ATI
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 providers? a. Meperidine b. Amitriptyline c. Gabapentin d. Propranolol
A. Meperidine Meperidine is an opioid and opioids are more effective for residual limb pain rather than phantom limb pain. Amitriptyline is a tricyclic antidepressant that can help manage chronic phantom limb pain. Gabapentin is an anti epileptic that can help manage chronic phantom limb pain. Propanolol is a beta blocker that can reduce the persistent dull, burning sensations of chronic phantom limb pain.
Results of enzyme linked immunosorbent assay testing for an 18 month old infant who has pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors? a. The infant's mother is likely HIV+ b. The infant's ELISA test result is probably a false positive for HIV c. Antiretroviral medications are inappropriate for infants who have HIV d. HIV+ status is contraindication for measles, mumps, and rubella immunizations.
A. The infant's mother is likely HIV+ It's most likely transmitted through mom. Antiretrovirals should be given as soon as possible. MMR vaccine should be given to infants with HIV.
A nurse is caring for a group of clients in a long-term care 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? a. Offer the client a nutritious snack b. Accompany the client back to his room c. Reorient the client to his surroundings d. Administer PRN anti anxiety medication.
B. Accompany the client back to his room.
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? a. "You might need glasses after the surgery" b. "You may drive home after the procedure" c. "Continue to wear your contact lenses until the day of the surgery." d. "Expect complete healing and clear vision in about a week"
a. "You might need glasses after the surgery" LASIK corrects myopia, hyperopia, and astigmatism which are common causes of nearsightedness. Despite having LASIK you may still need glasses. The client should not be driving home afterwards. They should not wear soft lenses for 2-3 week or hard contacts for 4 weeks prior to LASIK. Some clients are able to see an hour after the surgery but it may take 4 weeks for complete healing.
A nurse is admitting a child who has a urinary tract infection (UTI) and a history myelomeningocele. After completing the admission history, which of the following actions should the nurse plant to take? a. Attach a latex allergy alert identification band. b. Initiate contact precautions. c. Post signs in the client's bathroom to strain the client's urine. d. Administer folic acid with meals.
a. Attach a latex allergy alert identification band. Myelomenigocele is 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. Straining the urine is not for UTI or myelomenigocele. Folic acid should be taken during pregnancy.
A nurse is caring for 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? a. Collard greens b. Cottage cheese c. OJ d. Broccoli
a. Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard green=8 ox of milk. Cottage cheese is a lactose. OJ is high in vitamin C. Broccoli is his in folic acid.
A nurse participating in the community health fair is providing information to a client who has a blood pressure of 150/90 during a blood pressure screening. Which of the following actions should the nurse take? a. Give the client a written record of his BP to bring to their provider b. Encourage the client to go to the nearest emergency department. c. Instruct the client to follow up with provider within 6 months. d. Explain to the client that he is not at risk unless he has manifestations of hypertension.
a. Give the client written record of his BP to bring to their provider. When the BP is high during a HTN screening you want the client to visit the dr within 2 months for evaluation.
A nurse is assessing a client who is taking varenicline for smoking cessation. Which of the following findings is nurse's priority? a. Mood changes b. Nausea c. Altered sense of taste d. Skin rash
a. Mood changes The greatest risk to the client is the development of neuropsychiatric effects that can progress to depression and suicide.
The nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the following assessments is the nurse's priority? a. Pulmonary function b. CBC c. Urinary output d. Peripheral edema
a. Pulmonary function The nurse should apply safety and risk reduction priority-setting frameworks. 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.
A nurse is providing discharge teaching to parents whose infant has had a ventriculo-peritoneal 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 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 fever." Infection in the shunt insertion can happen especially 1-2 months after placement. The parents should report fever, vomiting, seizure activity, and decreases in responsiveness as it indicates infection. The fluid shunt redirects from he ventricles to the abdomen is minimal and absorbs readily into the peritoneum. Older children should wear a helmet when participating in physically active play to decrease the risk for injury; however it is not necessary for the parents to place a helmet on the infant.
