ATI Comprehensive Online Practice 2019 A
Nationally notifiable infectious conditions
-Foodborne botulism NOT -cytomegalovirus (CMV) -Erythema infectiosum -HSV-1
A nurse is providing teaching to a prevent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. -Remove the soiled dressing -Remove the inner cannula -Clean the stoma with 0.9% sodium chloride irrigation -Change the tracheostomy collar
ANSWER: -Remove the inner cannula -Remove the soiled dressing -Clean the stoma with 0.9% sodium chloride irrigation -Change the tracheostomy collar
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? A. Withdraw the catheter if the client begins coughing B. Apply suction for 10 seconds C. Advance the catheter 2 cm (0.8 in) after resistance is met D. Use medical asepsis when performing the procedure
CORRECT: Apply suction for 10 seconds Rationale: The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss. Rationale A: Suctioning can initiate the cough reflex as it opens the airway further and allows for more effective removal of mucus. Rationale C: Once resistance is met, the nurse should withdraw the catheter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissues. Rationale D: The nurse should use surgical asepsis when suctioning a newly created tracheostomy to reduce the risk for infection.
Herpes simplex virus (HSV)
Contact precautions
Infant reflexes
Rooting reflex: stroke the infant's cheek to assess the rooting reflex, which should cause the infant to turn towards that side and suck Extrusion reflex: Depress the infant's tongue to assess the extrusion reflex, which should cause the infant to stick out their tongue Asymmetric tonic neck reflex: Turn the infant's head to one side to assess, which should cause the infant to extend her arm and leg on that side and flex her arm and leg on the other side Glabellar reflex: Tap on the bridge of the infant's nose to assess, which should cause the infant to close her eyes tightly
A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? SATA -Nystagmus -Facial flushing -Diplopia -Nasal congestion -Headache
ANSWER: -Facial flushing Rationale: Flushing occurs from the point of the lesion upward -Nasal congestion -Headache Rationale Nystagmus: The nurse should expect the p/t experiencing spots in the visual field (not nystagmus) Rationale Diplopia: Blurred vision should be expect (not diplopia)
A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? A. "I should administer the ear drops as soon as I remove them from the refrigerator." B. "I should pull the top of the ear upward and back while instilling the medication." C. "I should massage behind the ear after I instill the drops." D. "I should have my child lie on the affected side for a few minutes after I put the drops in the ear."
ANSWER: "I should pull the top of the ear upward and back while instilling the medication." Rationale: The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back. Rationale A: The nurse should instruct the parent to allow otic medication stored in the refrigerator to warm to room temperature prior to administration to prevent dizziness and pain. Rationale C: The nurse should instruct the parent to gently massage the tragus on the area anterior to the ear to allow the medication to reach the entire canal. Rationale D: The nurse should instruct the parent to have the child remain lying on the unaffected side for a few minutes after instilling the medication to allow the medication to remain in the ear canal.
A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? A. "I should report a change in the color of my stools." B. "I can take acetaminophen to treat a headache." C. "I will take a calcium supplement while taking this medication." D. "I will return in a month to have my blood tested."
ANSWER: "I should report a change in the color of my stools." Rationale: The nurse should inform the client that red, black, or tarry stools can indicate bleeding, and adverse effect of warfarin, and the client should report these findings to the provider. Rationale B: The nurse should inform the client that taking acetaminophen can increase the risk of bleeding. Rationale C: The nurse should inform the client that calcium supplements are not indicated while taking warfarin; however, the client should maintain consistent intake of foods containing vitamin K Rationale D: The nurse should provide instructions to the client regarding monitoring requirements of the medication, including daily blood draw for the first 5 days to establish appropriate warfarin dosage
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? A. While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client. B. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. C. The newly licensed nurse uses a penlight to assess for changes in the contour of the body. D. The newly licensed nurse uses the dorsal surface of the hand to assess skin temperature.
ANSWER: The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. Rationale: The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment. Rationale A: Discussing self-examination techniques with the client while performing the breast examination provides the opportunity to demonstrate correct technique. Rationale C: The newly licensed nurse should use a penlight to provide adequate lighting when assessing contours. Rationale D: The newly licensed nurse should use the dorsal surface of the hand to assess skin temperature because it is sensitive to temperature changes.
