ATI comp 2023 ( this one)
A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?
"A client who requires airborne precautions should be placed in a negative-pressure airflow room."
A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?
"Have you had any stomach pain or bloody stools?" MY ANSWER
A nurse is admitting a client to the mental health unit after an attempted suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?
"How does this make you feel?"
A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
"I can designate my partner as my health care surrogate."
A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect?
"I have not vomited as much recently."
A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching?
"I should watch for common reactions like dry mouth and constipation."
A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?
"I told my doctor that I would like to start a support group for other people who are sick in my community."
A nurse is providing information to a client immediately before their scheduled Romberg test. Which of the following statements should the nurse make?
"I will be checking you once with your eyes open and once with them closed."
A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
"I will make sure my child receives a yearly influenza immunization." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza immunization.
A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?
"Sedation is a common adverse effect of this medication."
A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what is causing the constipation. Which of the following responses should the nurse make?
"The enlarged uterus compresses the intestines and causes constipation."
A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first?
A client who is confused and has been attempting to get out of bed
A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
A client who is receiving an MAOI and is requesting a cheeseburger for dinner
A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?
A client whose caregiver requests adult day care services
A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?
Acute confusion
A nurse is planning morning care for a client who has heart disease and type 2 diabetes mellitus. Upon review of the client's medical record, which of the following actions should the nurse take?
Administer daily medications.
A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?
Advocacy is a leadership role that helps others to self-actualize.
The nurse is reviewing the adolescent's electronic medical record (EMR). Which of the following findings requires immediate follow up by the nurse? Click to highlight the findings that require immediate follow up. To deselect a finding, click on the finding again.
After reviewing the information in the adolescent's EMR and recognizing cues, the nurse should identify that the adolescent has a potential skin infection, such as cellulitis. The skin assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 cm2 area of redness with small pustules, tenderness, and warmth, which can indicate infection. The adolescent's temperature and WBC count are above the expected reference range, which can also indicate infection. The adolescent's casual blood glucose and potassium are above the expected reference range, which can indicate infection or a complication of type 1 diabetes mellitus. The nurse should immediately follow up on these findings because they can indicate infection or other complications.
A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates the client needs additional nutrients added to the feeding?
Albumin 2.8 g/dL (3.5 to 5 g/dL)
A nurse is caring for a client who has become aggressive and potentially violent. Which of the following actions should the nurse take?
Allow the client time for reflection and decision making.
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
Auscultate the apical pulse at least 1 min.
A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
Autonomy
A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet.
When caring for a child, a nurse plans to use nonpharmacological 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"
A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?
Blurred vision
A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?
Borderline
A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?
Facilitate an interdisciplinary conference at the new facility for the family.
A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of their last menstrual period (LMP) was May 8. According to Naegele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?
February 15
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
Floating dark spots
A nurse is administering medications to a client who has a 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.
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect?
Grandiose delusions
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
Have the client wear a surgical mask while being transported outside the room.
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
A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?
Hypertension
A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?
Ideas of self-harm
A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first?
Inform the nurse manager of the issue.
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.
A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
Initiate transmission-based precautions.
A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship?
Establish the termination date of therapy.
A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?
Lack of remorse
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
A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?
Maintain regular notes about the nurse's time management skills.
A nurse is administering 1 unit of packed RBCs to a client. The client becomes anxious and reports shortness of breath and urticaria 15 min after initiation of the transfusion. Which of the following actions should the nurse take?
Prepare to administer epinephrine to the client.
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
Proceed with provision of medical care.
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.
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?
Radial vein of the inner arm
A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for the development of a pressure injury?
Recent weight loss
A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
Report of chest pain
A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
Sedentary lifestyle sedentary lifestyle is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.
The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips .
answer to left The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications.
A nurse is caring for a school-age child who has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?
Serum sodium 138 mEq/L
A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique?
Set the catheter tray on the overbed table at waist height.
A nurse is caring for a 1-month-old infant. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days.Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting.1600: Called to room by parent. The client who gave birth attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with pacifier.
The infant is at highest risk for developing dehydration , as evidenced by the infant's vomiting .
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.
