ATI - Comprehensive Final

A nurse is admitting a client who has manifestations that suggest TB. Which of the following actions is the nurse's priority?

Initiate airborne precautions.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first?

Initiate bag-valve-mask ventilation.

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process?

Instruct clients who are able to ambulate to leave.

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home?

"I'll stick with soft foods for now." Thrombocytopenia (a low platelet count) is common after a bone marrow transplant. To prevent bleeding until his platelet count improves, the client should avoid hard foods that could cause mouth trauma.

A nurse is caring for a client who takes warfarin to treat chronic A-fib and has early manifestations of Alzheimer's disease. The client's partner asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?

"It is likely that ginkgo biloba will interfere with the effectiveness of his other medications."

A nurse is providing teaching to a school-age child who has just had a fiberglass cast application following lower extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hours?

"Keep the cast above the level of your heart." [Immediately following the injury, and for at least the first 48 hours, the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return.]

A provider tells a client who reports practicing Hinduism that at 12-weeks of gestation she needs more protein in her diet and suggest eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?

"Let's discuss other foods that are also high in protein that you could substitute for meat." Many cultures have beliefs about food that the nurse should respect. Discussing nonanimal protein sources can help the client identify those that do not conflict with her religious and cultural beliefs.

A nurse is assessing a 66-year-old client during a routine physical examination at her first clinic visit and does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I had any immunizations." Which of the following responses should the nurse make?

"Let's go ahead with giving you this immunization." The Centers for Disease Control and Prevention recommends this immunization for people who are 65 years old and older. If the client did receive this immunization more than 5 years ago, the nurse should administer another one because the client is over 65.

A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications?

Aspiration [Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which is an indication of aspiration.]

A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following clients receives treatment first?

Hemothorax [The nurse should apply the survival potential priority-setting framework. The nurse should reserve the use of this framework for mass casualty situations, when resources are scarce and he must allocate resources to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The nurse should assign the highest priority to the client who has injuries that are severe but has the potential to survive with treatment. Therefore, the nurse should recommend that the client who has a hemothorax receive treatment first. A hemothorax is life-threatening, but with chest-tube insertion and stabilization the client is likely to survive.

A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider?

Hyperkalemia [The nurse should apply the urgent versus nonurgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. Therefore, hyperkalemia, which can cause life-threatening cardiac dysrhythmias, is the priority for the nurse to report to the provider.

A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?

Pulse oximetry of 85%

A nurse is providing teaching to the parents of a child who has a new prescription of lamotrigine for a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?

Rash [the greatest risk to this client is injury from Stevens-Johnson syndrome or toxic epidermal necrolysis, which are life-threatening reactions that manifest initially as a rash in the first 2-8 weeks of treatment with lamotrigine. The nurse should instruct the parents to report a rash immediately to the provider.]

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

Reading the newspaper. [With presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.]

A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 mm induration with slight redness. Which of the following conclusions should the nurse make?

The client has had an exposure to TB.

A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask?

"Does anyone smoke around or in the same house as your child?" [Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space. It also prolongs the inflammation and impedes drainage from the ear.]

A nurse in a substance use disorder program is interacting with a client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?

"I have read that problems with substances can have a variety of predisposing factors." The nurse should identify this response as a use of intellectualization. Intellectualization is an attempt to use intellectual processes to avoid expressing the emotions that stem from stressful situations.

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause for the client's sleeping difficulties?

"I often have a cup of coffee with my dessert before going to bed."

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?

"I will perform intermittent self-catheterization every 2-3 hours."

A nurse is teaching the parent of a child who has type 1 diabetes mellitus how to manage the child's disorder during illness, such as colds. Which of the following statements by the parent indicates an understanding of the teaching?

"I'll check his blood glucose more often."

A nurse at a long-term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements should indicate that the AP requires further teaching?

"Its almost time for your appointment. Let me do your hair for you and brush your teeth."

A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?

"Tell me about your favorite video game."

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make?

"Tell me what concerns you the most about being hospitalized."

A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make?

"The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common." [This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested.]

