ATI IIIT HCP

A nurse is caring for a client who has meningitis, a temperature of 39.7C (103.5F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications. a. Dehydration b. Seizures c. Burns d. Shivering

d. Shivering Dehydration is a complication that may occur as a result of a fever, however it is not considered a complication of the hypothermia blanket therapy Seizures are a complication associated with meningitis and should be monitored in this client; however, it is not considered a complication of the hypothermia blanket therapy, burns are associated with the improper use of heating pads, not a hypothermia blanket

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI? a. The client had an appendectomy 6 months ago b. The client has bipolar disorder c. The client is a male d. The client is 71 years old

d. The client is 71 years old Decreased immune system function increases the susceptibility of infection

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. What quadrant is McBurney's point located in?

RLQ

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? a. "I will need to wipe my perineal area from back to front after urination." b. "I will need to empty my bladder regularly and completely." c. "I will need to drink apple cider vinegar each day." d. "I need to drink 8 cups of liquid each day."

a. "I will need to wipe my perineal area from back to front after urination."

A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching? a. Press water from a sponge rather than wringing it b. Turn doorknobs using a clockwise motion c. Finish weekly household tasks within 1 or 2 days d. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile

a. Press water from a sponge rather than wringing it

A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? a. Reduced joint stress b. Maintenance of joint function c. Suppression of the inflammatory process d. Decreased stiffness

a. Reduced joint stress

A nurse is caring for a child who is admitted with suspected acute appendicitis. which of the following manifestations should indicate to the nurse that the child's appendix is perforated? a. Sudden decrease in abdominal pain b. Absent Rovsing's sign c. Flaccid abdomen d. Low-grade fever

a. Sudden decrease in abdominal pain A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. however, once peritonitis sets in, the pain returns and can spread into the whole abdomen

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a. Urinary tract infection b. Urinary incontinence c. Urinary frequency d. Urinary retention

a. Urinary tract infection

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's lab values? a. WBC 17,000/mm3 b. Neutrophils 3,000/mm3 c. RBC 4.2 million/mm3 d. Lymphocytes 3,000/mm3

a. WBC 17,000/mm3 The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection

A nurse is teaching a client who has a new prescription for aspirin to treat RA. The nurse should include to monitor for which of the following adverse effects of this medication? a. Constipation b. Bleeding c. Blurred vision d. Insomnia

b. Bleeding Aspirin can cause bleeding, tinnitus, gastric ulceration, nausea, and heartburn. The client should monitor and report manifestations of bleeding, such as black tarry stools.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? a. Replace the catheter every 3 days b. Check the catheter tubing for kinks or twisting c. Irrigate the catheter once each shift d. Clean the perineal area with an antiseptic solution daily

b. Check the catheter tubing for kinks or twisting These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder

A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication? a. Reduces risk of infection b. Decreases inflammation c. Improves peripheral blood flow d. Increases bone density

b. Decreases inflammation

A nurse is reviewing the medical record of a client who has a UTI. Which of the following findings should the nurse recognize as a risk factor? a. COPD b. Diabetes mellitus c. Anemia d. Osteoporosis

b. Diabetes mellitus

A nurse is providing teaching a client who has RA and a new prescription for methotrexate. Which of the following instructions should the nurse include? (Select all that apply) a. Expect to feel the medication's effects immediately b. Do not drink alcoholic beverages while taking this medication c. Report unexplained bruising to the provider d. Avoid people who have infections e. Take NSAIDS to help minimize the adverse effects of the medication

b. Do not drink alcoholic beverages while taking this medication c. Report unexplained bruising to the provider d. Avoid people who have infections

A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include? a. Take an antiemetic 1 hr following administration b. Drink 2 to 3 L of water per day c. Take the medication with an NSAID d. Rinse mouth 2 times per day with an alcohol based mouthwash

b. Drink 2 to 3 L of water per day Methotrexate can cause renal toxicity. The client should drink 2 to 3 L of water per day to promote excretion of the medication (The client should take an antiemetic 30 to 60 min prior to administration of the methotrexate to reduce the risk for nausea and vomiting)

A nurse is assessing a client for early manifestations of RA. Which of the following changes is an early manifestation of RA? a. Morning stiffness b. Fatigue c. Temporomandibular joint pain d. Baker's cysts

b. Fatigue Fatigue, weakness, and anorexia are early manifestations of RA

A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? a. Instruct the client to take antibiotics until dysuria is no longer present b. Instruct the client to avoid drinking carbonated beverages c. Instruct the client to drink 240 mL of tomato juice each day d. Instruct the client drink 1 L of fluid each day

b. Instruct the client to avoid drinking carbonated beverages The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation

A nurse in a provider's office is assessing a client who has RA. Which of the following findings is a late manifestation of this condition? a. Anorexia b. Knuckle deformity c. Low-grade fever d. Weight loss

b. Knuckle deformity

A nurse is teaching a client who has a new prescription for ciprofloxacin to treat an uncomplicated UTI. Which of the following instructions should the nurse include? a. "Take this medication with an antacid." b. "Monitor for tendon pain." c. "Drink 1,000 mL of fluid daily." d. "Expect urine to turn dark orange."

b. Monitor for tendon pain

A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching? a. "I should take my flu vaccine within one week of starting this medication." b. "I can expect a sore throat for the first week after starting this medication." c. "I should eat more bananas while taking this medication." d. "I should take aspirin for minor aches and pains while taking this medication."

c. "I should eat more bananas while taking this medication." The nurse should instruct the client to eat more potassium-rich foods such as bananas and citrus fruits while taking this medication. Prednisone can cause a loss of potassium, and the nurse should instruct them about the manifestations of hypokalemia such as muscle weakness and cramping and to notify the provider should these occur.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. Hypotension b. Numbness c. Shivering d. Reduced blood viscosity

c. Shivering

A nurse is teaching a client who is starting to take methotrexate to treat RA. Which of the following instructions should the nurse include in the teaching? a. "Avoid eating foods high in vitamin K." b. "Use an alcohol-based mouthwash after each meal." c. "Take the medication daily." d. "Drink at least 2 liters of water daily."

d. "Drink at least 2 liters of water daily." The client should drink 2 to 3 L of water per day because methotrexate can cause kidney damage. Adequate hydration optimizes drug excretion and helps prevent renal damage

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify? a. Maintain NPO status b. Monitor oral temperature every 4 hr c. Medicate the client for pain every 4 hr as needed d. Administer sodium biphosphate/sodium phosphate

d. Administer sodium biphosphate/sodium phosphate enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? a. Pernicious aneia b. Dehydration c. Prostate enlargement d. Bladder infection

d. Bladder infection The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection

A nurse is caring for an adult client who has a UTI. Which of the following manifestations should the nurse identify as a finding specifically associated with this client? a. Urinary retention b. Low back pain c. Incontinence d. Confusion

d. Confusion

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? a. WBC count b. Rheumatoid factor (RF) c. Antinuclear antibody (ANA) d. Erythrocyte sedimentation rate (ESR)

d. Erythrocyte sedimentation rate (ESR) Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases