/Time (hr) = X mL/hr • 1,000 mL/8 hr = X mL/hr • X = 125 • STEP 6: Round if necessary. • STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 1,000 mL to infuse over 8 hr, it makes sense to administer 125 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride at 125 mL/hr for 8 hr. 15. A nurse is providing teaching about nutrition management to the parent of an 18- month-old toddler who has phenylketonuria. Which of the following foods should the nurse recommend? • Baked potato • Rationale: The nurse should recommend low-protein foods to the parent of a toddler who has phenylketonuria. The nurse should also recommend the parent offer the toddler fruits, juices, and cereals with limited phenylalanine. 16. A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should the nurse take when using the fire extinguisher? • Slide the pin on top of the fire extinguisher straight put • Rationale: The nurse should pull the pin on the top of the fire extinguisher to allow for use to extinguish the fire. 17. A nurse is planning meals for a client who practices Judaism and reports that she strictly adheres to orthodox dietary laws. The nurse should recognize that which of the following dietary practices applies to the client's beliefs? • The client is permitted to eat fish that have scales: • Rationale: The nurse should recognize that Orthodox Jewish dietary laws permit the client to eat fish that have fins and scales, such as tuna. However, fish that do not have scales, such as catfish, are considered unclean and are not permitted. 18. A nurse is caring for a client who has a Clostridium difficile infection and is incontinent of stool following long-term antibiotic therapy. Which of the following actions should the nurse take? • Wear a gown while providing care for the client • Rationale: The nurse should wear a gown when providing care for a client who has a C. difficile infection and is incontinent of stool. Applying a clean, water- resistant gown prior to entering the client's room prevents the nurse's clothing from becoming contaminated while caring for the client. The nurse should remove the gown prior to exiting the client's room. 19. A nurse is planning the menu for a client who practices Seventh-Day Adventism. Which of the following food selections should the nurse make? • Scrambled eggs • Rationale: The nurse should select scrambled eggs in the client's dietary meal plan for a client who practices Seventh-Day Adventism. Most clients who practice Seventh-Day Adventistism are lacto-ovo vegetarians who consume vegetables, eggs, and dairy, but not meat. Clients who practice this religion also do not consume caffeine or alcohol. 20. A nurse in a long-term care facility discovers a small fire in a client's trash can. After moving the client to safety, which of the following actions should the nurse take next? • Pull the alarm to notify emergency services • Rationale: Evidence-based practice indicates the nurse should first rescue and remove clients in immediate danger and then activate the alarm to notify authorities of the situation. 21. A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include? • Smokeless tobacco provides a higher dose of nicotine than cigarettes • Rationale: Smokeless tobacco is placed in the mouth, where nicotine is then absorbed sublingually. A higher dose of nicotine is delivered with the use of smokeless tobacco compared to smoking cigarettes, because heat destroys nicotine. [Show Less]
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NR 546 Addiction Medication Table
Drug Name Indication (Bold is FDA approved) Neurotransmitter(s) Affected Target Symptoms Half-life (T1/2), Metabolism (CYP 450 enzyme) Notable Side Effects... [Show More] (link to NT or affected brain circuit) Initial Dosing Considerations Specific lifespan considerations (age, pregnancy, breastfeeding) Buprenorphine (Subutex) Indication: ◗ Maintenance treatment of opioid dependence (sublingual) ◗ Maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses (no more than 8 mg) of a transmucosal buprenorphine- containing product (implant) ◗ Moderate to severe opioid use disorder in patients who have initiated treatment with a transmucosal buprenorphine-containing product, followed by dose adjustment for a minimum of 7 days (injection) Affected Neurotransmitters: ◗ Partial agonist at mu opiate receptors ◗ Antagonist at the kappa opioid receptor ◗ Agonist at delta opioid receptors ◗ Partial agonist at nociceptin Half-life: Sublingual buprenorphine: 24–42 hours Naloxone: 2–12 hours Implant: Tmax is 12 hours; time to steady state is 4 weeks Metabolism: CYP450 3A4 Notable Side Effects: ◗ Headache, constipation, nausea ◗ Oral hypoesthesia, glossodynia ◗ Orthostatic hypotension ◗ Implant specific: insertion site pain, pruritis, erythema Side Effect Pathways: ✓ Binding at mu opioid receptors Initial Dosing Considerations: ◗ Patients must be in a mild withdrawal state prior to starting buprenorphine ◗ Day 1 – 8 mg ◗ Day 2 – 12 or 16 mg ◗ Days 3-7 – Increase in increments of 4 mg to max dose of 32 MG ◗ Observe patient for at least 2 hours with initial dose, then have 1–2 visits in first week ◗ Achieve the lowest dose that eliminates withdrawal symptoms and illicit opioid use ◗ During stabilization patients should be seen once per week ◗ During maintenance patients should be seen biweekly or monthly Specific lifespan considerations Age: ◆ Elderly - Use with caution ◆ Children and adolescents - Safety and efficacy have not been established Pregnancy: ◆ Controlled studies have not been conducted in pregnant women ◆ Buprenorphine may be opioid peptide receptors Target Symptoms: ◗ Opioid dependence preferable to methadone in pregnant women ◆ Neonatal withdrawal has been reported following use of buprenorphine during pregnancy ◆ Not generally recommended for use during pregnancy, especially during first trimester ◆ Effective June 30, 2015, the US FDA requires changes to the content and format of pregnancy and lactation information in prescription drug labels, including the elimination of the pregnancy letter categories; the Pregnancy and Lactation Labeling Rule (PLLR or final