ATI level 4 abc

A nurse is reviewing the laboratory values of a client who has Addison's disease. Which of the following findings should the nurse expect?

-Potassium 6.2 Hypercalcemia Hyperkalemia Hypoglycemia Hyponatremia

A nurse in an emergency department is caring for four clients. Which of the following clients should the nurse identify as requiring mandatory reporting?

A child who is accompanied by a parent to be treated for patterned burns on the arm

A triage nurse is prioritizing clients following a mass casualty disaster. Which of the following clients should the nurse treat first?

A client who is exhibiting manifestations of shock

A risk manager is reviewing incident reports. Which of the following incidents should the risk manager identify as a sentinel event?

A nurse discovers an IV extravasation of a vesicant medication

A nurse is assessing a client who has sepsis with systemic inflammatory response syndrome (SIRS). Which of the following findings should the nurse expect? SATA

Accelorated heart rate greater than 90/min (100/min) WBC 14000 (WBC greater than 12,000) Systolic blood pressure of less than 90 Platelet count of 70,000 (platelet count of less than 100,000) Absent bowel sounds

A nurse is planning care for a client who has viral encephalitis and is starting to take IV acyclovir. Which of the following interventions should the nurse include in the plan?

Administer over an hour Monitor kidney function studies after infusing the medication Use reconstituted solution within 24 hours Increase fluids by 2,000-3,000 for the first 2 hours after the medication is infused

A nurse is working on an inter professional collaboration plan of care for a client who has a stage III pressure ulcer. Which of the following actions should the nurse recognize as the role of a licensed practical nurse?

Administer pain medication

A nurse manager is teaching a group of nurses about professional negligence. Which of the following situations should the nurse manager include as an example?

Administering heparin to a client who is undergoing a lumbar puncture

A nurse manager is teaching a unit nurse about case management. Which of the following information should the nurse manager include in the teaching about the role of the nurse as a case manager?

Advocates for services the client needs

A nurse is teaching about managing care with the family of a client who has Parkinson's disease and takes dopamine. Which of the following information should the nurse include in the teaching?

Allow the client to perform ADL's Monitor for orthostatic hypotension high protein/high carb diet late morning/afternoon appointments to prevent rushing and fatigue

A nurse is teaching a client who has deep vein thrombosis and is receiving heparin injections. The nurse should instruct the client to report which of the following manifestations as an adverse effect of the medication?

An increase in nosebleeds

A nurse is caring for a client who is 6 hr postoperative following a total knee replacement. Which of the following actions should the nurse take to prevent pulmonary embolism?

Apply compression stockings to both of the client's legs

A nurse is caring for a client who has an adrenal gland disorder. which of the following actions should the nurse take? History/physical: Cushing's Disease: Striae on abdomen and thighs Bruising on lower extremities Open sore on ankle with cellulitis Acne on face and chest Potassium 4.6 Sodium 149 BUN 20 Hgb 12.8 Hct 42% Bounding peripheral pulses Distended neck veins Edema across sacrum

Apply pressure reducing overlay on the client's mattress

A nurse is teaching a client who had an organ transplant about cyclosporine therapy. Which of the following instructions should the nurse include in the teaching?

Avoid drinking grapefruit juice Is a lifelong therapy to prevent rejection Dental examinations every 3 months Report dark brown urine

A nurse is providing teaching to a client who has a halo device applied to prevent further cervical spinal cord injury following a diving accident. Which of the following information should the nurse include in the teaching?

Avoid leaning forward when attempting to stand

A nurse is providing dietary teaching to a client who has chronic kidney disease and is undergoing hemodialysis. Which dietary information should the nurse include?

Avoid salt substitutes because they are high in potassium Low protein diet Low potassium diet Take an iron supplement daily

a nurse is providing discharge teaching to a client who has hepatitis. Which of the following information should the nurse include?