For each assessment finding noted above, click to specify if the finding is expected of pneumonia, COPD, or heart failure. Tobacco use BNP level WBC level Oxygen saturation Temperature ABG results
The nurse should analyze cues of pneumonia that include tobacco use, elevated WBC count, a productive cough with blood-tinged sputum, elevated temperature, a decreased oxygen saturation level, and an ABG level indicating respiratory acidosis. The nurse should also analyze cues of COPD that include tobacco use and a decreased oxygen saturation. The nurse should also analyze cues of heart failure that include tobacco use, BNP level, and a decreased oxygen saturation.
A nurse is caring for a 5-year-old child. Complete the diagram by dragging from the choices below to specify what condition the child is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the child's progress.
The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottitis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds.
A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation.
The nurse should avoid cervical examination and insert a large-bore IV catheter because the client is most likely experiencing abruptio placentae indicated by the sudden onset of abdominal pain, contractions, and dark red vaginal bleeding. Cervical examination can cause further damage to the placenta and increase bleeding. The nurse should immediately establish IV access with a large-bore catheter to administer IV fluids and blood products if bleeding increases or if manifestations of fetal distress occur. The nurse should monitor the client's blood pressure and platelet count because of the risk of significant blood loss due to the abruption. Hemorrhage might not be visible as vaginal bleeding if it is concealed between the placenta and uterine wall. Therefore, manifestations of hypovolemic shock (decreasing blood pressure, increasing heart rate) can provide indications that internal placental bleeding is worsening. Abruptio placentae can also lead to alterations in coagulation, such as disseminated intravascular coagulation, further increasing the client's risk for hemorrhage. Therefore, the nurse should monitor the client's platelet count to identify if the client is at an increased risk for bleeding.
The client is at highest risk for developing evidenced by the client's
The nurse should determine that the priority hypothesis is the client is at the highest risk for developing pyelonephritis as evidenced by the client's urinalysis results. The urinalysis indicates dark cloudy urine, increased specific gravity, increased pH, increased red and white blood cells, positive nitrites, positive leukocytes, and trace amounts of blood, which indicate a urinary tract infection (UTI). If left untreated, a UTI can lead to pyelonephritis.
The nurse reviews the assessment data at 1800. Which of the following actions should the nurse plan to take?
The nurse should first address the client's respiratory rate , followed by the client's level of consciousness .
A nurse is caring for a client who is postoperative following administration of general anesthesia.
Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.
A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority?
Upper chest petechiae
A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?
"I will need to measure your weight daily."
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching?
"I will not allow anyone to smoke near my baby."
A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
"I would like to talk to you about the unit policies regarding break time."
A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?
"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments."
A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?
"Notify your provider if you experience increased thirst."
A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
"You will need to fast the night before the test."
A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 10 kg (22 lb) and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
0.6
A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
A client who has cellulitis and is receiving oral antibiotics every 8 hr
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 hospitalizations for diabetic ketoacidosis
A nurse is caring for multiple clients in an antepartum clinic. For which of the following clients should the nurse plan to perform fetal heart monitoring? (Select all that apply.)
A client who has premature rupture of membranes is correct. Clients who have premature rupture of membranes require fetal monitoring to assess and evaluate fetal well-being. A client who reports decreased fetal movement is correct. Clients who report decreased fetal movement require fetal monitoring to assess and evaluate fetal well-being. A client who has gestational hypertension is correct. Clients who have gestational hypertension require fetal monitoring to assess and evaluate fetal well-being. A client who is at 32 weeks of gestation and reports Braxton Hicks contractions is incorrect. Braxton Hicks contractions are an expected finding after 28 weeks of gestation. A client who has a urinary tract infection is incorrect. Clients who report urinary tract infections do not require fetal monitoring.
A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?
A client who has significant head trauma and agonal respirations
An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
A client who is at 33 weeks of gestation and has severe gestational hypertension
A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?
Apply suction for 10 seconds.
A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's guardian. Which of the following actions should the nurse take?
Ask the caller for verification of their identity.
A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?
Ask the client to point to items on a picture menu.
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?
Assist with deep breathing and coughing.
A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?
Audible stridor
A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula 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.
A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?
Confusion
A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?