rule) applies only to prescription drugs and will be phased in gradually for drugs approved on or after June 30, 2001 Breastfeeding: ◆ Some drug is found in mother’s breast milk ◆ Recommended either to discontinue drug or bottle feed Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) Indication: ◗ Maintenance treatment of opioid dependence ◗ Induction of treatment for opioid dependence (Bunavail only) Half-life: Buprenorphine: 24–42 hours Naloxone: 2–12 hours Metabolism: CYP 450 3A4 Notable Side Effects: ◗ Headache, constipation, nausea ◗ Oral hypoesthesia, glossodynia ◗ Orthostatic hypotension ◗ Implant specific: insertion site pain, Initial Dosing Considerations: ◗ Patients must be in a mild withdrawal state prior to starting buprenorphine ◗ Day 1 - 8 mg/2 mg ◗ Day 2 – 12 mg/3 mg or 16 Affected Neurotransmitters: ◗ Partial agonist at mu opiate receptors – Buprenorphine ◗ Antagonist at the mu opioid receptor - Naloxone ◗ Antagonist at the kappa opioid receptor ◗ Agonist at delta opioid receptors ◗ Partial agonist at nociceptin opioid peptide receptors Target Symptoms: ◗ Opioid dependence pruritis, erythema Side Effect Pathways: ✓ Binding at mu opioid receptors mg/4 mg ◗ Days 3-7 - Increase in increments of 4 mg/1 mg to max dose of 32 MG/8 mg ◗ Observe patient for at least 2 hours with initial dose, then have 1–2 visits in first week ◗ Achieve the lowest dose that eliminates withdrawal symptoms and illicit opioid use ◗ Stabilization (up to 2 months) and maintenance dose is generally 8 mg/2 mg up to 24 mg/6 mg ◗ During stabilization patients should be seen once per week ◗ During maintenance patients should be seen biweekly or monthly Specific lifespan considerations Age: ◆ Elderly - Use with caution ◆ Children and adolescents - Safety and efficacy have not been established Pregnancy: ◆ Controlled studies have not been conducted in pregnant women ◆ Buprenorphine may be preferable to methadone in pregnant women ◆ Neonatal withdrawal has been reported following use of buprenorphine during pregnancy ◆ Extremely limited data on sublingual naloxone exposure in pregnancy ◆ Not generally recommended for use during pregnancy, especially during first trimester ◆ Effective June 30, 2015, the US FDA requires changes to the content and format of pregnancy and lactation information in prescription drug labels, including the elimination of the pregnancy letter categories; the Pregnancy and Lactation Labeling Rule (PLLR or final rule) applies only to prescription drugs and will be phased in gradually for drugs approved on or after June 30, 2001 Breastfeeding: ◆ Some drug is found in mother’s breast milk ◆ Recommended either to discontinue drug or bottle feed Methadone (Dolophine, Methadose) Indication: ◗ Moderate-to-severe pain not responsive to nonnarcotic analgesics ◗ Maintenance treatment of opioid addiction (heroin or other morphine-like drugs), Half-life: 15 to 55 hours Metabolism: CYP 450 3A4, 2B6, 2C19, 2C9, and 2D6 Notable Side Effects: ◗ Dizziness ◗ Tiredness ◗ Sweating ◗ Legs swelling ◗ Rash or hives ◗ Chest pain Initial Dosing Considerations: ◗ Methadone is administered daily under close supervision ◗ When used for detoxification: Patient may receive methadone when there are significant symptoms of withdrawal, in [Show Less]
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ATI Med Surg Proctored Final Exam 2023 A+
An older adult is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that ... [Show More] the client has hypertonic dehydration? - CORRECT ANSWER Urine Specific gravity 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? - CORRECT ANSWER Aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? - CORRECT ANSWER "You should cut the opening of the skin barrier one-eight inch wider than the stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to minimize irritation of the skin from exposure to urine. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? - CORRECT ANSWER Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration. A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? - CORRECT ANSWER History of asthma A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? - CORRECT ANSWER Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? - CORRECT ANSWER Use a 30-mL syringe The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi. A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the expect? - CORRECT ANSWER Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client). - CORRECT ANSWER Current medications The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing. A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? - CORRECT ANSWER Inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation. A nurse is caring for a client who has a stage III pressure injury. Which if the following findings contribute to delayed wound healing? - CORRECT ANSWER Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500kcal/L. The IV pump should be set at how many mL/hr? (Rounding to the nearest whole number.) - CORRECT ANSWER 167 mL/hr A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - CORRECT ANSWER Add cabbage to the diet. To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage, cauliflower, and broccoli, are high in fiber. A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? - CORRECT ANSWER Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine. A nurse is teaching a client with systemic erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? - CORRECT ANSWER Infection The nurse should instruct the client to avoid contact with people who are ill and monitor for manifestations of an infection such as a fever or a sore throat. Prednisone can suppress the client's immune response and mask the manifestations of an infection. A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? - CORRECT ANSWER "I understand that I will have a permanent tracheostomy after the surgery." With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent. A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? - CORRECT ANSWER Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are 2 types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises. A nurse is