Bundle
BUNDLE OF ATI PREDICTOR VERIFIED 2023
7 Items
TI predictor exam 2023 PN Questions and Answers
hindu post mortem dont touch the patient's body Vancomycin Resistant Enterococcus (VRE) Methicillin Resistant Enterococcus (MRE); Precaution? PPE?... [Show More] Contact Precaution Gloves and Gown What is the signs of digoxin toxicity? blurred vision Patient taking warfarin and INR is 5 what to do? vitamin k Patient reports frequent vomitting what's the indication that the patient have hyperemesis gravidum Ketonuria Proteinuria indication of what in pregnancy Preeclampsia Blurred vision during pregnancy is an indication of Preeclampsia Newborn normal heart rate 110-160 Dorsalis pedis location front of the foot Bathing infant Sponge until the cord falls off A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. A. Use three pronged grounded plugs. What signs that indicates effectiveness of levothyroxine? weigh loss measure abdominal girth daily Ascites Clean traechostomy from inward to outward motion Lumbar puncture what to expect after headache candiasis white milky substance occupational therapy when patient having trouble with upper extremities like feeding self therapist for swallowing Speech therapy Palliative care purpose quality of life and comfort Pacrealipase take with meals HIgh ph and abnormal pac02 respiratory alkalosis A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? -make sure room is lite 44. Which of the following foods is a patient to avoid for 2 days before collecting a stool sample for guaiac testing? A) Milk B) Red meat C) Rice D) Grapefrui tE) Cereal B) Red meat Client privacy nurse talking in hallway tell them to stop the conversation A nurse is caring for a client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea. Which of the following actions should the nurse take first? - Administer an antiemetic A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching? - cleanse the skin around the stoma with a mild soap and warm water A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. difficle. Which of the following action by the nurse is appropriate? - Place the client on contact precautions A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? "It communicates my wishes for end-of-life care." A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client? a. Hypokalemia b. Muscular depression c. Laryngeal stridor d. Hyperglycemia c. Laryngeal stridor A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? A. Turn the client on their side. B. Administer an analgesic C. Administer antiemetic D. Monitor the client's vital signs. A. Turn the client on their side. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child's medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary glaucoma C. Hypertension A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth A. Excessive sweating A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? A general anesthetic is administered prior to ECT treatments acetaminophen overdose antidote acetylcysteine A nurse is performing a nutritional assessment on a client who has a calcium deficiency. The nurse should identify that the client is at risk for which of the following? Tetany A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding? diarrah A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol? A. Akathisia B. Acute dystonia C. Tardive dyskinesia D. Pseudoparkinsonism Screen the client for tardive dyskinesia A nurse is preparing to administer vancomycin to a client who has as infected wound. The nurse should plan to __ for which of the following adverse reactions? Ototoxicity A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? Tinnitus lithium carbonate labs? - thyroid hormone A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect? Answer: Tremors Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia. Nurse leaves the room but promises to come back later Fedility Patient active stage of dying what intervention should the nurse include in the plan of care The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle." When should the nurse perform sputum collection In the morning 94. A nurse is teaching the parent of an infant who has Down syndrome. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should expect him to have frequent diarrhea." B. "I should place a cool mist humidifier in his room." C."I should avoid the use of lotion on his skin." D."I should expect him to grow faster in length than B. "I should place a cool mist humidifier in his room." When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A) massage the fundus. B) administer Methergine, 0.2 mg PO, that has been ordered prn. C) assist the woman to empty her bladder. D) recognize this as an expected finding during the first 24 hours following birth. C) assist the woman to empty her bladder. The nurse is teaching the parents of a 3-year-old child who has been diagnosed with tonic-clonic seizures. What statement by the parent should indicate a correct understanding of the teaching? a. "I should attempt to restrain my child during a seizure." b. "My child will need to avoid contact sports until adulthood." c. "I should place a pillow under my child's head during a seizure." d. "My child will need to be taken to the emergency department [ED] after each seizure." c. "I should place a pillow under my child's head during a seizure." A patient in traction reports severe pain from a muscle spasm. What is the nurse's priority action? a. Assess the patient's body alignment b. Give the patient a PRN pain medication c. Notify the health care provider d. Remove some of the weights a. Assess the patient's body alignment What is the priority nursing care immediately after an amniocentesis? Monitoring for signs of uterine contractions pitting edema( check) - press firmly on affected extremity GERD taking med (idk what med) - 1 hr sitting up packed rbc adverse effect Fever belt restraints A. Sitting down when applied B. Check q 4 hrs A. Sitting down when applied Identifiers after checking the id band what's next identifiers A. Home Phone B. Medical Record Number C. MAR home phone Pump is not working what to do Tag the pump and replace it Interminent Catheter where to collect urine sample A. Drainage bag B. Sampling Port A catheter specimen must be obtained from the sampling port on the catheter bag. A nurse promise a patient to walk her to the courtyard later which ethical dilemma A. Veracity B. Nonmalificence C. Autonomy D. Fidelity D. Fidelity The nurse recieves telephone prescription, what to do next A. do not give until md sign rx B. give medication C. ask md to spell the rx B. give medication A nurse instilling a child ophthalmic solution A. Press lacrimal B. Dide lying position C. Eyes side to side D. Outer to inner Press lacrimal Child ear irrigation A. Side lying unaffected side B. Pull down A. Side lying unaffected side Varicella virus transmission precaution Airborne A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in the clean specimen cup D. Clamp the tubing below the collection port D. Clamp the tubing below the collection port Plan pregnancy the mother states I am not sure if I am ready to be a mother. What should the nurse response? These feelings are normal at the beginning A nurse is collecting date on a 6 month old infant. Which of the following should the nurse identify as unexpected and report to the provider? A. Head lag when pulled to a sitting position B. Weight that has double since birth C. Absence of a pincer grasp D. Respiratory rate of 30/min A. Head lag when pulled to a sitting position A nurse is caring for a client who takes warfarin to treat chronic atrial fibrillation and has early manifestations of alzheimer's disease. The clients partner ask the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse provide? A. Ginkgo biloba will probably interfere with the effectiveness of his other medication. B. You should ask his provider if ginkgo biloba is safe C. Ginkgo biloba is most effective in the later stage of alzheimer's disease D. People who have alzheimer's disease should adhere to the medication regimen their provider prescribed. A. Ginkgo biloba will probably interfere with the effectiveness of his other medication. Toddler food that risk for choking Grapes Hotdog Marshmallows and nuts Bagel A nurse is caring for a client who is receiving continuous enteral feeding through NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bag every 48 hours B.Chill the formula prior to administration C. Increase the infusion rate D. Request for isotonic enteral nutrition formula D. Request for isotonic enteral nutrition formula A nurse is preparing to administer an otic antibiotic to an adult client. Which of the following actions should the nurse plan to take? A. Hold the dropper 1 cm ( .5 inches) above th ear canal during administration. B. Apply pressure to the nasocomial duct following administration. C. Place a cotton ball to the inner ear for 30 minutes following administration. D. Straighten the ear canal by pulling down and back prior to administration. A. Hold the dropper 1 cm ( .5 inches) above th ear canal during administration. A nurse is reviewing a medical record of a client who has a prescription for a combination of oral contraceptive. The nurse should identify that which of the following findings is a contraindication to receiving this medication? A. High cholesterol level B. Liver disease C. Family history of ovarian cancer D. Client reports of hypermenorrhea B. Liver disease ( also gallbladder, heart disease, blood clots) A nurse is collecting data from a client who has hypothyroidism and take levothyroxine. Which of the following findings indicates that the client is experiencing acute levothyroxine overdose? A. Bradycardia B. Cold intolerance C. Tremor D. Hypothermia C. Tremor A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include? A. Position the child's car seat forward-facing at 1 year of age. B. Place the retainer clip 2 inches above the newborn's umbilicus C. Place the should harness in the slots that are level with the new born shoulder. D. Position the newborn's car seat at a 20 degree angle in the vehicle. C. Place the should harness in the slots that are level with the new born shoulder. [Show Less]