A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO3 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? A. Uncompensated metabolic acidosis B. Uncompensated respiratory acidosis C. Compensated respiratory acidosis D. Compensated metabolic acidosis
ANSWER: Uncompensated respiratory acidosis Rationale: A pH of 7.3 is below the expected reference range and indicates the client has acidosis. The PaCO2 of 54 mm Hg is above the expected range, which, when combined with the low pH indicates that the acidosis has a respiratory origin. The HCO3 of 26 mEq/L is within the expected reference range, indicating that the acidosis is not metabolic in origin and the body has not yet corrected the imbalance through compensation. Rationale A: An HCO3 of 26 mEq/L is within the expected reference range. In metabolic acidosis, the HCO3 and the pH are below the expected reference range. Therefore, these laboratory values do not indicate metabolic acidosis. Rationale C: In compensated respiratory acidosis, the pH is within the expected reference range. The laboratory values do not indicate compensation has occurred. Rationale D: An HCO3 of 26 mEq/L is within the expected reference range. IN compensated metabolic acidosis the HCO3 is below the expected reference range and the pH is within the expected reference range. Therefore, these laboratory values do not indicate metabolic acidosis.
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? A. "I should avoid eating smoked meat, cheeses. and ripe avocados while taking this type of medication." B. "I should watch for common reactions like dry mouth and constipation." C. "I will be at increased risk for high blood pressure while taking this medication." D. "I will take my daily dose of this medication every morning before breakfast.:
ANSWER: "I should watch for common reactions like dry mouth and constipation." Rationale: The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation. Rationale A: A client who is taking an MAOI should avoid foods that contain tyramine. Rationale C: Clients who are taking amitriptyline should monitor for hypotension and change positions slowly. Rationale D: The client should take a daily dose of amitriptyline, a tricyclic antidepressant, at bedtime to promote sleep and minimize drowsiness during the day.
A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? A."I can resume my daily aspirin therapy." B. "I will contact my provider if my eye feels itchy." C. "I will bend at my knees when picking an object up off the floor." D. "It's okay for me to pick up my grandchild who weighs 20 pounds."
ANSWER: "I will bend at my knees when picking an object up off the floor." Rationale: The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object. Rationale A: The client should avoid taking aspirin because its an anticoagulant effect. Rationale B: The nurse should instruct the client to expect eye itching and recommend the use of a cool compress to ease the discomfort of the itching. Rationale D: The client should avoid lifting anything that weighs more than 45 kg (10 lb) because it can increase intraocular pressure and damage the suture of the new lens.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? A. "Place your baby's care seat at a 30-degree angle." B. "Your baby's care seat should be rear-facing until he is 6 months old." C. "Swaddle your baby in a light blanket before placing him in the car seat." D. "Secure the retainer clip at the level of your baby's armpits."
ANSWER: "Secure the retainer clip at the level of your baby's armpits." Rationale: The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs. Rationale A: The nurse should instruct the parent to place the newborn's car seat at a 45 degree angle. Newborns' heads are large in proportion to their body and they do not have the muscle strength to hold their heads upright. Rationale B: The nurse should instruct the parent that the newborn should remain rear-facing in the back seat of the vehicle until the age of 2 or until reaching the age and weight the car seat manufacturer recommends. In a collision, this position decreases the force on the newborn's head and neck. Rationale C: The nurse should instruct the parent to place a blanket over the newborn once secure in the car seat. Blankets, coats, or heavy clothing can make it difficult to secure the shoulder harnesses tightly, leading to injury in the event of a collision.
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? A. "If you suspect you are pregnant, stop taking this medication." B. "You cannot become physically dependent on this medication." C. "Sedation is common adverse effect of this medication." D. "If you forget a dose, you can double your next."
ANSWER: "Sedation is a common adverse effect of this medication." Rationale: Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases. Rationale A: A client can take methadone to treat opioid withdrawal symptoms during pregnancy. Rationale B: A client can develop physical dependency with long-term use of methadone. Rationale D: Methadone can cause respiratory depression. The client should not take more than the prescribed dose at any time.
A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? A. "Set your hot water heater temperature at or below 120 degrees Fahrenheit." B. "Cover your baby with a light blanket while sleeping." C. "Make sure the slats on the baby's crib are no more than 3 inches apart." D. "Place your baby's car seat rear-facing until the age of 1 year old."