caring for a client who has tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? - CORRECT ANSWER A leak within the ventilator's circuitry The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? - CORRECT ANSWER Involuntary muscle spasms The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency. A nurse is providing discharge teaching to client who has osteoarthritis. Which of the following instructions should the nurse include? - CORRECT ANSWER "Rest frequently after periods of activity." The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often worsens after activity. Rest usually helps relieve the pain, so performing activities at a comfortable pace with periods of rest is appropriate. A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include? - CORRECT ANSWER "Apply heat to your joints prior to exercising." The nurse should instruct the client to apply heat to the joints prior to exercising to increase mobility and reduce pain. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump the nurse should monitor the client for which of the following findings? - CORRECT ANSWER Diaphoresis The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? - CORRECT ANSWER Lower back discomfort An abdominal aortic aneurysm involves widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain. A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? - CORRECT ANSWER Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space. The normal sodium level is 135-145 mEq/L A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection? - CORRECT ANSWER Blood pressure 160/90 mmHg Due to the kidney's role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension. A nurse is caring for a client whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? - CORRECT ANSWER Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation. A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? - CORRECT ANSWER Check the client's urine specific gravity The nurse should check the client's urine specific gravity to assess for fluid volume overload. A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER "You can suck on popsicles to numb your mouth." The nurse should instruct the client to suck on popsicles or ice chips, which can numb the mouth. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hour. Which of the following should the nurse take? - CORRECT ANSWER Irrigate the indwelling urinary catheter with a syringe. No drainage in the urinary drainage bag indicates an obstruction. The nurse should gently irrigate the indwelling urinary catheter as prescribed to clear the obstruction and allow urine and irrigating fluid to drain. A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? (Select all that apply) - CORRECT ANSWER Increased breast density BMI of 32 Undergoing hormonal replacement therapy for 10 years Women who have dense breast tissue are at an increased risk for developing breast cancer because they have more connective and glandular breast tissue. Postmenopausal obesity increases the risk for developing breast cancer. Hormone-related risks for developing breast cancer include the long-term use of oral contraceptives or hormone replacement therapy, early menarche, late menopause, and first pregnancy after 30 years of age. A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommend restricting the intake of which of the following nutrients? - CORRECT ANSWER Protein Dietary restrictions for clients who have chronic kidney disease vary based on the degree of kidney function; however, most clients need protein limitations. Predialysis protein restriction can help preserve some kidney function. A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following client statements indicates an understanding of the information? - CORRECT ANSWER "I will feel the urge to urinate following this procedure." After a TURP, the client will feel the urge to urinate. The nurse should reassure him that he will receive analgesics to help relieve this discomfort. A nurse is caring for client who is postoperative following a frontal craniotomy. The nurse should place the client in which if the following positions? - CORRECT ANSWER Semi-fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure. A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? - CORRECT ANSWER Increase the oxygen flow and request an arterial blood gas determination. The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements. A nurse is assessing a client who has Graves disease. Which of the following findings should the nurse expect the client to display? [Show Less]
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ATI Med surg proctored exam 2022 (NEW!) 75 QUESTIONS WITH 100% CORRECT ANSWERS
A nurse is assisting with he care of a client following a left femoral cardiac angiography. Thee nurse should place a sandbag on the client over which of t... [Show More] he following areas? - CORRECT ANSWER left groin A nurse is reviewing the lab results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas ABG values include: pH 7.22 PaCO2 68 mm Hg base excess -2 PaO2 78 mm Hg oxygen saturation 80% Bicarbonate 28 mEq/L. - CORRECT ANSWER respiratory acidosis A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER I will abstain from sexual intercourse A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance which of the following actions should the nurse take first? - CORRECT ANSWER cover the clients wound with a moist sterile dressing Based on a clients recent history a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? - CORRECT ANSWER Do you sleep well at night A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at Mcburneys point? - CORRECT ANSWER Mcburneys point is found between the naval and the anterior iliac crest (left lower) A nurse is reinforcing teaching about excercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER I should avoid injecting insulin into my thigh if I am going to go running A nurse is caring for a client who is postoperative following a tracheostomy and has copies and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin the clients secretions? - CORRECT ANSWER provide humidified