- Exam
- $19.45
- 0
- 140
ATI predictor 2023 Questions and Answers
An assistive personal and a nurse are turning a client onto the right side. which of the following actions by the AP requires the nurse to intervene Place... [Show More] s the pillow under the clients right arm. The AP should place pillow under the client's left arm to prevent internal rotation of the left shoulder. A nurse is assessing a client who has Raynaud's disease. which of the following findings should the nurse except? Blanching of the fingers and toes. A client who has Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone. butterfly rash over the cheeks and nose A client who has lupus erythematosus is likely to have a butterfly rash over the nose and cheeks a nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. which of the following instructions should the nurse include? (SATA) A speech pathologist will be performing a swallowing study for you. (client is at risk for aspiration due to difficulty swallowing, which is manifestation of multiple sclerosis) You should rest before eating a meal. (nurse should encourage the client to rest before each meal due to reported weakness and are easily fatigued). Thicken your beverages before drinking. (thicken to reduce aspiration due to difficulty swallowing) a nurse is caring for an older client. which of the following findings should the nurse recognize as a physiological change associated with aging? decreased lung expansion. (due to decreased mobility of the ribs). Older adult clients have decreased oral temps, decreased cardiac output, and increased systolic BP with a diastolic pressure that does not change. Increased incidence of orthostatic hypotension. nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. which of the follow actions should the nurse take first? measure clients vital signs. (use nursing process to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr. A nurse is assessing a client who has delirium. which of the following manifestations should the nurse expect? Rapid speech (delirium: rapid, inappropriate, incoherent, and rambling speech patterns). administer heparin 5,000 units subcutaneously. Available is 10,000 units/mL. how much should be adminsitered? 0.5ml Have/Quantity=Desired/X OR X=desired x quantity?have a nurse is caring for a client who states "my boss accused me of stealing yesterday. i was so angry I went to gym and worked out". the nurse recognize the client is demonstrating which of the following defense mechanisms? sublimation (The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior). what is used for intermittent catheterization for a client who has urinary retention Straight urinary catheter. a client who is 24 hr postoperative following abdominal surgery refuses to ambulate. which of the following actions should the nurse take first? ask the client to rate their pain level. (first action the nurse should take is to assess the client's level of pain. If indicated, the nurse should administer an analgesic, then wait 30 to 45 min to allow the analgesic to take effect before encouraging the client to ambulate. Management of the client's pain is a priority for encouraging postoperative activity). a nurse is teaching the parents of a preschooler about sleep promotion. the parents report that their child is demonstrating reluctance in going to bed at night and states " I am not tired." which of the following statements by the parents indicated an understanding of the teaching? we should read a story together every night before bedtime. a nurse is assessing a 2 month old infant during a well-baby examination. which of the following actions should the nurse take to assess the infant's rooting reflex? stroke the infant's cheek. (causes infant to turn toward that side and suck). a nurse is providing discharge teaching to a client with cataract extraction. which of the following statements by the client indicates an understanding of the teaching? "i will bend my knees when picking an object up off the floor". (The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object). a nurse is caring for a group of clients. for which of the following events should the nurse complete an incident report? a client's IV pump delivers an inadequate dose of medication. (The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report include significant complaints about care quality and visitor or client injury). a nurse is teaching a client who is taking misoprostol and currently is on long term therapy with NSAIDs for arthritis. the nurse provides client with which of the following info? Complete a serum pregnancy test before taking medication. (Misoprostol can induce uterine contractions. Clients of childbearing age must rule out pregnancy before taking misoprostol.) tends to cause diarrhea. reduces gastric acid secretion so ulcers can heal and reduces risk of new ulcer development. Magnesium containing antiacids increase the risk of diarrhea and the client should avoid these when taking misoprostol. a nurse is caring for a client who is at 28 weeks of gestation. the client asks the nurse to explain what causes her to have constipation. which of the following responses should nurse make enlarged uterus compresses the intestines and causes constipation. (During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation) small intestine absorbs more iron due to increased maternal needs, leading to constipation. intestine absorbs more water from the stool during pregnancy, leading to constipation. estrogen and progesteron levels increase during pregnancy causing decreased peristalsis and constipaiton. a nurse is caring for a client who has a fractured femur and has a fiberglass leg cylinder cast for 24 hours. which assessment finding should be priority the client's heel is reddened and tender. (The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel). a nurse is a mental health facility is planning care for a client who has anorexia nervosa. which of the following interventions should the nurse include in the client's plan of care? supervise the client during and after eating. (The nurse should monitor the client during and for 1 hr after meals to prevent the client from hiding food or purging). The nurse should establish specific meal times as part of a structured meal plan. The nurse should offer the client a structured meal plan to ensure appropriate caloric intake and adequate nutrition. encourage conversation that does not focus on the theme of food during meal times. The nurse should emphasize eating as a social activity. which foods are highest in vitamin A 1 medium raw carrot (The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of vitamin A and is therefore the best food to recommend to the client). (1 raw carrot (2,025 mcg/dL), 1/2 cooked spinach (737 mcg/dL), 1/2 cup cooked butternut squash (714 mcg/dL), 1 cup sliced cantaloupe (516 mcg/dL)) advanced directives You should complete advanced directives in the event you cannot express your own wishes. lithium carbonate. which of the following assessment findings should the nurse identify as priority? Confusion (early manifestation of lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, incoordination, ECG changes, and sedation. polyuria is expected. fine hand tremors are expected. lethargy is expected. a case manager is reviewing the medical records of several clients. for which of the following clients should the nurse request an interprofessional care conference? a client who has diabetes mellitus and has had repeated hospitalization for diabetic ketoacidosis. ( A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support). a community health nurse is assisting with the development of a disaster management plan. the nurse should include which of the following nursing responsibility in the disaster response stage of the plan? performing a rapid needs assessment. (Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage). new prescription for estradiol. which adverse effects should the nurse instruct client to monitor and report to the provider? headaches (Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events). Hypertension, swelling and tenderness due to fluid retention, and genitourinary candidiasis. a charge nurse is observing a newly licensed nurse performing a physical assessment on a client. which of the following actions by the nurse indicates that