A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" Which of the following responses should the nurse make?

"This must be so difficult for you."

A nurse is providing teaching to a client who has type 2 DM. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse make?

"You don't have to give up pasta; just adjust the amount you eat."

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include?

"You might need glasses after surgery." [LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.]

A nurse is providing teaching to a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following information should the nurse provide the client?

"Your risk of ectopic pregnancy increases with an IUD." [An IUD is a family planning device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.]

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP should indicate that further teaching is required?

"if the client seems confused i will raise all 4 side rails so that he doesn't hurt himself"

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and a myocardial infarction. Which of the following manifestations should the nurse identify as indications of an MI? (Select all that apply)

1. N/V 2. Diaphoresis and dizziness 3. Anxiety and feelings of doom

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.)

1. Sit with your back supported 2. Keep your knees at hip level 3. Use ergonomically designed computer keyboard

A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada". The nurse should make which of the following age assessments for this child?

12 months old The nurse should know that the infant must be less than 18 months old due to her anterior fontanel still being open. She should assess the infant at approximately 12 months old due to the presence of six teeth. Her skills - sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and her ability to say two words (12 months) - should also help the nurse estimate the infant's age as 12 months.

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization?

A 10-piece wooden puzzle. Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow for manipulation and exploration and meet the child's developmental and diversional activity needs.

A community health nurse is planning care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first?

A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy.

A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?

A client who has DKA and a blood glucose of 375 mg/dL. [The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage.]

A nurse on an oncology unit receives report at the beginning of her shift about four clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy d/t colorectal cancer and has an ostomy bag full of bright red, bloody drainage.

A nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first?

A client who is difficult to arouse and is unable to respond to questions.

A nurse in the labor and delivery suite is planning care for a group of four clients. Which of the following clients should the nurse see first?

A client who is in active labor and has late decelerations on the fetal heart monitor's strip

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client?

A nasal cannula [A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.]

A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first?

Accompany the client back to his room.

A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parent's presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan because it offers which of the following benefits?

Allows the child to manipulate toy medical equipment [A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express his fear of the unfamiliar medical equipment in the hospital. The nurse encourages the child to touch the equipment to decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.]

A nurse delegates a LPN to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the LPN should indicate to the nurse that she requires further teaching?

Ambulates the client's roommate while the client sleeps.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?

Apply continuous pressure to the lower part of his nose. With the child sitting up and breathing through his mouth, the nurse should apply continuous pressure with her thumb and forefinger to the soft lower area of the nose for 10 min. Most bleeding from the nose stops within that period.

A nurse in an acute care clinic is talking with a client who reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches that would help relieve her pain. Which of the following interventions should the nurse suggest?

Applying warm compresses to sore joints.

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable area for discussing clients' information?

Areas with no public access

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding?

Arm cast for a spiral fracture of the forearm [Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury.]

A nurse is admitting a child who has a UTI and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take?

Attach a latex allergy alert identification band. Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first?

Attempt to reduce environmental stimuli. least resrictive option

A nurse is teaching a client who has extensive deep partial- ad full-thickness burns and requires a topical antimicrobial medication. The nurse should explain to the client that the goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth

A nurse is preparing an older adult client who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home?

Blood pressure A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of another TIA or cerebrovascular accident.

A nurse is discussing medication administration for an older adult client with a newly licensed nurse. The nurse should identify that, due to physiological changes of aging, older adult clients might need dosage adjustments d/t an increase in which of the following parameters?

Body fat. Aging causes physiological changes in all organ systems. Tissue composition changes the nurse should be aware of include an increase in adipose tissue, a decrease in lean body mass, and a decrease in total body water. The increase in fatty tissue causes increased storage of lipid-soluble medications and lowers plasma levels of those medications.

A nurse in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiologic adaptation of pregnancy?

Breast tenderness.

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse finds that the client has absent breath sounds on the left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?

Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.

A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?

Collard greens

A health care facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the nurse manager take first?

Collect the staff's input about planning and implementing the change.

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

Compare the medical record number and name on the MAR with the client's identification band.