oxygen A nurse is reviewing the lab results of a client who is taking cyclosporine following a kidney transplant. Which of the following lab findings should the nurse identify as the most important to report to the provider? - CORRECT ANSWER increase in serum creatinine A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? - CORRECT ANSWER breath in through nose and out through pursed lips A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long term goals is appropriate with regard to the clients mobility? - CORRECT ANSWER propel a wheelchair equipped with knobs on the wheels A nurse is reinforcing teaching about an esophagogastrodudenscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching ? - CORRECT ANSWER you will remain NPO for 8 hours before the procedure A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - CORRECT ANSWER drop is systolic BP more than 10 mm Hg on inspiration A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to section. Which of the following is the priority finding the nurse should report to the provider? - CORRECT ANSWER abdomen is distended A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER avoid medications in a capsule or enteric form A nurse is caring for a client after a radical dissection. To which of the following should the nurse give priority in the immediate postoperative period? - CORRECT ANSWER ineffective airway clearance related to thick copious secretions A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? - CORRECT ANSWER Bypass surgery must be very frightening for you A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? - CORRECT ANSWER hypotension A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? - CORRECT ANSWER dyspnea, barrel chest, clubbing of the fingers, shallow respirations A nurse is assisting with thee care of a client who is postoperative and has a closed wound drainage system in place. Which of the following actions should the nurse take? - CORRECT ANSWER fully recollapse the reservoir after emptying it A nurse is caring for a Client who has Alzheimers disease. The nurse discovers the client entering the room of another client who comes upset and frightened. Which of the following actions should the nurse take? - CORRECT ANSWER attempt to determine what the client was looking for A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? - CORRECT ANSWER this test will measure the intraocular pressure of the eye A nurse is collecting data from a client who has open angle glaucoma. Which of the following findings should the nurse expect? - CORRECT ANSWER loss of peripheral vision A nurse in a providers office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - CORRECT ANSWER take this medication between meals A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - CORRECT ANSWER hardened skin A nurse is checking the suction control chamber of a clients chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? - CORRECT ANSWER verify that the suction regulator is on A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if thee biopsy will hurt. Which of the following responses should the nurse make? - CORRECT ANSWER the biopsy can be uncomfortable but we will try to keep you as comfortable as possible A nurse is assisting in the plan of care for a client who had removal if the pituitary gland. Which of the following actions should the nurse include in the plan? - CORRECT ANSWER change the nasal drip pad as needed A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? - CORRECT ANSWER large incisions will be made in the burned tissue to improve circulation A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? - CORRECT ANSWER wash daily with an antibacterial soap A nurse is caring for a client who has a temp of 103.5 and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? - CORRECT ANSWER shivering A nurse is reinforcing preop teaching for a client who is scheduled for surgery and is to take hydroxyzine preop. Which of the following effects of the medication should the nurse include in the teaching? - CORRECT ANSWER decreasing anxiety, controlling emesis, reducing the amount of narcotics needs for pain relief A nurse is collecting data from a client who has acute gastroenteeritis. Which of the following data collection findings should the nurse identify as the priority? - CORRECT ANSWER potassium of 2.5 mEq/L A nurse is caring for a client who is being evaluated for endometerial cancer. Which of the following findings should the nurse expect the client to report? - CORRECT ANSWER abnormal vaginal bleeding A nurse is reinforcing teaching with a client who has a new presicprion for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? - CORRECT ANSWER iron A nurse is caring for an older adult client who has dysphasia and left sided weakness following a stroke. Which of the following actions should the nurse take? - CORRECT ANSWER add thicker to fluids A nurse is caring or a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? - CORRECT ANSWER check the clients vital signs A nurse is caring for a client who asks why she is being preceived aspirin 325 mg daily following a MI. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? - CORRECT ANSWER to prevent blood clotting A nurse is caring for a client who has a spinal cord injury at T4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of thee following interventions should thee nurse take to prevent autonomic dysreflexia? - CORRECT ANSWER prevent bladder distention A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate TURP and has a 3 way urinary Catheter with a continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? - CORRECT ANSWER determine the latency of the tubing A nurse is caring for a client who is difficult to arrouse and very sleepy for several hours following a general tonic clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? - CORRECT ANSWER postical phase A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? - CORRECT ANSWER [Show Less]
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ATI Med Surg Proctored Exam
