ATI Predictor exam

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A. "I will have my husband wear a condom during intercourse." B. " I will check my temperature every 4 hours." C. I will wipe rom front to back after bowel movements" D. "I will notify my doctor if my baby moves fewer than 4 times in the 2 hour following each meal."

" I will have my husband wear a condom during intercourse" rationale: The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of increased risk for infection.

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A. "It is necessary to have written consent for invasive procedures" B. "Implied consent is appropriate for some aspects of nursing care" C. It is the responsibility of the provider to obtain express consent" D. "Informed consent should be obtained separately for each surgical procedure"

" It is the responsibility of the provider to obtain express consent" rationale: Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A. "I know this must be difficult, but your mother will calm down soon." B. "Lets discuss some strategies you can use when this happens again." C. Individuals near death are ready to let go toward the end." D. "Have you determined why she is crying and saying she is ready to die?"

" Let's discuss some strategies you can use when this happens again." Rationale: This response by the nurse offers to provide information, which can reduce anxiety and enhance decision making. This response creates a safe environment, fosters trust and respect, and is appropriate.

A nurse is caring for an adolescent client who has a positive human chorionic gonadotropin (hCG) test. She tells the nurse, " I dont think I can tell my parents that I am pregnant" which of the following responses should the nurse make? A "Do you think you might terminate the pregnancy?" B Give them a chance. Your parents will understand C. You must tell your parents as soon as possible D. You seem frightened to tell your parents

" you seem frightened to tell your parents" rationale: this is a therapeutic response because it provides the client with an opportunity to express any concerns or fears.

A nurse is caring for a client who is a sexual assault survivor. The client says " I feel so humiliated. I don't want anyone to know what happened to me" Which of the following responses should the nurse make? A. you will be just fine. Youll see B. Are you saying that you are fearful about what has happened to you? C. This is a normal feeling after what has happened to you D the best thing for you to do is put this out of your mind and think positive thoughts

"Are you saying that you are fearful about what others will think?"*The nurse is using the therapeutic response of clarification. This response helps the client to clarify her own thoughts.

A nurse is caring for an older adult client who dies during the night while his partner is at his side. The partner says " I can't believe hes gone." Which of the following responses should the nurse make? A. It must be hard to accept that this has happened B his suffering is over now and he is in a better place C. Would you like to take his personal items home with you D. He lived a long and full life

"It must be hard to accept that this has happened." rationale: This is a therapeutic response because the nurse is restating what the client has said, which allows the partner to hear what the nurse has received from her communication.

A nurse is caring for an adolescent client who was recently diagnosed with testicular cancer. When the nurse asks the client a question, he angrily spits in the nurse's face. Which of the following responses should the nurse make? A. I will come back to change your linens when you are feeling better B. who do you think you are to treat me like that C Why did you spit in my face D you seem to be very upset

"You seen to be very upset."*This is a therapeutic response because it allows the client to explore his feelings and can de-escalate the situation.

A nurse has been assigned to care for four clients on a med surg floor. Which of the following clients should the nurse evaluate first? A. A client 48 hours following abdominal surgery with redness and swelling at the edges of the incision. B. A client following knee replacement surgery complaining of pain and warmth in the calf. C. A client admitted with cholecystitis who reports frequent nausea and vomiting D. A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL

A client following knee replacement surgery complaining of pain and warmth in the calf Rationale: Thromboembolism is a potentially serious complication after joint surgeries and pain, warmth and redness are clinical manifestations of thromboembolism which can lead to a pulmonary embolism.

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A. A client who has COPD with an oxygenation saturation of 90%. B. A client who has diabetes mellitus with a hbA1C of 9% C A client who has heart failure with 2+ pitting edema of lower extremities D. A client who has a fever of 38.4 Celsius (101.2) with tenderness in RLQ

A client who has a fever of 38.4 (101.2) with tenderness in RLQ rationale: This indicates possible appendicitis.

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing. B. Loosen the dressing by pulling the tape away from the wound. C. Remove the entire old dressing at once. D. Open sterile supplies after applying sterile gloves.