A nurse is assessing a client who has AIDS and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider?

Decreased hemoglobin

A nurse is caring for a client who is taking acarbose to treat type 2 DM. For which of the following adverse effects of this medication should the nurse monitor?

Diarrhea

A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6-12 months to prevent which of the following outcomes?

Difficulty with language acquisition Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With the cleft in the palate, these infants could develop poor speech habits.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting.

A nurse participating in a community health fair is providing information to a client who has a BP of 150/90 mmHg during a blood pressure screening. Which of the following actions should the nurse take?

Give the client a written record of his BP to bring to their provider. When a client has an elevated reading at a hypertension screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.

A nurse is caring for a client who has dehydration and has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for the client?

Hct 55% [An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.]

A nurse in the emergency department is caring for a client who has Addison's disease and reports N/V, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse should prepare to administer which of the following medications?

Hydrocortisone Addison's disease causes adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal insufficiency is life-threatening, with severe fluid and electrolyte imbalances. Without treatment, sodium levels fall and potassium levels increase. Rapid infusion of IV fluids, such as 0.9% sodium chloride, and IV administration of high dose corticosteroids, such as hydrocortisone, to correct the glucocorticoid deficiency are essential.

A nurse is caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication?

INR 3.0

A nurse in an acute care facility is implementing the facility's disaster plan following a flood in the community. Which of the following actions should the nurse take?

Identify stable clients in the ICU to transfer to the medical-surgical units. The nurse should identify clients to transfer to medical-surgical units to increase the availability of ICU beds for clients from the external disaster who are critically ill.

A nurse is assessing a client who has multidrug-resistant TB and takes ethambutol. The nurse should identify which of the following findings as an adverse effect of this medication?

Loss of red/green color discrimination Ethambutol is an antitubercular medication that impairs ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the medication.

A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?

Meperidine. Opioids are more effective for residual limb pain rather than phantom limb pain. Additionally, meperidine is not recommended for chronic pain because using it long-term can cause accumulation of a toxic metabolite.

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PaCO2 40, and HCO3_ 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis [A pH of 7.25 indicates acidosis. If the cause is respiratory, the pH and PaCO2 values deviate in opposite directions. Since the PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic. Therefore, the nurse correctly reports to the provider that the client has metabolic acidosis.]

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter [Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language.]

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care?

Offering the client a diet high in fluid and fiber A client who is immobile is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function

A nurse is teaching the parent of a child who has severe reactive airway disease about glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it orally. Which of the following information should the nurse provide the parent?

Oral glucocorticoids are more like to slow linear growth in children. (Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (pts airways) resulting in an decreased risk for adrenal suppression).

A nurse is caring for a client who had a precipitous delivery. The nurse should identify which of the following assessments as the priority during the fourth stage of labor?

Palpating the client's fundus

A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia?

Patch the unaffected eye. Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem, such as strabismus. With strabismus, muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong one. This will result in central blindness if the child does not receive treatment by 6 years of age. To strengthen the weak eye muscles, the parents should patch the unaffected eye.

A nurse at a LTC facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's LOC?

Post a large calendar on the bulletin board.

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?

Prolonged Q-T intervals [Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged Q-T intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.]

A nurse is teaching a client who has chronic kidney disease about predialysis dietary recommendations. The nurse should include information about restricting his intake of which of the following nutrients?

Protein Dietary restrictions for clients who have chronic kidney disease vary with the degree of kidney function; however, most clients need protein limitations. Predialysis, protein restriction can help preserve some kidney function.

A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the following assessments is the nurse's priority?

Pulmonary function [The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Bleomycin can cause severe lung injury, including pneumonitis and pulmonary fibrosis, and it affects a significant percentage of clients receiving this medication; therefore, pulmonary function is the priority assessment.]

A nurse in the emergency department is caring for a child who has bruises that the nurse suspects are d/t child abuse. Which of the following actions should the nurse take?

Report the suspected abuse to local authorities.

A nurse is teaching self-administration of NPH insulin to a client who has type 2 DM. which of the following instructions should the nurse include?