A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. which of the f... [Show More] ollowing findings should the nurse identify as a contraindication to receiving this alternative therapy? Lymphedema A client who is ideal and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? Request an interpreter during the initial assessment A nurse is teaching a client. about the nurse of the incentive spirometer. which of the following instructions should the nurse include in the teaching? Hold breaths 3 to 5 seconds before exhaling A nurse is caring for a client who sustained a spinal cord injury in a diving accident. which of the following actions should the nurse take? Monitor urine output hourly A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a) Flush the catheter using a 10-ml syringe b) Use clean technique when changing the dressing c) Cleanse the site with povidone-iodine d) Change the dressing every 24hr A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following action should the nurse take first? a) Prepare the client for peritoneal lavage b) Check the color of the client's skin c) Administer an opioid analgesic d) Remove all of the client's clothing A nurse is caring for a client following a bronchoscopy. Which of the following action should the nurse take first? a) Provide the client with sips of water. b) Instruct the client to report bleeding. c) Inform the client they might experience a low-grade fever. d) Check the client's gag reflex A nurse is teaching a client about using a metered-dose rescue inhaler. which of the following statements should the nurse include in the teaching? Exhale fully before bringing the inhaler to your lips A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick- day rules. Which of the following statements by the client indicates an understanding of the teaching? a) "I will consume 250grams of carbohydrates daily while I'm sick." b) "I will monitor my blood glucose every 8hours." c) "I will not take my diabetes medications while I am sick." d) I will check my urine for ketones if my blood glucose is greater than 240 mg/dL A nurse is caring for a client who has duodenal ulcer. which of the following actions should the nurse take? (Click on the Exhibit button for additional information. Infuse packed RBCs A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect? a) HCO3-25 mEq/L b) PaO2 85mmHg c) pH 7.38 d) PaCO2 48 mm Hg A nurse is admi ng a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? a) Hiccups b) Sneezing c) Presence of a sharp spike prior to the QRS complex on the ECG d) Presence of intrinsic P waves following a QRS complex on the ECG A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. which of the following routine medications to give at 0800 should the nurse withhold? a) Metformin b) Metoprolol c) Valproic acid d) Fluticasone A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? a) Place pillows under the client's knees b) Apply compression stocking socks c) Avoid use of anticoagulants d) Discourage leg exercises while in bed A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority? In the last day, I have had a severe headache and pain around my right eye. A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate? a) BUN 8mg/Dl b) Creatinine 0.4mg/dL c) Hgb 20g/dL d) Potassium 6.8 mEq/L A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan? Encourage the client to change positions slowly A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect assess the stoma at which of the following locations? On top A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a) Insert a urinary catheter b) Administer IV fluids to the client c) Prepare the client for an intravenous pyelogram d) Initiate beta-blocker therapy A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take? a) Slow the transfusion rate if the client reports itching b) Prime the IV tubing with 0.45% sodium chloride c) Complete the transfusion within 2hrs. d) Administer through a 22-gauge A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a) Decrease carbohydrate intake b) Increase phosphorus intake c) Increase potassium intake d) Decrease protein intake A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking? a) "Can you count backwards from 10 in intervals of 7?" b) "Can you tell me the state where you were born?" c) "What do you understand about your condition?" d) What is mean by the saying "Don't beat around the bush?" [Show Less]
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ATI RN Maternity Proctored Exam
1. A nurse is care for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? - Renal agenesis 2. A nurs... [Show More] e in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy? - Breast tenderness 3. A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client to report to the provider during the first trimester? - Persistent vomiting 4. A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizzieness when lying on her back. Into which of the following positions should the nurse assist the client? - Lateral 5. A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? - Dry the newborn 6. Nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend? - Rock in a rocking chair 7. A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client’s fundus? - 3 cm below the umbilicus 8. A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? - “Your milk supply will noticeably increase in volume around the 3rd/4th day after delivery - 9. A nurse is teaching the guardian of a newborn about caring for the newborn’s umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? - They can cause delayed cord separation 10. A nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. Which of the following client responses indicates a understanding of the teaching? - If I notice that my eyes are puffy, I should call my provider 11. A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statemnts indicates an understanding of the teaching? - I should be careful to avoid becoming pregnant within next month 12. A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse provide? - We need to observe your baby more closely 13. A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? - Platelet count 135,000 