Comp exam 2 ATI quesiton

A nurse is assessing a client who has a suspected diagnosis of Gullian-Barre syndrome. Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?"

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levdopa/carbidopa

What is the priority action for a client experiencing a seizure?

Lower the patient to floor or bed Protect head Remove any nearby furniture Provide privacy Lay patient on their side with neck flexed Loosen clothing Notify HCP

​A 37-year-old pregnant client in her 3rd trimester reveals she has incontinence. What are three (3) points to discuss with the client to help her manager her incontinence?

Perform Kegel exercises Schedule bathroom breaks Monitor weight gain

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.

Perform hand hygiene Place package on work surface Open outermost flap away from self Open side flap, pulling to the side Open innermost flap toward self Use inner surface of package as sterile field.

The nurse is assessing a client with a left-sided stroke. What clinical manifestations can the nurse anticipate?

-Expressive and receptive aphaia -Agnosia -Agraphia -Right extremity paralysis -Depression and anger -Visual changes

A nurse is caring for a client with placenta previa. What interventions should be completed for this client?

Assess bleeding and leakage Assess fundal height Refrain from vaginal exams Admin Iv fluids, medications and blood products. Betamethasone may be ordered to promote fetal lung growth Have 02 equipment at bedside

A nurse in the emergency room is assessing a client who was brought in following seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves

A client is receiving home O2. What patient teaching should the nurse provide

Post a no smoking sign or a 02 in use sign Know where the closest fire extinguisher is Have client wear cotton clothing Ensure all electric machinery is in working order and grounded Do not use flammable material

What is an indication for taking tamoxifen

Prevent breast cancer in women with high risk of developing it

Nurse should follow when pouring solution....

Remove the bottle cap Place bottle cap face up on a clean surface Pick up the bottle with the label facing palm Pour 1 - 2 mL of solution into a receptacle Pour solution onto the gauze

​The nurse is assessing the fetus during labor and notes recurrent variable decelerations with minimal baseline variability. What is the priority nursing intervention for recurrent variable decelerations with minimal baseline variability?

Reposition pt from side to side or knee to chest DC oxytocin Admin 02 at 8-10L via nonrebreather Preform vaginal exam Assist with an amnioinfusion if prescribed

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?

Respite care

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure. Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A pediatric client was diagnosed with Reye Syndrome. Which of the following statements by the parent indicate understanding of this diagnosis? (select all that apply) "Reye Syndrome typically follows a viral illness.""There is no association between using aspirin for fevers and development of Reye Syndrome.""My son's liver function may return to full function.""His symptoms of irritability, confusion, and lethargy are expected with this diagnosis.""There is no known treatment for Reye Syndrome and its symptoms

Reyes syndrome typically follows a viral illness, most commonly the flu or chickenpox. Signs are irritability, confusion and lethargy It caught early liver function may return to full function

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse is caring for a client who has a new prescription for raloxifene. What are contraindications for this medication that the nurse should discuss with the client?

Contraindications are pregnancy, history of DVT and must stop three days prior to menstruation

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. the nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist sterile gauze dressing

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2 degrees celsius, Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room.

Gloves Goggles Gown Mask Perform hand hygiene

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon

What are risk factors for iron deficiency anemia in toddlers? Name three (3) dietary sources of iron.

High intake of cows milk before 1 Breastfeeding beyond six months-not introducing solids Vegetarian diet

What are two (2) contraindications for the administration of terbutaline during labor?

History of gestational DM, cardiac disease, preeclampsia, gestational HTN Discontinue if client cannot tolerate adverse effects

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?

Hand hygiene Remove bottle cap Place cap on a clean surface Palm label against the hand Pour 1 - 2 mL of solution into a receptacle Pour solution onto sterile gauze

Bipolar disorder is primarily managed with mood-stabilizing medications, such as lithium carbonate. List three (3) important teaching points to provide to the client regarding the possible adverse effects of lithium.​

Hand tremor, increased thirst and increased urination

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness

What are three (3) points the nurse should teach parents of an epileptic client on post-seizure management?

​Reinforce the need for rest Reinforce adherence to medication regimen Encourage parents to provide developmental stimulation

What is the role of the nurse when a client refuses treatment?

The nurse must be understanding and ask the patient what they believe the procedure entails. The nurse may also teach about the patient's current condition and educate on how the treatment will help the patient. Finally notify their health care provider.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lbs in the past 2 months

A nurse has provided education to a client with hypothyroidism who has a new prescription for levothyroxine. What statements by the client would indicate they understand the instructions

The patient must understand that they will be on this medication for the rest of their lives. This medication must be taken on an empty stomach and do not discontinue use without talking to your HCP.

A client is admitted for suspected meningitis. What priority interventions will be most important for the nurse to initiate

The priority intervention is to limit environmental stimulus

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?

The signs of dementia are progressive and irreversible

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching?