ANSWER: "Set your hot water heater temperature at or below 120 degrees Fahrenheit." Rationale: The nurse should instruct the client to set the maximum hot water temperature to no more than 49 C (120 F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn. Rationale B: The nurse should instruct the client that there should not be blankets, pillows, or stuffed toys in the newborn's crib. These items increase the risk for suffocation. The client should dress the newborn in a sleep sack or one-piece sleeper for naps and nighttime sleeping. Rationale C: The nurse should instruct the client that the crib slats should be no more than 5.7 cm (2.25 in) apart. Slats that are further apart increase the risk of injury. Rationale D: The nurse should instruct the client that the newborn's car seat should remain rear-facing until the age of 2 years old or the child exceeds the height and weight limit of the care seat according to the manufacturer. Maintain a rear-facing position decreases the risk of head and neck injuries to the child in the event of a collision.
A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? A. "Estrogen levels decrease during pregnancy, causing the stool to become hardened." B. "Decreased water absorption in the intestine during pregnancy causes constipation." C. "The intestine absorbs iron less efficiently during pregnancy, leading to constipation.: D. "The enlarged uterus compresses the intestines and causes constipation."
ANSWER: "The enlarged uterus compresses the intestines and causes constipation." Rationale: During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of intestines. These changes cause a decrease in motility, leading to constipation. Rationale A: Estrogen and progesterone levels increase during pregnancy, leading to decreased peristalsis and relaxation of the smooth muscles of the intestine, which can result in constipation. Rationale B: The intestine absorbs more water from the stool during pregnancy, leading to constipation. Rationale C: The small intestine absorbs iron more readily during pregnancy due to increased maternal needs, leading to constipation.
A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? A. "There's a protocol for reviewing your medical record, and I can initiate the process." B. "The medical record has a lot of medical terminology, and it might be difficult for you to understand." C. "You should really talk to your provider if you have any questions about your treatment." D. "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see."
ANSWER: "There's a protocol for reviewing your medical record, and I can initiate the process." Rationale: The client's record is the legal property of the facility, but the client has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the client with access to the medical record. Rationale B: The nurse is making a value judgment. which can make the client feel belittled and unworthy of the information. Rationale C: The nurse is violating the client's rights by rejecting the request, and this response also dismisses the client's concerns, which can make the client feel rejected. Rationale D: The nurse is giving inaccurate information, which violates the client's rights and causes confusion.
A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? A. "You should leave your glasses throughout the testing." B. "You should stand 15 feet away from the chart." C. "You should get three symbols on a line correct to pass the line." D "You should keep both eyes open during the testing."
ANSWER: "You should keep both eyes open during the testing." Rationale: The nurse should instruct the child to keep both eyes open during visual acuity testing. Rationale A: The nurse should screen the child with visual correction first, then repeat the screening without visual correction. Rationale B: The nurse should instruct the child to stand 3 m (10 feet) away from the chart during testing. Rationale C: The nurse should tell the child that in order to pass a line, the child should identify four of the six symbols correctly.
A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? A. "This type of nutrition is more effective than eating by mouth.: B. "You will receive fingersticks for blood glucose testing." C. "TPN is a way to provide vitamins and minerals without increased calories." D. "Taking TPN can increase the risk of developing a latex allergy."
ANSWER: "You will receive fingersticks for blood glucose testing." Rationale: A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring. Rationale A: The client should receive oral or enteral nutrition whenever possible because it enhances the immune system and maintains intestinal motility. However, the client should receive TPN when nutritional needs are greater than oral or enteral nutrition can provide, such as in a client who has burn injuries. Rationale C: TPN provides calories to clients who are unable to eat or who do not have a functioning gastrointestinal tract. A client who has a burn injury is in a hypermetabolic state and requires additional calories, carbohydrates, proteins, and fats. Rationale D: The nurse should check the client for an egg allergy, because this can result in an intolerance of the lipid solution and many lipids are composed of egg phospholipids.