A. Don clean gloves to remove the old dressing. rationale: use standard precautions by applying clean gloves whenever there is a possiblity of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile gloves.

A nurse is caring for a 13 year old female client who is admitted for an emergency appendectomy. While the nurse is reinforcing preoperative teaching, the client asks, Will I have a large scar from the surgery? Which of the following responses should the nurse make? A. It will be small enough that it won't show when youre wearing a bathing suit. B that isnt our biggest concern right now. you will be fine C you should be happy. You won't be in pain for much longer D What is your favorite class in school

A. It will be small enough that it won't show when youre wearing a bathing suit. rationale: nurse is providing info specific to clients concern

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line. B. Slow the infusion using the roller clamp. C. Disconnect the IV line from the pump. D. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.

A. Remove the sleeve of the gown from the arm without the IV line. Rationale: first remove gown from client's arm without the IV line. this will enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of IV flow.

A nurse is caring for a client who is 48 hour post op following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A. Absent bowel sounds B. Serum BUN level 22 mg/dl C. Absent dorsalis pedis pulses D. Serum Creatinine level of 1.3.

Absent dorsalis Pedis Pulse rationale: Absence of this pulse indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation.

A charge nurse on ped unit is making assignments for a nurse who has floated from labor and delivery unit. Which of the following clients is appropriate for charge nurse to assign. A. A preschooler with a hip spica cast who is being discharged today B. an infant scheduled for a surgical repair of ventricular septal defect tomorrow C. a toddler with a fractured femur who has been in Bryants for 5 days D an adolescent who is 2 days post op following an appendectomy.

An adolescent who is 2 days post op following an appendectomy rationale: The care require fundamental nursing skills and knowledge

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applies sterile gloves to open catheter package. B. Wipes the labia minora in an anteroposterior direction C. Spreads labia with dominant hand. D. uses one cotton ball to wipe the left and right labia majora.

B. Wipes the labia minora in an anteroposterior direction. Rationale: The nurse should wipe anteroposterior both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A. Administer epinephrine (Adrenaline) B. Elevate the lower extremities C. Determine respiratory status D. Apply oxygen via non-rebreather mask.

Determine respiratory status Rationale: The client is experiencing angioedema indicating a possible anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac. B. Apply gentle pressure in the outer opening of the eye for 2 min C. hold the eye dropper 0.5 cm (0.2 in) from cornea D. Instruct the client to close eyes tightly after administration

Drop eye medication into the lower conjunctival sac Rationale: avoid placing drops on cornea and causing damage.

A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A. administer an anti-anxiety medication B. Take the client to a place of seclusion. C. Obtain an order for soft wrist restraints. D. Engage the client in physical activity.

Engage the client in physical activity Rationale: Gross motor activities can reduce tension and lower anxiety levels.

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complications? A. Hyperkalemia B. Severe diarrhea C. Atelectasis D. Excessive vomiting

Excessive vomiting rationale: Metabolic alkalosis is a potential complication of excessive vomiting because of loss of acid from the body.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Provide the client with a glass of water. B. Assist the client to a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted.

Explain the procedure to the client Rationale: least invasive and reduces fear

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching? A " I should eat frequently" B "I should avoid eating 1-2 hours prior to my treatment" C "I should eat foods served cold" D I should eat low carb foods

I should eat low carb foods Rationale: Clients who are experiencing nausea should eat foods high in carbs such as crackers, yogurt, toast, bananas, and sherbet.

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care? A. Include family in client's care B. identify one's own beliefs and values C. determine client's cultural beliefs D encourage client to discuss influence of illness on cultural practices

Identify one's own beliefs and values

A nurse is caring for a client who has type 1 diabetes and is to receive hemodialysis. The client says " I dont even know why i am doing this. there is no cure. Which of the following statements should the nurse make? A it sounds as though you have given up B dialysis will help you live longer C you shouldnt complain. you are fortunate to have this option available to you d lets talk about what you are going to do after dialysis today

It sounds as though you have given up rationale: Restatement to encourage expression of feelings

A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A. pupil dilation B. Ataxia C. Lethargy D Bradycardia

Lethargy rationale: Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in level of consciousness, such as restlessness, irritability, and disorientation. Lethargy is the first sign of increased ICP.