14. A nurse at a family planning clinic preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching? - Use spermicidal jelly whenever you use your diaphragm 15. A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify a requiring intervention? - A newborn whose axillary temp is 36.1 degrees Celsius (96.9 degrees F) 16. A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? - Obtain blood samples for baseline lab values - 17. A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. the newborn is pink with acrocyanosis. Which of the following actions should the nurse take? - Continue to monitor the newborn routinely 18. A nurse is assessing a client who is 3 days post-partum. When examining the client’s uterus, which of the following techniques should the nurse use? - Measure the height of the fundus in fingerbreadths in relation to the umbilicus 19. A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan? - Reposition the newborn every 3 hours 20. A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statement? - The same hormone that is released in response to the baby’s sucking and causes milk to flow also making the uterus contract. 21. A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instructions? - I can conceive anytime I want after 10 days 22. A provider tells a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? - Lets discuss other foods that are high in protein that you could substitute for meat 23. A nurse is caring for a preterm infant in the nicu. Which of the following actions by the nurse will promote the infant’s optimal development? - Reducing ambient noise and lighting 24. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? - Use a photometer to monitor the lamps energy - 25. A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? - Apply ice pack to your breast 26. A nurse is caring for a client in labor and observing a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take? - Document the findings and continue to monitor 27. A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take? - Assist the client to ambulate in the hallway 28. A nurse is caring for a client who is 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? - Check fetal heart tones 29. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? - Double vision 30. A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increasing frequency of urination. The nurse should document this occurrence as which of the following? - Lightening [Show Less]
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MENTAL HEALTH FINAL EXAM 1 ATI QUESTIONS
1) A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should the... [Show More] nurse plan to take? Maintain close observation of the client. 2) A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? The client is able to identify the names of family members. 3) A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." Which of the following responses should the nurse make? "That must be very frightening." 4) A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? Maintaining adequate hydration 5) A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The nurse should tell the client to expect which of the following adverse effects? Sedation 6) A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. The nurse should identify which of the following interventions as the priority when planning care for this client? Promoting and maintaining client safety 7) A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to avoid? Pure vanilla extract 8) A nurse is planning care for a client who has a physical dependence to alprazolam and must discontinue the medication. Which of the following actions should the nurse include in the plan? Taper the medication gradually over several weeks. 9) A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. The client tells the nurse, "I have not had anything to drink for 6 hours." Which of the following findings should the nurse expect during alcohol withdrawal? Insomnia 10) A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care? Diazepam 11) A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that member of the group requires further teaching when she identifies which of the following findings as a manifestation of Alzheimer's disease? Sudden confusion 12) A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which of the following manifestations is a common adverse effect of this medication? Dizziness 13) A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse should identify that it is safe to administer which of the following medications while the client is taking lithium? Valproic acid 14) A nurse in the emergency department is caring for a toddler who has a fractured arm. Which of the following findings should the nurse identify as a possible indication of physical abuse? The parent provides a history that is inconsistent with the child's injury. 15) A nurse is evaluating the plan of care for a client who has antisocial personality disorder. Which of the following client actions indicates that he is making progress with the treatment? (Select all that apply.) Assisting another client who has depression to fill out a menu Requesting a weekend pass to go home 16) A nurse is providing teaching to a client who is to start taking valproic acid. Which of the following instructions should the nurse include? "You should have your liver function levels monitored regularly while taking valproic acid" 17) A nurse is teaching a client who has agoraphobia about systematic desensitization. Which of the following comments should the nurse include in the teaching? "You will slowly be exposed to increasing levels of public spaces." 18) A nurse is planning a staff education session about the administration of antidepressant medications to older adult clients. Which of the following information should the nurse include in the teaching? Older adult clients require a lower initial dose of antidepressant medication than adult clients. 