A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? A. 1 medium raw carrot B. 1/2 cup cooked spinach C. 1/2 cup cooked butternut squash D. 1 cup sliced cantaloupe
ANSWER: 1 medium raw carrot Rationale: The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of vitamin A and is therefore the best food to recommend to the client. Rationale B: The nurse should recommend a different food, because 1/2 cup cooked spinach contains 737 mcg/dL of vitamin A. Rationale C: The nurse should recommend a different food, because 1/2 cup cooked butternut squash contains 714 mcg/dL of vitamin A> Rationale D: The nurse should recommend a different food, because 1 cup sliced cantaloupe contains 516 mcg/dL of vitamin A.
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. A client who has a temperature of 38.2 C (100.8 F) and requests a cup of ice chips B. A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10. C. A client who has voided and is ready for a bladder scan. D. A client who is confused and has been attempting to get out of bed.
ANSWER: A client who is confused and has been attempting to get out of bed Rationale: The nurse should recognize that a client who is confused and has been attempting to get out of bed is at greatest risk for injury from a fall. Therefore, the nurse should attend to this client first. Rationale A: The nurse should provide ice chips to this client to provide hydrations. However, there is another client the nurse should attend to first. Rationale B: The nurse should recognize this as a moderate pain level and administer pain medication to maintain a level of comfort. However, there is another client the nurse should attend to first. Rationale C: The nurse should perform the bladder scan to determine the amount of residual urine. However, there is another client the nurse should attend to first.
A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? SATA A. "A speech pathologist will be performing a swallowing study for you." B. "You should rest before eating a meal." C. "You should restrict foods that are high in vitamin D." D. "Reduce your intake of dietary fiber." E. "Thicken your beverages before drinking."
ANSWER: A, B, E Rationale A: The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. Rationale B: The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued. Rationale C: The nurse should instruct the client to maintain adequate vitamin D levels, because vitamin D deficiency is a risk factor for multiple sclerosis. Rationale D: The nurse should instruct the client to increase dietary fiber and fluids to decrease the risk of constipation, which is a manifestation of multiple sclerosis. Rationale E: The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis.
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? A. Notify the provider if a thrill is palpated at the fistula B. Auscultate the affected extremity for a bruit C. Discourage range-of-motion exercises in the affected extremity. D. Perform venipuncture in the affected extremity.
ANSWER: Auscultate the affected extremity for a bruit. Rationale: The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency. Rationale A: The nurse should expect to palpate a thrill at the AV fistula, which indicates patency. The nurse should report the absence of a thrill to the provider. Rationale C: The nurse should encourage the client to perform range-of-motion exercises in the affected extremity to maintain muscle strength. Rationale D: The nurse should not perform a venipuncture in the client's affected extremity to prevent circulatory complications
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Slightly blue hands and feet B. Respiratory rate 40/min C. Axillary temperature 36.2 C (97.2 F) D. Apical pulse 136/min
ANSWER: Axillary temperature 36.2 C (97.2 F) Rationale: The expected reference range for the axillary temperature of a newborn is between 36.5 C to 37.5 C (97.7 F to 99.5 F). An axillary temperature of 36.2 C (97.2 F) or below in a newborn who is 2 hr old indicates cold stress and should be reported to the provider. Rationale A: Acrocyanosis, or slightly blue hands and feet, is an expected finding for a newborn who is 2 hr old. Rationale B: A respiratory rate of 40/min is within the expected reference range of 30 to 60/min for a newborn who is 2 hr old. Rationale D: An apical pulse of 136/min is within the expected reference range for a newborn who is 2 hr old. The newborn pulse rate can range from 80 to 100/min when asleep and up to 180/min when crying.
A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? A. Keep the client resting in bed. B. Ask the client to restate directions. C. Clear objects from the client's walking area. D. Evaluate the client's ability to swallow.
ANSWER: Clear objects form the client's walking area. Rationale: The nurse should plan to clear objects from the client's walking area because CN II is the optic nerve and a deficit can result in visual impairment which can lead to falls. Rationale A: A client who has a CN II deficit does not require bed rest but should have assistance when out of bed. Rationale B: The nurse should plan to ask clients to restate directions if they have a CN VIII deficit because CN VIII affects hearing. Rationale D: The nurse should plan to evaluate the swallowing ability of clients who have a CN IX deficit because it can impair swallowing.
A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? A. Lethargy B. Diaphoresis C. Bradycardia D. Cough
ANSWER: Diaphoresis Rationale: Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lower inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects. Rationale A: Lethargy is not an expected finding of MDMA use. Rationale C: Bradycardia is not an expected finding of MDMA use. Rationale D: Cough is not an expected find of MDMA use.