Avoid sexual intercourse until the antibody test is negative

A nurse is teaching an educational session about reducing health care associated infections. which of the following instructions should the nurse include?

Bathe clients daily with chlorhexidine wipes

A chief nurse officer (CNO) is comparing the quality of health care at her facility to the pest performing facilities nationwide to determine if quality improvement is required. Which of the following processes should the CNO plan to use as a comparison tool?

Benchmarking

A nurse is teaching a group of assistive personnel about preventing pressure ulcers. Which of the following images should the nurse include in the teaching

C. Place a pillow or blanket under clients legs or ankles to prevent rubbing. Head of bed positioned at less than 30 degrees to prevent shearing pressure

A nurse is caring for a client who has a pressure ulcer. Which of the following actions should the nurse take when cleaning the client's wound?

Clean wound with ISOTONIC SOLUTIION (not sterile water) Warm the cleaning solution to the client's body temperature

A nurse is preparing to administer nitroglycerin topical ointment to a client who had a myocardial infarction. Which of the following actions should the nurse plan to take?

Cleans the client's skin and allow to dry Apply a thin layer of medication ointment to the dosing paper Spread the medication over a 6.4 by 8.9 cm area of the skin Cover the medication site with plastic wrap Remove the medication in 6 hr

A nurse is teaching a newly licensed nurse about the degenerative disk disease. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

Clients who have this disease should participate in muscle strengthening exercises

The nurse is providing preoperative teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

Contact a trained interpreter to translate the teaching for the client

A nurse is staging pressure ulcers on a client's foot. Which of the following areas should the nurse identify as a stage III pressure ulcer?

D. Full thickness skin loss but does not extend past the underlying fascia, bones, or tendons (if blackened, it is unstageable)

A nurse is caring for a client who has hepatic encephalopathy and is receiving lactulose. The nurse should identify that which of the following findings indicate a therapeutic effect of the medication?

Decreased ammonia level

A nurse is reviewing the diagnostic test results of a client who is suspected of having Cushing's disease. The nurse should identify that which of the following findings supports this diagnosis?

Decreased lymphocyte count Increased urine glucose level Elevated salivary cortisol level Increased sodium

A charge nurse is facilitating conflict resolution between two coworkers regarding a client assignment. Which of the following conflict management strategies should the charge nurse use first?

Determine how each coworker manages personal conflicts

A nurse is the change agent for instituting a new facility policy. After gathering data related to the change, which of the following steps of change theory should the nurse take next?

Determine the level of the staff motivation for the change

A nurse manager is teaching a newly licensed nurse about the emergency medical treatment and active labor act (EMTALA). which of the following information should the nurse include?

EMTALA requires that all clients are stable prior to discharge or transfer

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take first?

Elevate the client's legs

The nurse is reviewing the lab results of a client who has severe burns from a home fire that occurred 6 hrs ago. Which of the following findings should the nurse expect?

Elevated Potassium Decrease sodium Increased hgb Increased hct

A nurse is caring for a client who has a diagnosis of heart failure. Which of the following actions should the nurse take first?

Evaluate the client's breath sounds

A nurse manager is informed that the family of a client is preparing to file a malpractice lawsuit. The nurse should identify which of the following situations as potential malpractice

Failure to identify an infiltrated IV

A nurse manager is teaching about the failure to communicate during a staff educational session. Which of the following examples should the nurse manager include?

Failure to report an elevated blood pressure during shift report (Failing to question illegible prescription is incorrect because it is an example of failure to act as an advocate)

A nurse is teaching a client who has HIV about zidovudine. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication?

Fever Seizures Diarrhea

A nurse is caring for a client who is postoperative following a craniotomy to remove a brain tumor. The nurse should notify the provider about which of the following findings?

Fixed and nonreactive pupils to light

A nurse is preparing to conduct research regarding catheter-related infections for a performance improvement initiative. Which of the following activities should the nurse identify as components of the research paper (SATA)?