19) A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? Severe Alzheimer's disease 20) A nurse is assessing a client who has binge-eating disorder. Which of the following findings should the nurse expect? Abdominal pain 21) A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? Request a prescription for an antianxiety medication. 22) A nurse is assessing a client who has conduct disorder. Which of the following findings should the nurse expect? Aggressive behavior toward others 23) A nurse in an acute mental health facility is leading a nursing staff discussion about the legal aspects of involuntary admissions. Which of the following information should the nurse include? An involuntary admission is justified if the client is a danger to others. 24) A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall very rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? Approach the client in a nonthreatening manner. 25) A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. For which of the following findings should the nurse question the provider's prescription? Hypotension 26) A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include in the teaching? "Ignore your child's attention-seeking behaviors that are not dangerous." 27) A nurse is interviewing a client who has anorexia nervosa. Which of the following findings should the nurse expect? Strenuous exercise regimen 28) A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? "Attending group therapy, even if you're tired, is an important part of your treatment." 29) A nurse is performing an admission assessment for a client who has restricting type anorexia nervosa. The nurse should expect which of the following findings? Decreased caloric intake 30) A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances? Opiates 31) A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client? Denial 32) A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? Talk to the client from two arm-lengths away. 33) A nurse is assessing a client who takes phenelzineu for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? Elevated blood pressure 34) A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? Report of intense guilt 35) A nurse is interviewing an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use? Avoid a nonjudgemental tone. 36) A nurse is providing teaching to the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include in the teaching? "Donepezil can improve cognitive functioning during the earlier stages of the disease." 37) A nurse is obtaining a client's medical history prior to scheduling the client for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as a potential complication of the procedure? Cardiac arrhythmia 38) A nurse is planning care for a client who has bipolar disorder and is experiencing manic episode. Which of the following interventions should the nurse include in the plan? Provide the client frequently with high-calorie finger-foods. 39) A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? Protect the client from impulsive behavior. 40) A nurse in an acute mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse include in the plan? Instruct the client to practice thought stopping. 41) A nurse is caring for a client who has alcohol use disorder. Following alcohol withdrawal, which of the following medications should the nurse expect to administer to the client during maintenance? Disulfiram 42) A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he isn't going to attend any further sessions and states, "I don't have time for all that talking." Which of the following responses should the nurse make? "It must be difficult for you to talk about family problems." 43) A nurse in an acute substance disorder unit is assessing a client who received treatment in the emergency department for a heroin overdose. Which of the following findings should the nurse anticipate during heroin withdrawal? Muscle aches 44) A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect? Dilated pupils 45) A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display? Anger with the nursing staff for hospitalizing him against his will 46) A nurse is developing a plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client? Permitting the client to spend some quiet time alone after each meal 47) A nurse in the emergency department is assessing a client who has heroin intoxication. Which of the following findings should the nurse expect? Respiratory depression 48) A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? Administer the medication at bedtime. 49) A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? Speak to the client using simple and concrete terminology. 50) A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. Which of the following findings should the nurse expect? Confusion 51) A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. To assess cognitive ability, I should ask the client to count backwards by sevens B. To assess affect, I should observe the client's facial expression C. To assess language ability, I should instruct the client to write a sentence 52) A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? D. Monitor the client for adverse effects of medications 53) A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? B. Identify client's perception of her mental health status 54) A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub 55) A nurse is planning a peer group discussion about the diagnostic and statistical manual of mental health disorders 5th edition. Which of the following information is appropriate to include in the discussion? B. DSM-5 establishes diagnostic criteria for individual mental health D. The DSM-5 assists nurses in planning care for client's who have mental health disorders E. The DSM-5 indicates expected assessment findings of mental health disorders 56) A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod 57)A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? B. False imprisonment 58) A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the clients and others 59) A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? B. Client was offered 8 oz of water every hour C. Client shouted obscenities at assistive personnel D. Client received chlorpromazins 15 mg by mouth at 1000 60) A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? B. Tell the nurse to stop discussing the behavior 61) A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? D. Intonation 62) A nurse in an acute mental health facility is communicating with a client. The client states. "I can't sleep. I stay up all night." The nur [Show Less]