The nurse in the emrgency department is caring 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? a. 6 month old b. 12 months old c. 18 months old d. 24 months old
b. 12 months old The nurse should know that the infant must e less than 18 months old due to her anterior fontanel still being open. She should assess the infants at approximately 12 months old due to the presence of 6 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 evaluating the injection site for a client who had a Mantoux skin test 48 hrs ago. The nurse finds 10mm of induration with slight redness. Which of the following conclusions should the nurse make? A. The client has active tb. b. The client has had exposure to tb c. The nurse must re-evaluate the results in 24 hrs. d. The test is negative for tb
b. The client has had exposure to tb A Mantoux test is a skin test that determines exposure to tb. Redness alone does not determine positive result. To confirm active tb the client needs X-ray or sputum test. Results should be read between 48-72 hrs
A nurse is providing teaching to a school-age child who has just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hrs? a. "Use a toothbrush to scratch under the cast if your skin itches." b. "Avoid moving your leg and the joints above and below the cast" c. "Keep the cast above the level of your heart" d. "Clean soil from the cast with soapy water"
c. "Keep the cast above the level of your heart" Immediately following the injury and for at least for then first 48 hrs, the child should keep the affected limb above the level of the heart to prevent edema and pain and to promote venous return. The child should avoid strenuous activities but should use the muscles of the leg and the joints above and below the cast.
A nurse is caring for a client who has 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? a. Don a gown before entering the room and remove it before exiting. b. Wear a mask while in the client's room c. Don gloves when entering the room and use of hand sanitizer when exiting d. Take no special precautions unless you have direct contact with the client.
c. Don gloves when entering the room and use of hand sanitizer when exiting Clients who have MRSA require contact precautions. Delivering the tray would require contact with the environment which is why they need gloves. IF tf the client is getting treatment by a nurse the nurse may need a gown and or gloves.
A nurse at a long-term care 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 level of orientation? a. Encourage the client to make choices about meals and activities. b. Use written signs to label specific rooms. c. Post a large calendar on the bulletin board. d. Place a wander alert electronic alarm bracelet on the client's wrist.
c. Post a large calendar on the bulletin board. Posting a large calendar in central location will assist this client with orientation. Labeling specific rooms with symbols rather than written signs, can help decrease the client's confusion.
A nurse is teaching self-administration of NPH insulin to a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include? a. Alternate injecting into the abdomen and the thigh b. Shake the vial withdrawing the dosage. c. Rotate injection sites within the same area. d. Discard the vial if the insulin is cloudy.
c. Rotate injection sites within the same area. To prevent lipodystrophy, the client should rotate injection sites, making them about 2.5 cm apart within the same anatomical area. The client should use the same general area because absorption varies with the site of injection. The client should roll the vial between his palms not shake it. NPH is usually cloudy.
A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts? a. Have the charge nurses for each shift get together and discuss the issues between shifts. b. Direct the nurses from each shift to discuss their issues and present their solutions to the nurse manger. c. Set up a series of meetings for all staff members to attend to discuss issues. d. Remain uninvolved and allow the nurses from each shift to resolve the issues among themselves.
c. Set up a series of meetings for all staff members to attend to discuss issues. The nurse manager is using the conflict resolution strategy of collaboration by involving everyone involved in the conflict among the staff to communicate and work together to devise and implement a win-win solution.
A healthcare facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the use manager take first? a. Discuss with the charge nurses their responsibility in implementing the change. b. Post a sign-up sheet for in-service training session about the new system. c. Ask informal leaders to participate in the early implementation process. d. Collect the staff's input about planning an implementing.
d. Collect the staff's input about planning an implementing.
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 parent should wait no longer than 6-12 month to prevent which of the following outcomes? a. Repeated ear infections b. Nutritional deficits c. Immune system deficits d. Difficulty with language acquisition
d. Difficulty with language acquisition. Language may be hard to acquire because the infant needs to use the palate for vocalizing sounds. Poor nutrition is possible but there are other techniques parents can practice.
A nurse is caring for a client who is taking warfarin. Which of the flowing laboratory values should the nurse recognize as an effective response to the medication? a. Hct 45% b. Hgb 15g/dL c. aPTT 35 sec d. INR 3.0
d. INR 3.0 Warfarin is measured with INR levels. The goal is for the patient to have 2-3.5 levels. Anything above 3.5 puts the client at risk for bleeding. aPTT monitors the effectiveness of heparin.
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 post op complication? a. Pain scale score of 5 out of 10 b. Urine output of 65mL/hr c. 20 mL of bright red drainage from the drain. d. Pulse oximetry of 85%
d. Pulse oximetry 85% Clients who have had abdominal surgery should have an oxygen saturation above 93%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention. Clients must have at least urine output of 30 mL/hr. Blood drainage of 20 mL of bright red fluid is an expected finding.