Formulate research problem Conduct a pilot study Communicate the conclusion of the study

A nurse manager is discussing Medicare reimbursement with a group of staff nurses. The nurse should identify that Medicare will deny reimbursement for which of the following events?

Fractured hip from a fall while ambulating postoperatively

A nurse in risk management is evaluating a retinal event. Which of the following actions should the nurse take?

Gather data WITHIN the facility and Develop a plan to reduce the risk for client injury

A nurse is caring for a client identifies an ethical dilemma concerning the client's treatment. Which of the following actions should the nurse take next?

Gather relevant information

A nurse is caring for client who is in the active phase of labor and has amniotic fluid embolus. Which of the following actions should the nurse take?

Give oxygen via nonrebreather mask at 10 L/min

A nurse is assessing a newborn. Which of the following findings should the nurse identify as a manifestation of sepsis?

Grunting Decreased urinary output Pallor, jaundice, or petechiae Hypotension Decreased cardiac output

A nurse is caring for a client who has cirrhosis. The client has an ammonia level of 120 mcg/dL, slurred speech, and is disoriented to person and place. The nurse should identify these findings possibly indicate which of the following complications of cirrhosis?

Hepatic encephalopathy

A nurse is caring for a client who has a chronic kidney disease and is taking hydrochlorothiazide. The nurse should monitor the client's lab values for which of the following findings?

Hypokalemia

A nurse is assessing a client who has heart failure and reports chest pain and difficulty breathing. The nurse should identify that which of the manifestations indicate the client is experiencing cariogenic shock? (SATA)

Hypotension Agitation Cool, clammy skin Tachypnea Urine output less than .5-1 ml/kg/hr

A nurse is assessing an infant who has meningitis. which of the following manifestations should the nurse expect?

Hypothermia

A nurse is teaching a client who has been newly diagnosed with systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

I should inspect my skin daily for cuts and rashes

A nurse is providing teaching to a client following a kidney transplant from a cadaver donor. Which of the following statements by the client indicates an understanding of the teaching?

I will need to continue hemodialysis until my new kidney is functioning well

A nurse is teaching a client who has AIDS about preventing infections. Which of the following statements by the client indicates an understanding of the teaching?

I will report a temperature higher than 100 degrees to my dr.

A nurse is teaching a group of nurses about the role of a case manager. Which f the following information should the nurse include in the teaching?

Identifies cost-effective equipment

A charge nurse is preparing an education session for newly licensed nurses about the purpose of incident reports in a blameless culture. Which of the following information should the charge nurse include.

Incident reports are used to reduce future preventable adverse events

A nurse is planning care for a child who has cystic fibrosis. Which of the following interventions should the nurse include?

Increase the child's daily fat intake to 40% of total calories Give pancreatic enzymes 30 minutes of meal

A nurse is monitoring a client who had a stroke. The nurse should identify which of the following findings as an indication of increased intracranial pressure?

Increased body temperature Hypertension Bradycardia Widened pulse pressure

A nurse is caring for a client who has a Parkinson's disease. Which of the following actions should the nurse take to promote client's mobility?

Instruct client to perform range-of -motion exercises Assist the client to walk with WIDE based gait

A nurse manager notices that he has exceeded the amount of money allocated for labor costs for the quarter. Which of the following should the nurse manager take?

Involve staff nurses in budget planning

A nurse is providing discharge teaching for a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

Lie down when you take this medication

A nurse is caring for a client who has Addison's disease and is receiving an infusion of .9% sodium chloride. The client develops acute adrenal insufficiency. Which of the following actions should the nurse take?

Maintain IV infusion NaCl to prevent hyponatremia Implement a decrease in potassium diet Avoid administering potassium-sparing diuretic Check the client's blood glucose level for hypoglycemia hourly

A nurse is developing a plan of care for a client who has a traumatic brain injury after a fall. which of the following medications should the nurse expect to administer to the client to reduce intracranial pressure?