Rotate injection sites within the same area. To prevent lipodystrophy, the client should rotate injection sites, making them about 2.5 cm (1 in) apart, within the same anatomical area.

A nurse is providing teaching to a client who has a new prescription for sertraline. The client asks the nurse if he should continue to take St. John's wort for depression. Which of the following instructions should the nurse give the client?

Stop taking the herbal supplement while taking the medication. [Taking the antidepressant sertraline and the herbal supplement St. John's wort together puts the client at risk for serotonin syndrome.]

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first?

Stop the medication infusion [The greatest risk to the client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.]

A nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction?

Sudden oliguria [The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This type of reaction results from the client's antibodies reacting to the transfused RBCs.]

A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication?

Temperature [Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.]

A nurse is accepting a transfer from the PACU of a client who has had a subtotal thyroidectomy. Which of the following equipment should the nurse have available at the bedside for this client?

Tracheostomy tray With the laryngeal edema that is common post thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk for hemorrhage by increasing tension on the incision during insertion. The nurse should have a tracheostomy tray available for this client.

A nurse is preparing to administer 100 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take?

Use separate syringes for administering insulin glargine and NPH insulin. The nurse should not mix insulin glargine with any other insulin. The nurse should administer the NPH insulin and insulin glargine separately.

A nurse is planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse plan for this client?

Walking with a staff member The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff.

A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. The client should hold the mouthpiece 2-4 cm (1-2 in) from his mouth 2. Tilt his head back slightly, and then open his mouth 3. Next, he should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway 4. After holding his breath for 10 seconds, the client should resume his usual breathing pattern.

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse?

A leak within the ventilator's circuitry [The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.]

Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. The nurse has limited experience with children. Which of the following actions should the nurse manager take?

Assign a unit nurse to act as a resource to act as a resource for the medical-surgical nurse. [Assigning a nurse who usually works on the pediatric unit to work with the medical-surgical nurse will provide consistent support]

A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client?

Build trust with the client by sitting quietly with him [The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and the use of silence are actions that promote trust which encourages the client to speak more openly about issues and concerns.]

A nurse is assessing a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection?

Candidiasis [Candidiasis, or oral thrush, results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS.]

A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The nurse notes that her left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first?

Check neurovascular status distal to the injury

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer?

Corticosteroids Corticosteroids, such as prednisone, are the treatment of choice for systemic manifestations of SLE because of their rapid anti-inflammatory action.

A nurse is reviewing the medical record of a client who is requesting a prescription for sildenafil citrate. Which of the following data in the client's record should the nurse identify as a contraindication for the use of this medication?

Current use of isosorbide to treat HF. Taking any nitrates, such as isosorbide and nitroglycerin, is a contraindication for sildenafil, a medication that treats erectile dysfunction. Taking it concurrently with nitrates can cause life-threatening hypotension.

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)?

Headache DDS is a CNS disorder. It is a complication that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood's pH. Clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes headache, nausea, vomiting, decreased level of consciousness, seizures, and restlessness. When it is severe, clients progress to confusion, seizures, coma, and death.

A nurse is caring for a client who has pseudomembrane colitis d/t Clostridium difficile infection. Which of the following interventions is the nurse's priority?

Performing hand hygiene before and after contact with the client.

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)?

Record urinary output after emptying the indwelling urinary catheter.

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings should indicate to the nurse that the AAA is expanding?

Report of sudden, severe back pain [An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities, that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.]

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day.

a nurse is providing discharge teaching to parents whose infant has had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. which of the following statements by the parents indicates an understanding of the teaching? a. we will check his abdomen daily for signs of fluid accumulation b. we will notify the doctor right away if he has a fever c. we should keep a helmet on him when he's awake d. we can expect him to have occasional seizure episodes

b. we will notify the doctor right away if he has a fever Infection is a risk after a ventriculoperitoneal shunt insertion, especially 1 to 2 months after placement. The parents should report fever, vomiting, seizure activity, and decreases in responsiveness, as these can indicate infection.