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor? A. Maternal respirations. B. Fetal heart rate. C. Maternal deep-tendon reflexes. D. Maternal Urinary output

Maternal Respirations Rationale: Excessive levels of magnesium can suppress neuromuscular transmission, placing the client at risk for respiratory depression.

A nurse is caring for a client who was admitted to the unit 3 hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern? A. Urinary output of 75 mL over the past 3 hours B. 8 point elevation in presurgery diastolic BP C. Oxygen saturation of 90% on oxygen at 2L per nasal cannula D. Core body temp of 97.2 F (36.2 C)

Oxygen saturation of 90% on oxygen at 2 L per nasal cannula Rationale: Hypoxemia can be caused by a number of potentially life threatening conditions in post op period

A nurse is caring for a child who is 24 hr. postoperative following a supratentorial craniotomy. the nurse should maintain the child in which of the following positions? A. Prone with head of bed flat B. Dorsal recumbent with head of bed elevated to 15 degrees C. supine with head of bed elevated to 30 degrees D side lying with head of bed elevated to 45 degrees.

Supine with hob elevated 30 degrees rationale: this position facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain.

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider? A. Tachycardia B. Vomiting C.Hypotension D. Dilated pupils

Tachycardia Rationale: Symptoms of alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors.

A nurse in a long-term facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching (select all that apply) A. urinary tract b. surgical wound c musculoskeletal system d. respiratory tract e. blood stream

Urinary surgical wound respiratory blood stream

A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching? A. Place proper lights and reflectors on the bicycle. B. Use a properly fitted bicycle helmet. C. wear light colored clothing at night. D. use hand signals when turing.

Use a properly fitted bicycle helmet Rationale: this should always be worn to prevent head injuries.

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly. B. use a different scale each time. C. Weigh the client on arising. D. Weigh the client without clothing.

Weigh the client on arising Rationale: arising each day after voiding and before breakfast. An increase of 1 kg (2.2 lb is equal to 1,000 mL (1L) of retained fluid.

A nurse is caring for an older adult client who is to undergo surgery for a hip fracture. The client says " I guess Ive lived long enough, and its my time" which of the following responses should the nurse make? A. The doctors and nurses will take good care of you. There's nothing to worry about" B. This is just a minor setback. You will be on your feet in no time C You are in really good shape for your age D you feel that your life is ending?

You feel that your life is ending rationale: The nurse is using restatement to promote communication.

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning? A. advocate B. clinician c. educator d manager

advocate rationale: a nurse advocate acts as a liaison between clients and providers in order to improve or maintain quality of care clients receive.

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A. Provide a toy doctor's kit to play with. B. Keep all syringes and needles out of sight until needed. C. Use an approach that is firm but direct. D. Allow the child to manipulate the medical equipment.

allow the child to manipulate the medical equipment rationale: Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

A nurse is caring for a client who is diabetic and is being discharged home following and above the knee amputation. which of the following health care professionals should be involved in the interdisciplinary team meeting? select all that apply. a. dietician b. physical therapist c. hospice nurse d social worker e respiratory therapist

dietician physical therapist social worker

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A. assign a security guard to stay at the client's door. B. request a prescription from the provider for soft restraints. C. discuss the risks associated with leaving with the client D. remove the telephone from the client's room

discuss the risks associated with leaving with the client rationale: Discussing risks associated with leaving is priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician prescribed discharge.