Mannitol

A nurse is caring for a group of postpartum clients. Which of the following tasks should the nurse delegate to an assistive personnel?

Measure the urine output of a client who is receiving magnesium sulfate

A nurse is teaching a group of community members about emergency preparedness planning. Which of the following statements by a community member indicates an understanding of the teaching?

My children should be involved in developing our family disaster plan

A nurse in an emergency department is assessing a toddler and notes linear bruising across her buttocks. The guardian reports that the child was disciplined with a wooden spoon by a day care worker. Which of the following actions should the nurse take?

Notify the local authorities of suspected abuse

A charge nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to a LPN

Obtain a blood glucose level from a client who has type 1 diabetes

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Offer oral fluid via oral syringe to the infant every 10 minutes

A nurse manager is facilitating conflict resolution between two nurses who disagree about the need to make a referral to a social worker. Which of the following conflict management strategies should the nurse manager use?

Offer self to constructively facilitate communication

A community health nurse is planning a public health presentation aimed at minimizing health care disparities. Which of the following age groups should the nurse identify as the priority for increasing health literacy?

Older adults

A community health nurse is teaching a newly licensed nurse about the types of psychiatric health care settings available in the community. Which of the following should the nurse identify as a primary care setting?

Outpatient counseling clinic

A nurse provider's office is caring for an older adult client who recently had a total knee arthroplasty. The client requires short-term rehabilitation in a skilled nursing facility. Which of the following parts of Medicare should the nurse expect to cover the majority of the cost of treatment?

Part A

A public health nurse is teaching an educational session about emergency preparedness. the nurse should include which of the following actions is part of the preparedness phase of the disaster management cycle?

Participate in mass casualty exercises

A nurse is caring for a client who has acute respiratory distress syndrome and is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent the client from acquiring ventilator-associated pneumonia

Perform mouth care every 2 hours maintain head of bed to 30 degrees Turn client every 2 hours Check the client's need for suctioning every 2 hours

A nurse is assessing a client who has thrombocytopenia.. Which of the following findings should a nurse expect?

Platelets 130,000 (reference range 150,000-450,000)

A nurse is performing an admission assessment on a client who has meningitis. Which of the following findings should the nurse expect?

Positive Kernig's sign

A nurse manager identifies that the number of client medication administration errors on the unit has increased. When creating a cause and effect chart, which of the following information should the nurse manager include

Possible reasons for the medication errors

A nurse is teaching a group of newly licensed nurses about different levels of care. Which of the following should the nurse use as an example of primary care?

Prenatal care

A nurse is planning care for a client who has acute viral hepatitis. which of the following interventions should the nurse include in the plan?

Provide the client with a high-carbohydrate, high calorie diet with moderate fat and protein to promote healing

A nurse suspects that a client is experiencing a pulmonary embolism. Which of the following actions should the nurse take. first

Raise the head of the client's bed

Following a mass casualty disaster, a nurse is assigning a triage tag to a responsive client who has a major burn injury covering 15% of the body surface area. Which of the following triage categories should the nurse assign to the client?

Red Requires immediate treatment (major burns)

A nurse manager suspects that a nurse is chemically impaired. which of the following actions should the nurse manager take first?

Remove nurse from the work environment

A nurse is caring for a client who has a referral for occupational therapy. The nurse should identify on the referral form that the client needs assistance with which of the following?

Self-grooming activities (ADLs)

A nurse manager is teaching a group of nurses about occupational safety and health administration. Which of the following information should the nurse include in the teaching?

Sets standards for hazardous exposures in the workplace

A nurse manager is attempting to resolve a conflict by asking the nurses to focus on the positive, rather than the negative, aspects of the situation. Which of the following conflict resolution strategies is the charge nurse using?

Smoothing

A nurse is assessing a client who has sepsis. For which of the following findings should the nurse notify the rapid response team?