Contact Child Protective Services.
A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?
Cough
A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?
Delegate non-nursing tasks to ancillary staff.
A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care?
Encourage the parents to bring toys from home.
A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?
Determine the client's perception of the personal impact of the crisis.
A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
Determine the client's reading skills.
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.
A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect?
Diaphoresis
A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
Difficulty performing ADLs
A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Dyspnea
A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take?
Inject 20 units of air into the NPH insulin vial.
A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?
Install a raised toilet seat at home.
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?
Instruct the client to avoid coughing during the procedure.
A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?
Instruct the client to elevate the affected extremity when sitting.
A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
Instruct the client to void.
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 3 to 5 days. The parents should introduce new foods one at a time over 3 to 5 days to identify potential food allergies.
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.
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
Irritability
A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
Jaundice
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Keeps the head of the bed elevated to 45° for 1 hr after feedings
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Make a referral for social services.
A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Measure the client's daily weight.
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.
A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect?
Nuchal rigidity
A nurse working on an inpatient mental health unit is caring for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?
Observe the client every 15 min.
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?
Occlusive dressing on the insertion site
A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching?
Oranges
A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit?
Orthostatic hypotension
A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer?
Oxytocin
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
Perform gastrostomy feedings through a client's established gastrostomy tube.
A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?
Performing a rapid needs assessment
A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect?
Persistent uterine contractions The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding.
A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum
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.
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 recognize the client is demonstrating which of the following defense mechanisms?
Sublimation
A nurse in an acute 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.
A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
Survey the scene for potential hazards to staff and children.
A nurse is providing teaching to a client who has a prescription for levothyroxine 25 mcg PO daily. Which of the following instructions should the nurse include in the teaching?
Take the medication on an empty stomach 30 min before breakfast.
A nurse on a medical-surgical 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.
A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG).
The client is at greatest risk for developing dysrhythmias as evidenced by electrolyte imbalance .
Drag words from the choices below to fill in each blank in the following sentence.
The client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia .
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority?
The client's heel is reddened and tender.
A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn off the CPM machine during mealtime.
A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), PaO2 56 mm Hg (80 to 100 mm Hg), PaCO2 54 mm Hg (35 to 45 mm Hg), HCO3- 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values?
Uncompensated respiratory acidosis
A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED).
Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should monitor the client's level of consciousness and place the client on fall and seizure precautions.
A nurse in an emergency department (ED) is assessing a client. Exhibit 1 Exhibit 2 Exhibit 3 Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months agoCurrent medications: Haloperidol 5 mg PO TIDSumatriptan 50 mg PO every 2 hr PRN headache
Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas values as multiorgan failure can occur. To evaluate interventions and track the client's condition, the nurse should monitor the client's temperature, hydration status, and provide for early detection of complications.
The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include?
When generating solutions, the nurse should educate the client on how to prevent future UTIs by cleansing the perineum prior to intercourse. During intercourse, bacteria from the skin can enter the urinary tract, causing infection.
A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?
Urine specific gravity 1.052 (1.005 to 1.03) The nurse should recognize the client's urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.03. An increased urine specific gravity indicates dehydration from vomiting.
A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?
Use a protective cover on the scale when weighing the infant.
A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
Use a three-point gait.
A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?
Use the ventrogluteal site.
A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
Verify the client and blood product information with another licensed nurse.
A nurse is caring for a client who has a new diagnosis of anorexia nervosa.
When analyzing cues, the nurse should first address the client's electrolyte imbalance. The client has hypokalemia, which increases the risk for cardiac arrhythmias. Once the client's medical concerns are addressed, the nurse should then focus on the underlying psychological issues behind the eating disorder, such as the client's fear of weight gain.
Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.
When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm.
Hep a b c Client's risk from bloodborne transmission Laboratory results Antiviral treatment Physical examination findings Client's risk from fecal-oral transmission
When analyzing cues, the nurse should recognize that manifestations of hepatitis A, hepatitis B, and hepatitis C include jaundice, yellow sclerae, right upper quadrant pain upon palpation, dark yellow urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an underdeveloped country and the client's occupational risk as a perioperative nurse for contracting hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the current standard of practice for treating hepatitis B and hepatitis C infections is with antiviral medication.
Click to highlight the findings that indicate the client's urinary tract infection is improving. To deselect a finding, click on the finding again.
When evaluating outcomes, the nurse should identify that the client's urinary tract infection (UTI) is improving as evidenced by the client's urine specific gravity, pH, and WBC results.
A nurse is caring for a client. Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU.Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia.Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred.
When generating solutions, the nurse should identify that oxygen therapy, monitoring blood glucose, and keeping lights in the client's room dim are anticipated prescriptions. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, the nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% and avoid hypoxia. The nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury. The nurse should also dim the lights in the client's room, because many clients who have increased ICP experience photophobia.
1100: Client alert and oriented person, place, and time. Client had episode of diarrhea, perineal care provided. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr.
When recognizing cues, the nurse should determine that the client's painful edematous area on their sacrum and that the client has only been repositioned every 4 hr requires follow up. The client has manifestations of a pressure injury that need to be addressed. The client should be repositioned at least every 2 hr to prevent worsening of the pressure injury and to relieve pressure from the sacral area.
A nurse is assessing a newborn who is 3 days old.
When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.
A nurse in a provider's office is caring for a client. Exhibit 1 Exhibit 2 Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting.Client has a history of type 2 diabetes mellitus, hypertension, and COPD.
When recognizing cues, the nurse should identify that the client's report of frequency, dysuria, and urgency are manifestations of a UTI and should be reported to the provider. These manifestations occur due to bacteria invading the urinary tract through the urethra. frequency, dysuria and urgency
A nurse is caring for a client who is postoperative following an appendectomy.
When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider.
A nurse in an outpatient mental health clinic is caring for a client.
When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.
A nurse is caring for an adolescent in the emergency department (ED). Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Chloride 103 mEq/L (98 to 106 mEq/L) BUN 15 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL) Glucose 80 mg/dL (74 to 106 mg/dL) Total protein 7 g/dL (6.4 to 8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5 g/dL) WBC count 19,500/mm3 (5,000 to 10,000/mm3) Aspartate aminotransferase (AST) 30 units/L (10 to 40 units/L) Alanine transaminase (ALT) 20 units/L (4 to 36 units/L)
When recognizing cues, the nurse should recognize that manifestations of bacterial meningitis can include fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness. The adolescent is experiencing these symptoms. Encephalitis is characterized by fever, nuchal rigidity, and altered mental status. Reye syndrome is characterized primarily by altered mental status and impaired hepatic function.
A nurse is caring for a client who is pregnant. Exhibit 1 Exhibit 2 Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.1500: Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.
When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea.
Which of the following assessment findings should the nurse report to the provider as unexpected? For each assessment finding, click to specify if the finding is expected or unexpected.
When taking action, the nurse should identify that the client's urine color, voiding pattern, oxygen saturation, and blood pressure are expected findings and do not need to be reported to the provider. The client's report of orange urine is an expected finding due to the prescribed medication phenazopyridine, which can cause reddish-orange discoloration of urine. The client's voiding pattern is an expected finding due to increased fluid intake of 3 L daily. The client's oxygen saturation is an expected finding due to the client's history of COPD. The client's blood pressure is an expected finding due to the client's history of hypertension. . The nurse should identify that the client's temperature, skin, and bowel elimination are unexpected findings and should be reported to the provider. The client's temperature is above the expected reference range, which can be an indication of Clostridium difficile. The client's diarrhea can also be an indication of C. difficile. The client's unexpected bruising can be an indication of Stevens-Johnson syndrome. C. difficile and Stevens-Johnson syndrome are potential side effects of trimethoprim/sulfamethoxazole.
A nurse is caring for a client following a laparoscopic cholecystectomy. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to person, place, and time. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Client denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision intact upon inspection, no redness, swelling, or drainage noted.
When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration.
A nurse is caring for a client in the emergency department (ED). Exhibit 1 Exhibit 2 Exhibit 3 Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered.
When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells and assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection.
A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse should instruct the parent to change the tracheostomy collar.
A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 (2500 to 8000/mm3). Which of the following interventions should the nurse include in the plan?
Withhold administering the varicella vaccine to the child.