the charge nurse should intervene? the newly licensed nurse writes detailed notes while performing a head to toe assessment (record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment). macular degeneration expected findings decreased central vision. due to bleeding into the macula or yellow spots under the retina). double vision (cataracts) floating dark spots (retinal detachment) intraocular pressure increased (glaucoma) colostomy care for a client with two piece pouching system. cleanse skin at stoma site using washcloth and warm water to reduce risk of skin irritation. throughly dry skin around stoma using a patting motion before applying skin barrier. activate adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. nurse should cut the skin barrier opening no more than 0.3 cm (0.13in) larger than the stoma to reduce risk of skin irritation. An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? A. Collection of a stool specimen B. Preparation of a client's postoperative bed C. preparation of teaching plan about pneumonia D. Insertion of a nasogastric tube D. insertion of nasogastric tube. a nurse is preparing a sterile field in order to insert indwelling urinary catheter for a male client. which of the following should nurse do to maintain surgical aseptic technique? set catheter tray on the overbed table at waist height. (To maintain sterility, the nurse should place the catheter tray on a work surface at or above waist level). The nurse is providing dietary teaching to the parents of a 6-month old infant. which instruction should the nurse include? introduce new foods one at a time over 5 to 7 days. (to identify potential food allergies). NO WHOLE MILK. 100% fruit juice to not exceed 120 to 180 ml per day, after age 6 month. planning care for a client who is receiving heparin to treat DVP of left lower leg. which intervention should the nurse include in the plan of care. elevate the affected leg. (The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency). place warm compression on affected area to reduce swelling and promote comfort. encourage 2-3 L of fluid daily to decrease platelet aggregation and prevent dehydration. encourage patient to ambulate once anticoagulant is initiated. TPN (total parenteral nutrition) Highly concentrated, hypertonic lots of minerals less water Calories, fluids & nutrients Central venous access device required you have to have a central line not a peripheral line it would burn the tissue* also you will use a filter A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring. Check patient for egg allergy, intolerance of the lipid solution and many lipids are composed of egg phospholipids. a nurse is teaching a group of guardians about child safety measures. which shows understanding of the teaching? i should have my child avoid sun exposure between 10am and 2pm. (To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. Can skateboard from age 5< a nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure sensitive valve. which of the following info should the nurse include in the teaching? keep the catheter clamped when not in use. (The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure-sensitive valve that prevents blood reflux.) change dressing at least every 5-7 days. flush catheter daily with heparin when not using it regularly. cystic fibrosis has been receiving oxygen therapy for past 36 hrs. indication of oxygen toxicity? substernal pain (manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis). oxygen toxicity can have crackles too. a nurse is planning care for a client who is receiving hemodialysis via an established AV fistual in the right arm. which of the following interventions should the nurse include in the client's plan of care auscultate the affected extremity for a bruit. (The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency. Should report absence of a thrill to the provider. a nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. which should nurse take first? massage the uterus to expel clots. a nurse is planning care for a child who has acute lymphoid luekemia and an absolute neutrophil count of 400/mm3. which interventions should the nurse include in the plan? withhold administering the varicella vaccine to the child. (A child who has severe immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed). nurse is providing teaching to a client about newborn safety. which of the following statements should the nurse include in the teaching? set your water heater temperature at or below 120 degrees fahrenheit. (The nurse should instruct the client to set the maximum hot water temperature to no more than 49° C (120° F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn). a nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. which of the following actions should the nurse take? initiate fall precautions for the client. (common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy). a nurse manager is on a planning committee to develop an emergency preparedness plan. the nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? notify the incident commander. (notify the incident commander to initiate the command hierarchy and maintain order). a nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. which actions should the nurse take when suctioning the client's airway? apply suction for 10 seconds. (suction for only 5 to 15 seconds to minimize oxygen loss) advance catheter 1 to 2 cm to prevent damaged bronchial tissues. closed head injury, which medication is used to reduce intracranial pressure? mannitol. (The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema). child has varicella. when can they return to school? when crusts have formed on every lesion. (no longer contagious after crusts have formed on all lesions.) immediate postpartum period. which finding requires immediate intervention by the nurse? boggy uterus. (can indicate hemorrhage). initiating discharge planning for a client who had a stroke and is experiencing right sided weakness. which action should nurse take first? request a referral for the client to receive physical therapy. (The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy). conducting visual acutiy testing using the snellen letter chart for a school age child who has eyeglasses. which instructions should the nurse give to child? you should keep both eyes open during the testing (this is for visual acuity). child should stand 10 ft away correction glasses first then again without visual correction. need 4-6 symbols to pass the line correctly. 39 weeks of gestation, during second week of labor nurse observes early decelerations on the monitor tracing. which action should nurse take? continue to observe fetal heart rate. (Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing). nurse is providing discharge teaching to a parent about care safety. which statement is correct. secure the retainer clip at the level f your baby's armpits. performing gastric lavage for a client who has GI bleeding and an NG tube in place. use 0.9 Sodium chloride for irrigation of the NG tube. (The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube.) solution should be room temperature. volumes of 200-300ml at a time to reduce risk of injury to client. school-age child, administering ear drops i should pull the top of the ear upward and back while instilling the medication. children younger than 3 years of age should pull pinna downward and back. multiple sclerosis. which manifestation is expected nystagmus. (Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis). MRSA (methicillin-resistant Staphylococcus aureus) contact precautions. Autonomic Dysreflexia. which findings are expected facial flushing. nasal congestion. headache. signs of true labor cervix transitions to an anterior position and begins to dilate in preparation for birth. contraction felt in lower abdomen and back contractions increase with ambulation cervix progressively shortens and thins placing tracheostomy tube (steps) remove inner cannula. remove soiled dressing. clean the stoma with 0.9% sodium chloride irrigation change tracheostomy collar. Digoxin toxicity symptoms nausea, vomiting, diarrhea, vision changes, arrythmias, anorexia, abdominal pin. bradycardia, muscle weakness. client has schizophrenia and is taking chlorpromazine. which finding is a priority to report to provider temperature of 39.4C (102.9F). (neuroleptic malignant syndrome) a nurse is assessing a newborn who is 2 hours old. which finding should nurse report to provider? expected axillary temperature for newborns is between 36.5-37.5 (97.7F to 99.5F) apical pulse (80 to 100 when asleep and up to 180 when crying. RR -> 30-60/min a nurse in ED has a client with cardiac tamponade. which assessment finding is expected. Pulsus paradoxus (a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension). acute glomerulonephritis. what is expected finding protein. (A client who has glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report). Amitriptyline i should watch for common reactions like dry mouth and constipation (increase dietary fiber, fluid intake, and chewing sugar free gum can alleviate anticholinergic effects). vitamin k for newborn to prevent bleeding of newborn. 37 weeks of gestation and experiencing abruptio placentae. Which is an expected finding? persistent uterine contractions and dark red vaginal bleeding. a nurse is administering cyclophosphamide orally to a school-aged child who has neuroblastoma. which action should nurse take when administering this medication? maintain hydration with liberal fluid intake. to prevent hemorrhagic cystitis. an elevation of which laboratory value indicates cellular injury of myocardial tissue? troponin T a nurse is caring for a patient who requires PT following discharge. which action should nurse take? involve the client in selection of a physical therapy provider. toddler has infectious gastroenteritis. which action should nurse take initiate oral rehydration therapy for the toddler. (Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed). blood transfusion, which finding should indicate to the nurse that the client is having a hemolytic transfusion reaction? low back pain. Expect tachycardia expect hypotension HSV (herpes simplex virus) contact precautions. cranial nerve 2 optic nerve Thrombocytopenia avoid venipunctures when possible. due to decreased platelet count and are at risk for bleeding. avoid to reduce risk of bleeding. TPN solution at 60l/hr. pump stopped working, what should nurse do while waiting for a new infusion pump? provide dextrose 10 % in water solution using manual drip tubing at 60ml/hr. [Show Less]