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ATI RN MEDSURG 2020/2021 PROCTORED EXAM- LATEST (CORRECT STUDY GUIDE). Q&A WITH RATIONALES
1. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for3 years. Which of the following test should the... [Show More] nurse monitor? a. Fasting blood glucose b. Stool for occult blood c. Urine for white blood cells d. Serum calcium Rationale:ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abd pain). 2. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of thefollowing findings should the nurse report to the surgeon? 1. Heart rate 90/min 2. Absent bowel sounds → normal findings after major bowel surgery; takes several days to return to normal. 3. Hgb 8.2 g/dl 4. Gastric pH of 3.0 Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. 3. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonate Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and keeps pt. on urinating 4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansertron. Rationale: No idea what the Exhibit is all about; wont be able to answer it. 5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Transmucosal fentanyl b. Intramuscular meperidine c. Oral acetaminophen d. Intravenous dexamethasone Rationale:ATI pg. 27 6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? a. PR interval b. QRS duration c. T wave d. ST segment Rationale: ST elevation indicates MI. ST depression indicates ischemia 7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? a. Pat the skin on the radiation site to dry it b. Apply OTC moisturizer to the radiation site c. Cover the radiation site loosely with a gauze wrap before dressing d. Use a soft washcloth to clean the area around the radiationsite Rationale: pg. 584. Dry the area thoroughly using patting motions. 8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a. Diphenhydramine b. Acetaminophen c. Pantoprazole d. Furosemide Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent cardiovascular/respiratory distress. 9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? a. Lungs clear b. Apical pulse 82/min c. Hyperactive bowel sounds d. Blood pressure 90/50 mm Hg Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation, paralytic ileus. So effectiveness would indicate opposite of this 10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Compensated respiratory alkalosis d. Uncompensated respiratory acidosis Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis 11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours A. Decreased BUN ELEVATED DT fluid loss B. Hypoglycemia (High due to stress) C. Hypoalbuminemia (Low due to fluid loss) D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase) (Page 481 ch 75 med surge ati pdf 10.0) 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the followingactions should the nurse take ? a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderate carbs page 317, chapter 49 Peptic ulcer disease med surge ati pdf 10.0) b. Provide the client with four full meals a day (Small frequent meals) c. Encourage the client to to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr prior and following a meal) d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines) 13. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the followingfactors should the nurse include in the teaching? SATA. (p.70 chapter 13) Born with a high weight Chronic infections of the middle ear Use a loop diuretic Perforation of the ear drum Frequent exposure to low volume noise 14. A nurse is preparing to administer fresh frozen plasma to a client . Which of the following actions should thenurse take? (Chapter 92 page 606 med surge ati pdf 10.0) Administer the plasma immediately after thawing (Blood must be warm, you also have a 30 minute window to give it so bacteria doesn’t grow. So it doesn’t necessarily have to be right away.) Transfuse the plasma over 4 hour (Can be in 2 to 4 hours) Hold the transfusion if the client is actively bleeding (YOU HAVE TO GIVE IT. That’s the whole point! The patient is losing blood so you have to replace it. We give fresh frozen plasma because he or she may have clotting deficiencies) Administer the transfusion through a 24 gauge saline lock (Has to be a 18 or 20 gauge) 15. A nurse is assessing a clients who reports numbness and tingling of his toes and exhibits a positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect? (ch 44 page 277 MSATI PDF 10.0) Hypoatremia Hyperchloremia Hypermagnesemia Hypocalcemia (low calcium = low ca causes increased firing = spasms. Learned this is LVN school.) 16. A home health nurse is teaching a clients how to care for a peripherally central catheter in his right arm.Which of the following statements should the nurse include in the teaching? (Chapter 27 cardiovascular diagnostics and therapeutic procedures p. 165 MS ATI PDF 10.0) Change the transparent dressing over the insertion site every 48 hours - transparent dressing can be up to 7 days Clean the insertion site with mild soap and water - when showering, must insertion site must be covered !!!!! No water can be in it . Measure your right arm circumference once weekly- does not say in the chapter Use a 10 milliliter syringe when flushing the catheter - flush with 10 ml NS b4 and after med administration 17. A nurse is caring for a client who has a central venous access device. Which of the following assessmentfindings should the nurse report to the provider? (P.166 MS ATI PDF 10.0) RBC count of 4.7 million/mm 3 BUN 22 mg/ dl - not dramatically high enough to pay attention to. WBC count of 16,000/ mm 3 - phlebitis is a complication , infection is a complication that can happen 7 days after insertion , also temp increase if 1 degree can happen. Blood glucose of 120 mg/dl [Show Less]
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