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? A. Encourage the parents to bring toys from home B. Use a visual analog scale to rate the toddler's pain C. Inform the toddler about the procedure 1 week before hospitalization D. Stress to the parents the need for maintaining the hospital's daily routine
ANSWER: Encourage the parents to bring toys from home Rationale: To help decrease the toddler's anxiety, the nurse should encourage the family to bring familiar objects from home, such as toys, blankets, and feeding utensils. Rationale B: The visual analog scale is appropriate for children who are 8 years and older Rationale C: Toddlers have a limited ability to understand concepts of time. The parents should inform the toddler about the procedure shortly before or immediately before it occurs. Rationale D: The toddler will adjust to the hospitalization best if the routine mirrors their home schedule.
A nurse is preparing to administer 2 units of fresh frozen plasma to a client Which of the following actions should the nurse plan to take? A. Allow the plasma to warm for 30 min before transfusion B. Confirm the client's identification by checking the room number C. Enter the plasma product number into the client's medical record D. Administer each unit of plasma over 4 hr.
ANSWER: Enter the plasma product number into the client's medical record. Rationale: The nurse should complete documentation following blood product therapy, which includes recording the type of product, amount administered, product number, infusion time, and client response. Rationale A: The nurse should transfuse the plasma immediately after obtaining it from the blood bank to maintain integrity of the clotting factors. Rationale B: The nurse should confirm the client's identification by verifying that the client's name and facility-assigned number on the identification bracelet match the information provided on the units of plasma. Rationale D: The nurse should plan to administer each unit of plasma over 30 to 60 min. The nurse should slow the rate of infusion if the client shows indications of fluid overload.
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? A. Encourage the client's problem-solving abilities. B. Discuss the client's previous experience with loss C. Promote the client's self-esteem D. Establish the termination date of therapy
ANSWER: Establish the termination date of therapy Rationale: This task occurs in the orientation phase of a therapeutic relationship Rationale A: This task occurs in the working phase of a therapeutic relationship. Rationale B: This task occurs working phase of a therapeutic relationship. Rationale C: This task occurs in the working phase of a therapeutic relationship.
A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? A. Fever unresponsive to antipyretics B. Pain in weight-bearing joints C. Decreased heart rate D. Peeling of the soles of the feet
ANSWER: Fever unresponsive to antipyretics Rationale: The nurse should expect a child who has acute Kawasaki disease to have a high fever that is unresponsive to antibiotics or antipyretics. Rationale B: The nurse should expect the child to report pain in the weight-bearing joints during the subacute phase of Kawasaki disease. Rationale C: The nurse should expect tachycardia during the acute phase of Kawasaki disease. Rationale D: The nurse should expect peeling of the palms of the hands and soles of the child's feet during the subacute phase of Kawasaki disease.
A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? A. Ensure that the staff nurse changes the dressing. B. Notify the nurse manager. C. Complete an incident report. D. Gather more information about the staff nurse's actions.
ANSWER: Gather more information about the staff nurse's actions. Rationale: The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action. Rationale A: It is the charge nurse's role to advocate for the client to receive the care the provider prescribed. However, this is not the first action the charge nurse should take. Rationale B: The charge nurse should notify the nurse manager that the occurrence happened. However, this is not the first action the charge nurse should take. Rationale C: The charge nurse should complete an incident report describing the occurrence. However, this is not the first action the charge nurse should take.
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? A. Decreased acuity B. Hemoptysis 275 mL/24 hr C. Fever D. Weight loss 2.3 kg (5 lb)
ANSWER: Hemoptysis 275 mL/24 hr Rationale: Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report. Rationale A: The nurse should report decreased activity to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. Rationale C: The nurse should report fever to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. Rationale D: The nurse should report anorexia and weight loss to the provider because it can be an indication of pulmonary infection. However, another finding is the priority.