- Exam
- $18.45
- 0
- 153
ATI comprehensive predictor 1 Questions and Answers 2023
APGAR Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp... [Show More] ) Respirations (strong cry, weak cry, absent) Woman in labor (un-reassuring FHR) (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Infant with Spina Bifida Prone so that sac does not rupture Prolapsed cord Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. FHR patterns for OB Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Heroin withdrawal neonate irritable, poor sucking lead poisoning test at 12 months of age pt with leukemia may have epistaxis due to low platelets when a pt comes in and is in active labor first action of nurse is to listen to fetal heart tones/rate NCLEX answer tips choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. 1 tsp 5 mL 1 oz 30 mL 1 cup 8 oz 1 quart 2 pints 1 pint 2 cups 1 g (gram) 1000 mg 1 kg 2.2 lbs I lb 16 oz centigrade to Fahrenheit conversion F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 birth weight doubles by 6 months triples by 1 year early sign of cystic fibrosis meconium in ileus at birth hemophilia is x linked passed from mother to son perform amniocentesis before 20 weeks to check for cardiac and pulmonary abnormalities Rh mothers receive Rhogam to protect next baby anterior fontanelle closes by...posterior by.. 18 months, 6-8 weeks caput succedaneum diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days pathological jaundice occurs: physiological jaundice occurs: before 24 hours (lasts 7 days) after 24 hours placenta previa s/s placental abrution s/s there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) bethamethasone (celestone) surfactant. premature babies Developmental 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup Apgar measures HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate Guthrie test Tests for PKU. Baby should have eaten protein first Transesophageal fistula esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) Stranger anxiety is greatest at what age? 7-9 months..separation anxiety peaks in toddlerhood infants IM site Vastus lateralis Toddler 18 months+ IM site Ventrogluteal IM site for children deltoid and gluteus maximus ECG no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure. Myelogram NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site Liver biopsy administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk Paracentesis semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia laparoscopy CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup PTB low grade afternoon fever pneumonia rusty sputum asthma wheezing on expiration emphysema barrel chest kawasaki syndrome strawberry tongue pernicious anemia red beefy tongue downs syndrome protruding tongue cholera rice watery stool malaria stepladder like fever--with chills typhoid rose spots on the abdomen diptheria pseudo membrane formation measles koplick's spots sle (systemic lupus) butterfly rash pyloric stenosis olive like mass Addison's bronze like skin pigmentation Cushing's moon face, buffalo hump hyperthyroidism/ grave's disease exophthalmos myasthenia gravis descending musle weakness gullian-barre syndrome ascending muscle weakness angina crushing, stabbing chest pain relieved by nitro MI crushing stabbing chest pain unrelieved by nitro cystic fibrosis salty skin DM polyuria, polydipsia,polyphagia DKA kussmal's breathing (deep rapid) Bladder CA painless hematuria BPH reduced size and force of urine retinal detachment floaters and flashes of light. curtain vision glaucoma painful vision loss. tunnel vision. halo retino blastoma cat's eye reflex increased ICP hypertension, bradypnea,, bradycarday (cushing's triad) shock Hypotension, tachypnea, tachycardia Lymes disease bullseye rash intraosseous infusion often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist. sickle cell crisis two interventions to prioritize: fluids and pain relief. glomuloneprhitis the most important assessment is blood pressure children 5 and up should have an explanation of what will happen a week before surgery Kawasaki disease (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. ventriculoperitoneal shunt watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees 3-4 cups of milk a day for a child? NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA MMR and varicella immunizaions after 15 months! cryptorchidism undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence CSF meningitis HIGH protein LOW glucose Head injury or skull fx no nasotracheal suctioning otitis media feed upright to avoid otitis media! positioning for pneumonia lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!) [Show Less]
- Exam
- $15.45
- 0
- 117
ATI Predictor Practice Questions and Answers 2023
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints (15-30min)... [Show More] . Which of the following should the actions the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client's peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client's condition every 15 minutes. D. Document the client's condition every 15 minutes. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery b. Give cromolyn nebulizer solution every 6 hr c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr d. Administer analgesics on a scheduled basis for the first 24 hr A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea d. A client who has a hip fracture and a new onset of tachypnea A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Shave hairy areas of skin prior to application b. Wear gloves to apply the patch to the client's skin c. Apply the patch within 1 hr of removing it from the protective pouch d. Remove the previous patch and place it in a tissue b. Wear gloves to apply the patch to the client's skin A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hr (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain a. A client who was just given a glass of orange juice for a low blood glucose level A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler's position during the feeding d. A residual of 65 mL 1hr postprandial a. A history of gastroesophageal reflux disease A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values? a. Serum glucose level- increased b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased a. Serum glucose level- increased A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV d. Administer calcium gluconate IV A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison c. Previous violent behavior A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field d. Set up the sterile field 5 cm (2 in) below waist level a. Place the cap from the solution sterile side up on clean surface A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime a. Eat a light snack before bedtime A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments c. Identify environmental hazards in the home A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. "Can you tell me who visited you today?" b. "What high school did you graduate from c. "Can you list your current medications?" d. "What did you have for breakfast yesterday?" b. "What high school did you graduate from A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8% b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast d. HbA1c level less than 7% d. HbA1c level less than 7% A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client's seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy c. The client is showing evidence of phenytoin toxicity A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing b. Moderate sanguineous drainage on the drip pad c. Bruising to the face d. Absent gag reflex a. Increase in frequency of swallowing A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom b. Monitor the child's cardiac status A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction c. Use of tobacco decreases the level of athletic ability A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium d. Platelet count c. Serum potassium A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. "I will let the client know that I am available as the interpreter." b. "I will receive a small fee for interpreting for this client." c. "I am glad I'm available today, but when I'm not, you can use a family member." d. "I will let the client know that an interpreter is unavailable during the night shift." a. "I will let the client know that I am available as the interpreter." A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A two-day old newborn who has a respiratory rate of 70 b. A 16-hour old new newborn who has yet to pass meconium c. A 2-day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl a. A two-day old newborn who has a respiratory rate of 70 A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin b. A client who has fractured left tibia and pallor in the affected extremity A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? a. Weight gain b. Dry mouth c. Sedation d. Shuffling gait d. Shuffling gait A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? a. Clean the base of the cord with hydrogen peroxide daily b. The cord stump will fall off in 5 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off d. Keep the cord stump dry until it falls off A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas b. Potato pancakes c. Wheat crackers d. Canned barley soup b. Potato pancakes A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech d. Hypochondriasis c. Disorganized speech A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the client's legs b. Place a towel roll under the client's neck c. Apply an orthotic to the client's foot d. Position a pillow under the client's knees c. Apply an orthotic to the client's foot A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution a. Provide anticipatory guidance classes to parents through public schools A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation b. 10cm (4 in) laceration c. Fractured tibia d. 95% full thickness body burn a. Below the knee amputation A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? a. Hgb 12.8 g/dl b. Potassium 4.2 meq/l c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 d. Platelets 100,000/mm3 A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl b. Prealbumin 10 mcg/dl A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? a. A client who is postoperative following a bowel resection with an NGT set to continuous suction b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs a. A client who is postoperative following a bowel resection with an NGT set to continuous suction A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor. Which of the following nursing actions should the nurse take? a. Continue the monitor the fetal heart rate b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion a. Continue the monitor the fetal heart rate A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. b. Compare the current infusion with the prescription in the client's medication record. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. WBC count 2,900 /mm3 b. Fasting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min a. WBC count 2,900 /mm3 A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. a. You may breastfeed unless your nipples are cracked or bleeding. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the client's information? Exhibit. a. Level of consciousness. b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds a. Level of consciousness. A nurse is caring for a client who has hyperthermia. Which of the following actions for the nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket c. Administer oral acetaminophen d. Initiate seizure precautions d. Initiate seizure precautions A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include? a. Document the client's conditions every 15 minutes b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours a. Document the client's conditions every 15 minutes A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid d. Initiating IV fluid A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I would not worry about that. B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have questions about your mom dying. Let's talk about it. B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. E. You sound like you have questions about your mom dying. Let's talk about it. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 d. A client who is taking warfarin and has INR of 1.8 A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone a. Clarify the source of the referral A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information b. Your partner can be a great source of support for you at this time c. Is there a reason you don't want your partner to know about your procedure? d. The provider will be tactful when talking to your partner a. You have the right to decide who receives information A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage. a. 7.5% b. 15% c. 8.1% d. 13.3% a. 7.5% A nurse is caring for a client who is 4hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a-Perform fundal massage b-Pour water from a squeeze bottle over the client's perineal area. c-Insert an indwelling urinary catheter. d-Apply cold therapy to the client's perineal area. b-Pour water from a squeeze bottle over the client's perineal area. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. a. Avoid hot tub while wearing the patch A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan. a. Teach the client to shift his weight every 15 min while sitting b. Place the client upright on a donut c. Assess pressure points every 24hr d. Turn and reposition the client every 3hrs while in bed. b. Place the client upright on a donut A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let's talk about how you can change your response to stress d. We should establish our roles in the initial session. d. We should establish our roles in the initial session. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon b. Whole grain bread A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit b. Activate the facility's fire alarm system c. Close all nearby windows and doors d. Use the unit's fire extinguisher to attempt to put out the fire a. Transport the client to another area of the nursing unit b. Activate the facility's fire alarm system c. Close all nearby windows and doors d. Use the unit's fire extinguisher to attempt to put out the fire A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. Heightened perceptual field b. Rapid speech c. Feelings of dread d. Purposeless activity a. Heightened perceptual field A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) a. Tremor b. Polydipsia c. Acetone Breath odor d. Diaphoresis e. Inability to concentrate a. Tremor d. Diaphoresis e. Inability to concentrate A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses d. Weak femoral pulses A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations b. Locate financial support to open a shelter for abuse survivors c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel c. Teach parenting skills to families at risk for abuse A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke c. Applying a condom catheter for a client who has a spinal cord injury A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take sucralfate with meals three times per day" b. "I will avoid food and beverages that contain caffeine" c. "I will decrease my daily protein intake to 15 grams per day" d. "I will use ibuprofen as needed to control abdominal pain b. "I will avoid food and beverages that contain caffeine" A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech c. Provide humidification of the room air A nurse is caring for four clients. Which of the following tasks can the nurse delegate to assistive personnel? a. Assess effectiveness of antiemetic medication b. Perform chest compressions during cardiac resuscitation c. Perform a dressing change for a new amputee d. Apply a transdermal nicotine patch b. Perform chest compressions during cardiac resuscitation [Show Less]
- Exam
- $23.95
- 0
- 133
ATI Predictor Practice Exam 1 Questions and Answers 2023