Vitamin A Vitamin B12 Vitamin C Vitamin K

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

"Use contraception while taking this medication"

A nurse is caring for a client who has experienced a mild traumatic brain injury. Describe the manifestations of increased intracranial pressure the nurse should be alert fo

-Headache -Vomiting -Altered LOC -Back Pain -Papilledema

A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this disease process.

-Hyperkalemia -Increased BUN and creatinine -Decreased cortisol -Hyponatremia -Increased WBC -Hypercalcemia -Hypoglycemia

A hospitalized client with a sealed radioactive implant asks the nurse, "can my family visit me?" What education should the nurse provide regarding visitors?

-Limit visits to 30 minutes and have visitors maintain a six foot distance

A nurse is caring for a client who has been admitted with renal calculi. List three (3) nursing interventions necessary to manage renal calculi in this client's care.

-The nurse must strain the urine, manage pan, and increase their daily fluid intake.

a client has been diagnosed with tuberculosis and has been prescribed rifampin. What should the nurse include in teaching about this medication?

-Urine and other secretions may turn orange -Immediately report pain or swelling or joints -Report loss of appetite -This medication can interfere with oral contraceptives

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

A private room

A nurse is caring for a client who has dementia. When performing a mental status examination the nurse should include which of the following data?

Ability to perform calculations Recall ability Long-term memory level of orientation

What type of respiratory failure is caused by Guillain-Barre' syndrome?

Acute respiratory failure

​A 10-year-old presents in status asthmaticus complaining of chest tightness and has audible wheezing. Name three (3) priority actions and steps the nurse should take.

Administer beta-agonists, corticosteroids and theophylline Fluid replacement Place on 02

A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler. What instructions should the nurse include concerning use of these inhalers

Administer the albuterol inhaler prior to the beclomethasone inhaler

​The nurse is performing discharge teaching to the caregivers for a child who had a cardiac catheterization. What are three (3) teaching points the nurse should include?

Avoid baths for a few days and showers for 24 hours Drink fluids Report fevers of any tingling in legs

A 52-year-old client is admitted for severe gastritis secondary to alcohol consumption. Identify labs and diagnostics the nurse will monitor.

CBC, AST, ALT, BUN, Creatinine, H, pylori and the doctor will likely order and endoscopy

A nurse is completing discharge teaching for a client receiving disulfiram as a deterrent to drinking. What information will the nurse provide to the client regarding how it works and precautions to take?

Blocks the breakdown of alcohol in the body, which leads to a toxic alcohol-related compound that can cause people who drink alcohol while taking this medication to become very sick. Side effects associated with this are metallic taste in mouth, , headache, drowsiness and tiredness.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

​Identify three (3) clinical manifestations of hydrocephalus in an infant client

Bulging fontanel Poor feeding Rapid increase in head circumference

A nurse is caring for a client who has refused his morning medications. How should the nurse respond to the client?

Determine why they don't want to take it and if they understand what the medication if for and the potential side effects of not taking the medication.

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?

Developing a respiratory infection

​A nurse is caring for a client who is admitted to the unit for self-mutilation. What type of behavioral therapy would the nurse expect to be ordered for this client?

Dialectical behavioral therapy which is a form of cognitive behavioral therapy

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container

adverse effects of amitriptyline

Drowsiness; Dry mouth; Blurred vision; Constipation; Urinary retention; Dizziness; Delayed orgasm and low sex drive, particularly in men; Increased heart rate; Disorientation or confusion; Low blood pressure, which can cause lightheadedness; Increased appetite; Weight gain; Fatigue; Headache; Sensitivity to sunlight; Nausea; Seizures (particularly with maprotiline)Some cyclic antidepressants are more likely to cause particular side effects. For example, desipramine and protriptyline are more likely to make you sleepy than do other cyclic antidepressants. Amitriptyline and doxepin are more likely to cause weight gain than do other cyclic antidepressants. Choosing one particular cyclic antidepressant over another may help you avoid particular side effects.

A nurse is administering albumin to a client. What are three (3) clinical manifestations of circulatory overload?​

Dyspnea, orthopnea, increase in BP, peripheral and pulmonary edema and wheezing.

​The nurse is developing a teaching plan for the upcoming discharge of a child who has a resolving sickle cell crisis. While developing the plan the nurse knows it is imperative to include what information?

Educate the child and family about the importance of consuming adequate nutrition and promoting rest. Teach them about genetic counseling. Educate them to keep the immunizations up-to-date. Encourage the child to wear medical identification tags or wristband. Teach parents and child to promote good hand hygiene and avoid people who have virus/infection/cold.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Evaluate the client's neurological status

A nurse is caring for a client who has a new prescription for alosetron. What are the expected therapeutic effects of this medication?

Expected side effects are increased firmness in stool, decrease in urgency and decreased frequency of defecation.

A nurse is assessing for strabismus in a 7-year-old client. Identify three (3) clinical findings noted with strabismus.