A nurse is assessing a client who has obstructive sleep apnea. For which of the following complication should the nurse monitor? A. Weight loss B. Urinary retention C. Hypertension D. Hypoglycemia
ANSWER: Hypertension Rationale: The nurse should assess the client for hypertension, a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias. Rationale A: The nurse should identify weight gain as a risk factor for obstructive sleep apnea and provide recommendations for weight control to the client to reduce manifestations. Rationale B: The nurse should expect the client to develop enuresis, rather than urinary retention, as an expected finding of obstructive sleep apnea. Rationale D: The nurse should not expect hypoglycemia. The nurse should monitor the client for decreased oxygen levels.
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? A. Include chicken broth in the toddler's diet. B. Feed the toddler the BRAT diet. C. Initiate oral rehydration therapy for the toddler. D. Offer the toddler flavored gelatin.
ANSWER: Initiate oral rehydration therapy for the toddler. Rationale: Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed. Rationale A: The nurse should identify that chicken and beef broths contain excessive amounts of sodium and very few carbohydrates Rationale B: The BRAT diet (bananas, rice, applesauce, and toast) contains little nutritional value, inadequate amounts of protein and electrolytes, and is high in simple carbohydrates. It is contraindicated for a child who has acute diarrhea. Rationale D: Gelatin is high in carbohydrates, low in electrolytes, and high in osmolality, which can prolong diarrhea and electrolyte imbalance.
A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? A. Install a raised toilet seat at home. B. Maintain the hip at an angle greater than 90 degrees. C. Minimize the use of a walker. D. Place pillow under the knees when lying down.
ANSWER: Install a raised toilet seat at home. Rationale: The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation Rationale B: The client should maintain the hip at an angle less than 90 degrees when sitting to minimize hip flexion and prevent hip dislocation. Rationale C: The client should use a walker to minimize the risk of falls or injury. Rationale D: The client should not have a pillow under the knees when lying down, because it can impede circulation and result in flexion contractures.
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? A. Provide the infant with 1 cup of cereal. B. Give the infant 240 mL (8 oz) of juice per day C. Introduce new foods one at a time over 5 to 7 days D. Give whole milk first, then small amounts of solid food
ANSWER: Introduce new foods one at a time over 5-7 days Rationale: The parents should introduce new foods one at a time over 5-7 days to identify potential food allergies Rationale A: Infants' portion sizes in general should be 1 Tbsp per year of age. For infants under 12 months of age, 1/2 to 3/4 Tbsp is appropriate Rationale B: The parents should offer the infant 100% fruit juice, not to exceed 120 to 180 mL (4-6 oz) per day, after 6 months of age Rationale D: The parents should not offer the infant whole milk, because the majority of the infant's calories should come from human milk or commercial, iron-fortified formula
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? A. Instills 100 mL of air into the NG tube after checking for residual. B. Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr C. Adds 20 mL of blue dye to each feeding to help detect aspiration D. Keeps the head of the bed elevated to 45 degrees for 1 hr after feedings
ANSWER: Keeps the head of the bed elevated to 45 degrees for 1 hr after feedings Rationale: The nurse should keep the client's head elevated to 30 degrees to 45 degrees for 1 to 2 hr after feedings to decrease the risk for aspiration. Rationale A: The nurse should inject 10 to 30 mL of air into the NG tube before checking for residual to clear the tube of any feeding. Instilling excessive air into the tube can cause abdominal distention and discomfort. Rationale B: The nurse should use 20 mL of tap water to flush the NG tube before and after each feeding. Using 0.9% sodium chloride irrigation can lead to hypernatremia. Rationale C: The nurse should avoid adding dye to the feeding to detect aspiration because using dye can increase the risk of complications.
A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? A. Mark the edges of stairs for contrast. B. Cover exposed extension cords with throw rugs. C. Use 40-watt bulbs in lighting fixtures. D. Instruct the client to obtain vision testing once every other year.
ANSWER: Mark the edges of stairs for contrast. Rationale: Marking the edges of stairs with pain or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls. Rationale B: Extension cords should be removed form high-traffic areas in the home and placed along the edges of walls. Placing cords under throw rugs can increase an older adult client's risk for falls. Rationale C: The nurse should ensure that an older adult client's home has adequate lighting. This includes the use of light fixtures that can use at least 75-watt bulbs to optimize the client's visibility. Rationale D: The nurse should instruct older adult clients to receive vision testing at least once each year. For the client who has impaired vision, it might be necessary for the nurse to recommend vision testing more often.