Systolic blood pressure 88 (less than 90)

A nurse is reviewing the ECG strip of a client who is experiencing angina. Which of the following abnormal characteristics should the nurse expect to find?

T wave inversion (ischemia of the heart as a result of angina)

A nurse is caring for a client who has sepsis. Which of the following manifestations should indicate to the nurse that the client might be progressing to septic shock?

Tachycardia hypotension hypothermia Decrease urine production

A nurse is caring for a client who has a new diagnosis of esophageal cancer. The client's family tells the nurse that they do not want the client to know about the diagnosis. Which of the following actions should the nurse take to uphold client autonomy?

Tell the family the client has the right to know about their health

A nurse is reviewing the medical record of a male adult client who was admitted with angina. Which of the following should indicate to the nurse the client might have experienced a myocardial infarction History/Physical: 48 year old male who has hypertension and hypothyroidism Family history of acute coronary syndrome and colon cancer Client reports chest pain lasting less than 15 minutes Vitals: Temp 102 degrees fahrenheit HR 88/min, regular RR 20/min BP 132/82 O2 95% on 2L

Temperature

A nurse is teaching a family member of a client who has a new diagnosis of disseminated intravascular coagulation (DIC). The nurse should include that DIC is a disorder that alters which of the following?

The blood-clotting process

A nurse is having a disagreement with a coworker about client assignment. When following the chain of command, which of the following individuals should the nurse contact to discuss the conflict?

The charge nurse

A charge nurse is delegating client care assignments for a group of nurses. The charge nurse should identify that which of the following factors is the priority when making assignments?

The level of intensity of care

A nurse in a substance use treatment facility is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of fidelity?

The nurse keeps a promise to take a walk outside with a client after group therapy

A nurse is caring for a client who has sepsis and has developed disseminated intravascular coagulation (DIC). Which of the following actions should the nurse take?

The nurse should administer anticoagulants to limit collating

A charge nurse is educating unit nurses about the ethical principle of nonmaleficence. Which of the following should the nurse include in the teaching?

The nurse uses a mechanical lift to move a client from a bed to a chair which prevents harming the client

A client asks a nurse how to apply for medicaid services. The nurse should refer the client to which of the following agencies?

The state welfare office

A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which of the following actions should the nurse plan to take?

Transfuse the platelets through a small filter Administer over 15-30 minutes to prevent clumping Administer platelets immediately without warming No need to match client's blood type to the platelets because the platelets are pulled from multiple donors and have no antigens.

A nurse is teaching about preventing a vasovagal attack for a client who has a bradydysrhythmia. which of the following information should the nurse include?

Use an arm reacher to grab items that are on the top shelf

A nurse is developing a plan of care for a client who has sustained burns to the lower half of his body and is to receive hydrotherapy. Which of the following actions should the nurse include in the plan?

Use forceps and scissors to remove the loose, dead tissue from the client's wound to promote healing perform hydrotherapy 1-2 times a day to clean and decried the wound The nurse should perform hydrotherapy by placing the client on a special shower table and washing small areas of client's wound. Immersion in whirlpool or tub is no longer performed due to increase risk of infection The nurse can leave small blisters intact to serve as a protective barrier that promotes healing. However, the nurse should open large blisters and thoroughly clean the area with mild soap and water

A nurse is discussing the prevention of encephalitis at a community health fair. The nurse should recommend which of the following actions to prevent encephalitis.

Use insect repellent that contains DEET

A nurse is teaching a client who has a new prescription for carvedilol following a myocardial infarction. Which of the following information should the nurse include?

You should check your pulse before taking this medication

A nurse case manager is providing discharge teaching to a client who is scheduled to receive home health visits. Which of the following statements should the nurse include in the teaching?

Your initial home health visit will include family and caregivers assisting with your care at home

A nurse is reviewing the laboratory values of a client who is in hypovolemic shock. Which of the following findings should the nurse expect?

pH level of 7.25 Metabolic Acidosis