Eyes that appear crossed or an eye that seems to wander. Uncoordinated eye movements. Asymmetric corneal light reflex

A couple is being evaluated for infertility after attempting to conceive naturally for 2 years. What are three (3) risk factors for males and three (3) risk factors for females that can affect fertility?​

Female: Age greater than 35 years old, past hx of spontaneous abortion, more than 1 year of coitus without contraceptives Male: Hx of STI, substance abuse, exposure to hazardous teratogenic

The nurse is providing education to a client with phenylketonuria who is planning her pregnancy. What foods should the nurse teach the client to consume?

Foods low in phenylalanine Foods such as fish, poultry, meat, eggs and dairy products.

The client with Klebsiella in the urine is ordered the medication ciprofloxacin. Identify three (3) complications associated with this medication the client can develop with administration of this medication.

GI upset, rupture of the Achilles tendon and superinfection

A nurse is preparing to administer the MMR immunization to a client. What are two (2) contraindications for this vaccine?

Gelatin allergy Neomycin allergy Pregnancy

​A client receiving the chemotherapeutic agent, leuprolide for treatment of prostate cancer. What is one (1) important point to discuss with the client to prevent musculoskeletal complication

Increase calcium and vitamin D intake and increase bone mass with weight-bearing exercises

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake

​A client with hypokalemia is ordered potassium chloride. Identify three (3) points to teach the client about prior to the first dose.

Instruct client to avoid salt substitutes, explain the purpose of the medication and correct administration.

A 14-year old client has been prescribed risperidone for autism spectrum disorder. What should the nurse instruct the parent of the client on how to administer the medication

It can be taken with or without food and at the same time daily

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take?

Keep familiar personal items at the bedside

List the pertinent information that should be in a transfer repor

Medical diagnosis, demographic information, overview of health status, alterations that could cause immediate concern, last set of vital signs, medication (including PRN), diet, activity, any specific equipment they may require, advanced directive and families involvement in care

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect?

Muscle distortion Pain behind the ear Impaired taste

​The 24-year-old client inquires about use of the diaphragm for birth control. What five (5) instructions would be provided by the nurse to explain use of the diaphragm?

Must be fitted by provider Replace every 2 years Apply spermicidal jelly on the cervical side Diaphragm can be in place up to 6 hr before intercourse but cannot stay in longer than 24hrs Empty the bladder prior to insertion Diaphragm can be washed with soap and water

A school nurse is teaching a group of nurses newly hired to work in the school system about pediculosis capitis (head lice). Which of the following information is appropriate to include in the teaching?

Nits that are shed into the environment are capable of hatching for up to 10 days.

What are the expected clinical manifestation associated with a herniated lumbar disk?

Numbness and weakness in the foot, leg and/or toes. Foot drop can also occur.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad on the bed under the client's leg The nurse should apply clean gloves and remove old dressing Clean the puncture site in a circular motion Open sterile dressing set and supplies Irrigate the wound until the solution becomes clear

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Place the child in isolation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side

A nurse is instructing a client who has a new prescription for nitroglycerin transdermal patch about the administration. What instructions should the nurse include?

Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate sites. Remove old patch, wash skin with soap and water, and dry thoroughly before applying new patch. Remove the patch at night to reduce the risk of developing tolerance to nitroglycerin. Be medication-free between 10 and 12 hrs daily.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision

A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?

Provide mittens for the client to wear at night

A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis?

Pruritus of the scalp

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse for dressing changes

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

Serum albumin 3.2 g/dL

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

Shake the container vigorously

A nurse is caring for a client involved in a suspected bioterrorism event involved in a suspected bioterrorism event involving exposure to cutaneous anthrax. Which of the following manifestations should the nurse anticipate?

Skin lesions with pruritus

The nurse is assessing paternal adaptation and bonding with a newborn infant. What are three (3) ways the nurse can facilitate bonding between the newborn and father?

Skin-to-skin contact, holding the infant and eye contact Talking, singing and reading to the patient

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hrs

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through the tasks one step at a time

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate?

Tell me what you like to cook for dinner

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advanced directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed concent?

The client

A nurse is assessing a client who has rea score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care

​The nurse is caring for a child with epiglottitis. What are three (3) expected findings during the assessment of this client? List three (3) nursing interventions the nurse will be expected to carry out

Tongue protruding, inspiratory stridor, anxiety with respiratory distress, sore throat, highfever, restlessness, sit with chin pointing out, and mouth open. The nurse should not examine throat or use tongue blade. Use oxygen and high humidity, maintain hydration, and maintain upright position. Use postural drainage and CPT.

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply?

Transparent dressing

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

​What are the guidelines that nurses should follow when considering whether or not a client requires restraints?

Use a restraint when there is no other option and use the least restrictive restraint first.

A nurse is planning to care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed.

​The nurse is teaching a group of parents about infant car seat safety. What are two (2) discharge teaching points the nurse should include in the parent's discharge plan on car seat safety?

Use an approved rear-facing car seat in the back seat Keep in rear-facing car seat until age 2 or until pt reached max height and weight for that seat