A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? A. Constipation B. Nausea C. Wheezing D. Muscle rigidity
ANSWER: Nausea Rationale: The nurse should instruct the client to monitor for and report manifestations of digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes. Rationale A: The nurse should inform the client that diarrhea, rather than constipation, is a manifestation of digoxin toxicity. Rationale C: The nurse should inform the client that wheezing is a manifestation of anaphylaxis, not digoxin toxicity. Rationale D: The nurse should inform the client that muscle weakness, rather than rigidity, is a manifestation of digoxin toxicity.
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? A. Liver B. Oranges C. Chicken D. Red wine
ANSWER: Oranges Rationale: A client who is prone to uric acid calculi formation can eat citrus fruits. Rationale A: A client who is prone to uric acid calculi should avoid eating organ meats, which contain purine. Rationale C: A client who is prone to uric acid calculi should avoid eating chicken, which contains purine. Rationale D: A client who is prone to uric acid calculi should avoid consuming red wines, which contain purine.
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? A. Persistent uterine contractions B. Bright red vaginal bleeding C. Hyperactive deep-tendon reflexes D. Fundal height of 40 cm
ANSWER: Persistent uterine contractions Rationale: The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding Rationale B: The nurse should expect a client who has placenta previa to experience a relaxed uterus and bright red vaginal bleeding. With abruptio placentae the nurse should expect to find dark red vaginal bleeding Rationale C: The nurse should expect a client who has preeclampsia to have hyperactive deep-tendon reflexes Rationale D: The nurse should expect a client who has placenta previa to have a fundal height that is greater than expected gestational age
A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actins should the nurse take? A. Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. B. Dampen the skin before applying the skin barrier and ostomy pouch. C. Place the skin barrier over the stoma and hold it for 30 seconds. D. Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma.
ANSWER: Place the skin barrier over the stoma and hold it for 30 seconds. Rationale: The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. Rationale A: The nurse should cleanse the skin at the stoma site using a washcloth and warm water to reduce the risk of skin irritation. Rationale B: The nurse should thoroughly dry the skin around the stoma using a patting motion before applying the skin barrier to ensure the pouch adheres to the client's skin. Rationale D: The nurse should cut the skin barrier opening no more than 0.3 cm (0.13 in) larger than the stoma to reduce the risk of skin irritation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? A, Administer the TPN solution at the same rate using manual drip tubing. B. Offer the client oral fluids in place of TPN solution C. Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr D. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr
ANSWER: Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr Rationale: The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN solution. Rationale A: The nurse should administer the TPN solution using an infusion pump to deliver it at a controlled rate and reduce the risk of hyperglycemia. Rationale B: The nurse should continue to provide fluids by IV infusion to a client who has been receiving a continuous TPN infusion to prevent rebound hypoglycemia. Rationale C: The nurse should infuse an IV solution that will maintain adequate blood glucose levels to reduce the risk for hypoglycemia.
A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? A. Carotid Bruit B. Tracheal deviation C. Pulsus paradoxus D. Heart murmur
ANSWER: Pulsus paradoxus Rationale: The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration that inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension Rationale A: The nurse should expect to hear a carotid bruit when assessing a patient who has atherosclerosis Rationale B: The nurse should expect to assess tracheal deviation in a client who has pneumothorax Rationale D: The nurse should expect to auscultate muffled heart sounds, which are an expected finding of cardiac tamponade, along with fatigue and dyspnea
A nurse is assessing a client who has delirium. Which manifestation should the nurse expect? A. Projecting blame B. Excessive clinging C. Rapid speech D. Social awkwardness
ANSWER: Rapid speech Rationale: Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns Rationale A: Paranoid personality disorder projects blame Rationale B: Dependent personality disorder demonstrates excessively clinging behavior Rationale D: Schizotypal personality disorder exhibit social awkwardness
A nurse is working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? A. Report of persistent constipation B. Hgb 14 g/dL C. Albumin 4.2 g/dL D. Recent weight loss
ANSWER: Recent weight loss Rationale: Weight loss can increase the risk for pressure injury. Inadequate nutrition will cause decreased nutrients for the skin and tissues and increases the chance for shearing against the bony prominences. Rationale A: Diarrhea and exposure to stool place the client at risk for developing a pressure injury. Rationale B: The client's Hgb level is an indication of nutritional status. This value is within the expected range for an adult client. A decreased hemoglobin level indicates poor delivery of oxygen to the tissues, which is a risk factor for impaired skin integrity. Rationale C: The client's albumin level is an indication of nutritional status. This value is within the expected reference range for an adult client. A decreased albumin level indicates inadequate nutrition, which is a risk factor for impaired skin integrity.