A nurse is caring for a newborn whose parents asks why the baby is receiving vitamin K. The newborn should receive vit K to prevent which of the following?... [Show More] a. Bleeding b. Potassium deficiency c. Infection d. Hyperbilirubinemia a. Bleeding Newborns should receive vit K at birth bc they have low levels of it, which can lead to bleeding A charge nurse is observing a new nurse admin enteral feeding via an NG tube. Which of the following actions by the new nurse indicates understanding of the procedure? a. Instills 100 mL of air into the NG tube after checking residual b. FLushes NG tube with 0.9% sodium chloride irrigation every 2 hours c. Adds 20 mL of blue dye to feeding to detect aspiration d. Keeps the HOB elevated to 45 degrees for 1 hour after feedings d. Keeps head of bed elevated to 45 degrees for 1 hour after feedings. The nurse should keep the clients head elevated to 45 degrees for 1 hour after feedings to decrease the risk of aspiration A nurse is teaching a client about foods high in Vitamin A. Which of the following foods should the nurse recommend as havin the highest amount of vitamin A? a. 1 medium raw carrot b. 1/2 cup cooked spinach c. 1/2 cup cooked butternut squash d. 1 cup sliced cantaloupe a. 1 medium raw carrot The nurse determines that carrots are the best source to recommend bc 1 medium raw carrot contains 2,025 mcg/dL of vitamin A A Rn is planning care for a group of clients and is working with a LPN and an AP. Which of the following tasks should the RN delegate to the LPN? a. Collection of stool specimen b. Prep of a client's post-op bed c. Administration of a unit of packed RBC's d. Insertion of an NG tube d. Insertion of an NG tube The nurse should delegate the insertion of a NG tube to the LPN bc this task is within their scope of practice A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? a. The client's partner tells the nurse that the client understands the procedure b. The nurse locates the provider's prescription for the surgical procedure c. The nurse witnesses the provider's explanation of the procedure. d. The client is able to accurately describe the upcoming procedure d. The client is able to accurately describe the upcoming procedure A nurse is caring for a client who is receiving TPN solution by a continuous IV infusion at 60 mL/hr. The nurse discovers that infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? a. Admin the TPN solution at the same rate using manual drip tubing b. Offer the client oral fluids in place of TPN c. Infuse 0.9% NaCl using manual drip tubing at 30 mL/hr d. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr d. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr A nurse is assessing a client who has schizophrenia & is taking chlorpromazine. which of the following findings is the priority for the nurse to report to the provider? a. Temperature 39.4 degrees Celsius (103 degrees Fahrenheit) b. Headache c. Constipation d. Vomiting a. Temperature 39.4 degrees Celsius (103 degrees Fahrenheit) The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine in which the client can have a high temperature, dysrhythmia, decreased LOC, and a labile BP. Therefore, the priority finding for the nurse to report to the provider is hyperpyrexia A nurse is teaching the parent of a school aged child about the admin of ear drops. Which of the following responses by the parent indicates an understanding of the teaching? a. "I should administer the ear drops as soon as a remove them from the fridge." b. "I should pull the top of the ear upward and back while instilling the med." c. "I should massage behind her ear after i instill the drops." d. " I should have her lie on the affected side for a few min after I put the drops in her ear." b. "I should pull the top of the ear upward and back while instilling the med." The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years to straighten the ear canal and allow the medication to reach the entire canal. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply) a. Nystagmus b. Facial flushing c. Diplopia d. Nasal congestion e. Headache b. Facial flushing d. Nasal congestion e. Headache A nurse is caring for a client who has a deficit w/ CN II. Which of the following actions should the nurse plan? a. Keep the client resting in bed b. Ask the client to restate directions c. Clear objects from the client's walking area d. Evaluate the client's ability to swallow c. Clear objects from the client's walking area The nurse should plan to clearobjects from teh client's walking area because a CN 2 deficit can result in visual impairment and lead to falls A nurse is providing teaching to the parent of a child who has a permanent tracheostomy. Identify the sequence of steps that the parent should follow to perform tracheostomy care Remove the soiled dressing Remove the inner cannula Clean the stoma with 0.9% sodium chloride irrigate Change the tracheostomy collar 1. Remove the inner cannula 2. Remove the soiled dressing 3. Clean the stoma with 0.9% sodium chloride irrigation 4. Change the tracheostomy collar [Show Less]
- Exam
- $11.95
- 0
- 124
ATI Comprehensive Predictor 2023 A Questions and Answers
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should re... [Show More] cognize the client is demonstrating which of the following defense mechanisms? Sublimation Rationale: The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? Initiate fall precautions for the client Rationale: The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy. A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? The client is able to accurately describe the upcoming procedure Rationale: The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? Places a pillow under the client's right arm. Rationale: The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Introduce new foods one at a time over 5 to 7 days. A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement? Contact Rationale: The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first Massage the uterus to expel clots Rationale: Using the EBP approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? "Secure the retainer clip at the level of your baby's armpits" A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies. "Which of the following actions should the nurse take? (SATA) -Refer the client to a community based social workers -Initiate a consult with a home health care provider -Give the client information about local support groups Rationale: -A social worker is necessary to help a client with self-care, as well as assist in locating agencies who can help the client face challenges with self-care and paying for necessary ostomy supplies -A home health nurse can assist the client in learning to care for the colostomy as well as provide medication management and emotional support -A client who has cancer and a new colostomy can get help with coping from a support group and possibly receive assistance obtaining supplies from local agencies A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Investigate environmental factors that might be contributing to client injury during these hours. Rationale: When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem. A nurse is caring for a client who has terminal illness and requests lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? "I will provide you with information about medical treatment to include in your living will" Rationale: The nurses' responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themself by providing information about what end-of-life preferences to document. A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? Rapid speech Rationale: Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns A night shift nurse is giving a change of shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? The client needs assistance when transferring from the bed to a wheelchair. Rationale: The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Boggy uterus Rationale: When using urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi have formed at the placenta. A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? Develop a safety plan with the client Rationale: The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering. Flumazenil Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client's respirations with a bag valve mask. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plant of care to prevent injury in the home? Mark the edges of the stairs for contrast Rationale: Marking the edges of stairs with paint or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? Provide information about scheduling issues to the staff. Rationale: The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by guardian indicates an understanding of the teaching? "I should have my child avoid sun exposure between 10 am and 2 pm" Rationale: To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? Insertion of a nasogastric tube Rationale: The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? Axillary temperature 36.2 C (97.2 F) Rationale: The expected reference range for the axillary temperature of newborn is between 36.5 C to 37.5 C (97.7 F to 99.5 F). An axillary temperature of 36.2 C (97.2 F) or below in a newborn who is 2 hr old indicates cold stress and should be reported to the provider. A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? Involve the client in selection of a physical therapy provider/ Rationale: The nurse should involve the client in the referral process, including selection of the physical therapist and the location. A nurse in an emergency department is assessing a client who reports taking MDMA. Which of the following should the nurse expect? Diaphoresis Rationale: Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects. A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? Place the BP cuff in a labeled bag to send it for decontamination. Rationale: The nurse should place the BP cuff in a labeled bag before removing it from the client's room and sending it to the proper facility location for decontamination. A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? WBC count 2,800/mm3 Rationale: Clozapine can cause agranulocytosis, which can be life-threatening. Therefore, a WBC count of less than 3,000/mm3 is a contraindication for the client to receive clozapine. The nurse should withhold the medication and notify the provider of the client's WBC count. A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure sensitive valve. Which of the following information should the nurse include in the teaching? "You should keep the catheter clamped when not in use" Rationale: The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure-sensitive valve that prevents blood reflux. A nurse is conducting visual acuity testing when using the Snellen letter chart for a school age child who has eyeglasses. Which of the following instructions should the nurse give to the child? "You should keep both eyes open during the testing" Rationale: The nurse should instruct the child to keep both eyes open during visual acuity testing. When caring for a child, a nurse plans to use non-pharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? Blowing bubbles with liquid soap to "blow the hurt away" Rationale: Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themself and into the air. A nurse is preparing to administer heparin 5,000 units SQ. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? 0.5 mL 5,000 units/ 10,000 units = 0.5 mL A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. Rationale: The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? (Audio) Clang association Rationale: Clang association is an alteration in speech in which the client uses words based on their sound, rather than their meaning. Clients who have neurological disorders can also have this alteration in speech. A nurse is assessing a school age-child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? Hemoptysis 275 mL/24 hr Rationale: Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report. Fever A nurse is caring for a client who ha bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? Move the client to a quiet place away from others. Rationale: The client's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other clients by moving the client to a quiet place away from others. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Place the skin barrier over the stoma and hold it for 30 seconds. Rationale: The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. A nurse is teaching the parent of a school-age about administering ear drops. Which of the following response by the parent indicates an understanding of the teaching? "I should pull the top of the ear upward and back while instilling the medication." Rationale: The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back. A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? Neurologic status Rationale: This client is experiencing slurred speech and extremity weakness, which are indications of a stroke, a potential complication of cardiac catheterization. The nurse should report these findings to the provider. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr. Rationale: The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN solution. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? Explain to the client why this information will be shared. Rationale: It is the responsibility of the nurse to advocate for the client, provide confidential information, and explain legal requirements. Reporting communicable disease occurrences helps with identifying outbreaks and overall disease trends. A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A client's IV pump delivers an inadequate dose of medication. Rationale: The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report include significant complaints about care quality and visitor or client injury. A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Obtain the client's blood pressure before the nurse administers medication. Rationale: The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of function for an AP. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? Low back pain Rationale: The nurse should expect low back pain in a client who is having a hemolytic transfusion reaction. A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? Initiate oral rehydration therapy for the toddler. Rationale: Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed. A nurse is administering medications to a client who has percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of. the tube? Flush the client's gastrostomy tube with 30 mL of water before administering the medication. Rationale: The nurse should flush the gastrotomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency. A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? Double-bag soiled dressings in plastic bags for disposal. Rationale: The client should double-bag soiled dressings in plastic bags to prevent the spread of micro-organisms to other household members. [Show Less]
- Exam
- $22.45
- 0
- 151
ATI Predictor exam Questions and Answers 2023
A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this d... [Show More] iagnosis? A. Increased appetite B. Elevated Temperature C. Bradycardia D. Drowsiness Elevated Temperature Rationale: The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium. A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A. "I know this must be difficult, but your mother will calm down soon." B. "Lets discuss some strategies you can use when this happens again." C. Individuals near death are ready to let go toward the end." D. "Have you determined why she is crying and saying she is ready to die?" " Let's discuss some strategies you can use when this happens again." Rationale: This response by the nurse offers to provide information, which can reduce anxiety and enhance decision making. This response creates a safe environment, fosters trust and respect, and is appropriate. A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A. pupil dilation B. Ataxia C. Lethargy D Bradycardia Lethargy rationale: Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in level of consciousness, such as restlessness, irritability, and disorientation. Lethargy is the first sign of increased ICP. A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A. facial edema b. urinary frequency c. acid indigestion d. breast leakage Facial edema rationale: facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider. A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? A. Notify the provider B. Obtain a chest x-ray C. Flush the catheter. D. Stop the infusion. Stop the infusion Rationale: This prevents further damage to vessel and minimizes any additional harm to the client A nurse is reinforcing teaching with a caregiver who has aphasia. The nurse should include which of the following communication strategies in the teaching? A. Cue the client by providing picture cards that portray common needs. B. Increase the volume of the voice when speaking to a client. C. Encourage the client to limit hand gestures when communicating. D. Vary the use of phrases and terminology in discussions. Cue the client by providing picture cards that portray common needs. Rationale: Using picture cards enhances communication. The nurse should include this communication strategy in the teaching. A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A. Administer epinephrine (Adrenaline) B. Elevate the lower extremities C. Determine respiratory status D. Apply oxygen via non-rebreather mask. Determine respiratory status Rationale: The client is experiencing angioedema indicating a possible anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status. A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complications? A. Hyperkalemia B. Severe diarrhea C. Atelectasis D. Excessive vomiting Excessive vomiting rationale: Metabolic alkalosis is a potential complication of excessive vomiting because of loss of acid from the body. A nurse is caring for neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). because of administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal retractions C. Hypoglycemia D. Hypothermia hypoglycemia rationale: Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery. A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A. "It is necessary to have written consent for invasive procedures" B. "Implied consent is appropriate for some aspects of nursing care" C. It is the responsibility of the provider to obtain express consent" D. "Informed consent should be obtained separately for each surgical procedure" " It is the responsibility of the provider to obtain express consent" rationale: Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching. A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A. assign a security guard to stay at the client's door. B. request a prescription from the provider for soft restraints. C. discuss the risks associated with leaving with the client D. remove the telephone from the client's room discuss the risks associated with leaving with the client rationale: Discussing risks associated with leaving is priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician prescribed discharge. A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? A. reduced bleeding time B. decreased plasma globulins C. improved activity tolerance D. increased immune functioning Reduced bleeding time rationale: Platelets are responsible for triggering the process of blood clotting. Clients who have leukemia are prone to bleeding because of low platelet counts and should experience a reduced bleeding time as a result of a transfusion of platelets. A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A. "I will have my husband wear a condom during intercourse." B. " I will check my temperature every 4 hours." C. I will wipe rom front to back after bowel movements" D. "I will notify my doctor if my baby moves fewer than 4 times in the 2 hour following each meal." " I will have my husband wear a condom during intercourse" rationale: The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of increased risk for infection. A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A. Provide a toy doctor's kit to play with. B. Keep all syringes and needles out of sight until needed. C. Use an approach that is firm but direct. D. Allow the child to manipulate the medical equipment. allow the child to manipulate the medical equipment rationale: Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure. A nurse has assigned four tasks to an assistive personnel. Which of the following should the nurse instruct the AP to perform first? A. take an ABG specimen to the lab. B. Transport a client to the radiology department for an xray. C obtain a clean catch urine sample for a newly admitted client D pass fresh water to clients Take an ABG specimen to the lab rationale: ABG samples are kept on ice and should be transported immediately to the lab or the specimen will deteriorate. A nurse is caring for a client who is diabetic and is being discharged home following and above the knee amputation. which of the following health care professionals should be involved in the interdisciplinary team meeting? select all that apply. a. dietician b. physical therapist c. hospice nurse d social worker e respiratory therapist dietician physical therapist social worker A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A."I will only be on this medication for 4-6 months because it can lead to physical dependence" B. I can have 1-2 alcoholic beverages each week C I will need to stop taking Xanax 2 weeks before beginning this medication D I can have 6-8 ounces of grapefruit juice each day "I can have 1-2 alcoholic beverages each week" rationale: this medication does not interfere with CNS depressants such as alcohol A charge nurse on ped unit is making assignments for a nurse who has floated from labor and delivery unit. Which of the following clients is appropriate for charge nurse to assign. A. A preschooler with a hip spica cast who is being discharged today B. an infant scheduled for a surgical repair of ventricular septal defect tomorrow C. a toddler with a fractured femur who has been in Bryants for 5 days D an adolescent who is 2 days post op following an appendectomy. An adolescent who is 2 days post op following an appendectomy rationale: The care require fundamental nursing skills and knowledge A nurse at a long term care facility is participating in quality improvement project to reduce occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? a. prospective audit b. outcome audit c. process audit d. structure audit outcome audit rationale: An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile. A nurse is caring for a child who is 24 hr. postoperative following a supratentorial craniotomy. the nurse should maintain the child in which of the following positions? A. Prone with head of bed flat B. Dorsal recumbent with head of bed elevated to 15 degrees C. supine with head of bed elevated to 30 degrees D side lying with head of bed elevated to 45 degrees. Supine with hob elevated 30 degrees rationale: this position facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain. A nurse is caring for a client who is 48 hour post op following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A. Absent bowel sounds B. Serum BUN level 22 mg/dl C. Absent dorsalis pedis pulses D. Serum Creatinine level of 1.3. Absent dorsalis Pedis Pulse rationale: Absence of this pulse indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation. A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A. Promoting oxygenation B. Management of pain C. Maintaining hydration D. Preventing infection Promoting oxygen Rationale: Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling has been linked to severe hypoxia and can be fatal. Rest should be encouraged to decrease expenditure of oxygen and energy. A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A. A client who has COPD with an oxygenation saturation of 90%. B. A client who has diabetes mellitus with a hbA1C of 9% C A client who has heart failure with 2+ pitting edema of lower extremities D. A client who has a fever of 38.4 Celsius (101.2) with tenderness in RLQ A client who has a fever of 38.4 (101.2) with tenderness in RLQ rationale: This indicates possible appendicitis. A nurse is caring for a client who has a compound fracture of the tibia and fibula and is skin traction. The client reports pain of 6 on a scale of 0-10 under the traction bandage. Which of the following actions should the nurse take? A. Administer an analgesic. B. Assist the client to shift positions. C. Check pedal Pulse. D. Distract the client with music therapy. Check pedal Pulse Rationale: Pressure on peroneal nerve can occur when skin traction is applied to lower extremities which can result in foot drop. Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? A. Bathe a client who is scheduled for physical therapy at 9 am. B. Perform fingersticks for glucose levels on a client who have diabetes. C. Stock procedure rooms. D. Distribute clean linens. Perform fingersticks on clients with diabetes mellitus. Rationale: To attain accurate readings, these levels should be attained prior to eating breakfast. A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A. A client who has cystic fibrosis and has a paroxysmal cough. B. A client who is prescribed cromolyn sodium (Crolum) and has a peak expiratory flow rate of 79%. C. A client who has celiac disease and abdominal distention. D. A client who is prescribed digoxin (Lanoxin) and has 3 episodes of vomiting. A client who is prescribed digoxin (Lanoxin) and has 3 episodes of vomiting. Rationale: Vomiting, slow heart rate, and anorexia are clinical findings associated with digoxin toxicity which is an acute condition. A nurse is caring for a client who has radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? A. Promote adequate intake of calcium. B. Evaluate neurovascular status. C. Elevate the extremity above the heart. D. Apply ice intermittently for the first 24 hours. Evaluate neurovascular status Rationale: neurovascular compromise is a manifestation of compartment syndrome and must be detected in early stages to avoid permanent damage. A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? A. Evaluate level of consciousness. B. Place client on bed rest. C. Encourage increased fluid intake. D. Initiate continuous ECG monitoring. Evaluate level of consciousness Rationale: A change in level of consciousness is earliest manifestation of fat embolism syndrome. A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern? A. A client who is 26 weeks of gestation and reporting leukorrhea. B. A client who is 10 weeks of gestation and reporting urinary frequency. C. A client who is 37 weeks of gestation and reporting perineal discomfort. D. A client who is 34 weeks of gestation and reporting abdominal tenderness A client who is 34 weeks of gestation and reporting abdominal tenderness Rationale: Abdominal or uterine tenderness is an early clinical finding associated with abruption placenta, which could lead to an unstable status. A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching? A. Place proper lights and reflectors on the bicycle. B. Use a properly fitted bicycle helmet. C. wear light colored clothing at night. D. use hand signals when turing. Use a properly fitted bicycle helmet Rationale: this should always be worn to prevent head injuries. A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A. administer an anti-anxiety medication B. Take the client to a place of seclusion. C. Obtain an order for soft wrist restraints. D. Engage the client in physical activity. Engage the client in physical activity Rationale: Gross motor activities can reduce tension and lower anxiety levels. A nurse has been assigned to care for four clients on a med surg floor. Which of the following clients should the nurse evaluate first? A. A client 48 hours following abdominal surgery with redness and swelling at the edges of the incision. B. A client following knee replacement surgery complaining of pain and warmth in the calf. C. A client admitted with cholecystitis who reports frequent nausea and vomiting D. A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL A client following knee replacement surgery complaining of pain and warmth in the calf Rationale: Thromboembolism is a potentially serious complication after joint surgeries and pain, warmth and redness are clinical manifestations of thromboembolism which can lead to a pulmonary embolism. [Show Less]
- Exam
- $22.95
- 0
- 103
Purchase the bundle to get the full access instantly
- 3 Million+ Study Documents
- 100% Money Back Guarantee
- Immediate Download Access
Add To Cart
Reviews 0
Bundle Details
$31.95
- Trusted by 800,000+ Students
- 24/7 Money Back Guarantee
- Download is directly available
97
0
Seller Details