A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first? A. Ask a social worker to identify the client's insurance eligibility for rehabilitation services. B. Request a referral for the client to receive physical therapy. C. Arrange for the delivery of prescribed medications to the client's home. D. Provide the client with a list of community resources.
ANSWER: Request a referral for the client to receive physical therapy. Rationale: The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy. Rationale A: The nurse should ask a social worker to determine the client's insurance eligibility for rehabilitation services to enable continuity of care closer to the time of discharge. However, there is another action the nurse should take first. Rationale C: The nurse should arrange for the delivery of prescribed medications to the client's home to ensure the client has the medications available. However, there is another action the nurse should take first. Rationale D: The nurse should provide the client with a list of community resources once the health care team establishes which services will be used for rehabilitation. However, there is another action the nurse should take first.
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? A. Displacement B. Regression C. Suppression D. Sublimation
ANSWER: Sublimation Rationale: The client is exhibiting behaviors consistent with sublimation, which is displaced when a client substitutes socially unacceptable behavior for acceptable behavior Rationale A: Displacement occurs when a client transfers emotions of a particular situation to another nonthreatening situation Rationale B: Regression occurs when a client reverts to a childlike pattern of behavior that might have been exhibited previously Rationale C: Suppression is the denial of a disturbing feeling or situation
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? A. The client reports leg itching under the cast around the mid-upper thigh area. B. The client reports increased pain when the leg is lowered below the level of the heart. C. The client's cast became wet during a sponge bath. D. The client's heel is reddened and tender.
ANSWER: The client's heel is reddened and tender. Rationale: The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse nurse should identify is a reddened and tender heel. Rationale A: The client is at risk for dry, itching skin so the nurse should offer the client a hair dryer to use on the cool setting to blow air on the skin to relieve the itching. However, there is another finding that is priority. Rationale B: The client is at risk for swelling that can cause pain when the leg is in the dependent position so the nurse should elevate the client's leg to reduce edema and pain. However, there is another finding that is priority. Rationale C: The client is at risk for skin breakdown caused by a wet cast so the nurse should make sure the cast is completely dry to reduce the risk of skin breakdown. A fiberglass cast is waterproof, and water will not affect the integrity of the cast. However, there is another finding that is the priority.
A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8lbs) and is being breastfed. Which of the following findings indicates effective breastfeeding? A. The newborn nurses every 4 hr during the day and sleeps through the night. B. The newborn has six to eight wet diapers per day C. The newborn's current weight is 3.18 kg (7 lb) D. The newborn has sticky, greenish stools
ANSWER: The newborn has six to eight wet diapers per day Rationale: Measuring the number of wet diapers per day is an effective measurement of adequate intake. Six to eight wet diapers each day after the fourth day of life indicates effective breastfeeding. Rationale A: Measuring duration and frequency of nursing is not an effective way to evaluate the effectiveness of breastfeeding. Rationale C: A newborn is expected to gain 20 to 28 (0.04 to 0.06 lb) per day after the fourth or fifth day and surpass the birth weight in 10-14 days. Slow weight gain can be an indication of ineffective breastfeeding. Rationale D: The breastfed newborn's stool should be yellow, soft, and seedy by the end of the first week of life. Newborns who continue to have meconium in their stool after the first week of life should be evaluate for ineffective breastfeeding
A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG in place. Which of the following actions should the nurse take? A. Instill chilled lavage solution into the client's NG tube. B. Attach the client's NG tube to low intermittent suction C. Use 0.9% sodium chloride for irrigation of the NG tube D. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time
ANSWER: Use 0.9% sodium chloride for irrigation of the NG tube. Rationale: The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube Rationale A: The nurse should use lavage solution that is a t room temperature to reduce the risk of injury to the client. Rationale B: After instilling the lavage solution, the nurse should manually withdraw the solution and blood from the client's NG tube. Rationale D: The nurse should instill the solution in volumes of 200 to 30 mL at a time to reduce the risk of injury to the client