A nurse is collecting data on a child who is diagnosed with bacterial epiglottis. Which of the following clinical findings are associated with the illness (select all that apply) A. drooling B. stridor C. difficulty swallowing D. Croupy cough E. High grade fever.

drooling stridor difficulty swallowing high grade fever

A nurse is caring for neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). because of administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal retractions C. Hypoglycemia D. Hypothermia

hypoglycemia rationale: Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern? A. Facial abrasions B. Penetrating head wound C. Incomplete amputation of the foot D. Tibia fracture requiring open reduction

incomplete amputation of the foot Rationale: injury is life threatening but survivable if immediate care is received

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice to use to decrease skin irritation. A. Abdominal Binder B. Montgomery straps. C. Hypoallergenic tape D. Plastic tape

montgomery straps

A nurse at a long term care facility is participating in quality improvement project to reduce occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? a. prospective audit b. outcome audit c. process audit d. structure audit

outcome audit rationale: An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

purulent exudate

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider? A. fine hand tremors B. mild thirst C. weight gain D. slurred speech

slurred speech rationale: this is an early finding associated with lithium toxicity and can precipitate onset of seizures or comas.

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of following should be included in teaching? A. Lentils B. Soybeans C. Broccoli D. Oatmeal

soybeans rationale: Soybeans are a source of complete protein

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A."I will only be on this medication for 4-6 months because it can lead to physical dependence" B. I can have 1-2 alcoholic beverages each week C I will need to stop taking Xanax 2 weeks before beginning this medication D I can have 6-8 ounces of grapefruit juice each day

"I can have 1-2 alcoholic beverages each week" rationale: this medication does not interfere with CNS depressants such as alcohol

A nurse is caring for client who has major depressive disorder. The client tells the nurse, "Don't bother me. Find someone else to talk with. I don't have anything worth saying. Go find someone you can help." Which of the following statements should the nurse make? A. surely you don't think i dont want to talk to you B. I would like to sit quietly with you for awhile C. I am assigned to take care of you, so I intend to spend time with you D. Lets talk about what you would like for lunch today

"I would like to sit quietly with you for a while."*This is a therapeutic response because the nurse is offering self. This response lets the client know that the nurse has the desire to understand.

A nurse is caring for a client who had a spontaneous miscarriage at 9 weeks of gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following statements should the nurse make? A. It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend. B. When a pregnancy ends spontaneously, there is often something wrong with the fetus C. You are young and will have other children D. The best thing for you is to go home and relax

"It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend."*This is a therapeutic response because the nurse is offering empathy and providing information regarding a support network that the client can access.

An emergency department nurse takes a telephone call from a client who states, "I have just taken 100 amitriptyline tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live." Which of the following responses should the nurse make? A. Please stay on the phone with me so we can talk about your feelings B. Why do you think you have no reason to live C How do you feel about what youve just done D I am sure things are not as bad as they seem now

"Please stay on the phone with me so we can talk about your feelings."*This is a therapeutic response because the nurse has given the client opportunity to share his feelings. The nurse is also encouraging the client to stay on the phone so that emergency personnel can get to the client's home.

A nurse is making morning rounds when a client says, "I almost died last night." Which of the following responses should the nurse make? A. If i were you, I would tell your provider about this B. i am sure people get those dreams when they are away from home C that must have been frightening. tell me more about it D why would you dream about something like that

"That must have been frightening. Tell me more about it."*This therapeutic response directly addresses the client's concern. The nurse uses the communication tool of empathy in responding to this client's concerns and clarifies the client's feelings.

A client is scheduled for a lumbar puncture to rule out bacterial meningitis. She tells the nurse that she is fearful of becoming paralyzed from the needle being placed into her spinal column. Which response should nurse make? A. lets not focus on the negative. lets focus on getting better B why are you feeling so anxious about this procedure C the needle is inserted below the third lumbar vertebrae, well below the point at which your spinal cord ends. D. Your doctor is very skilled in this procedure. Everything will be all right.

"The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends." rationale: This is a therapeutic response that provides information that specifically addresses the client's concerns and helps to decrease anxiety and fears.

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates further teaching is needed? A. "My child will need to be followed medically for at least 5 years" B. "My child can resume moderate activity after his fever subsides" C. This illness will not recur because my child has now had it" D. In a few weeks or months my child could experience sudden, involuntary movements"

"This illness will not recur because my child has now had it." Rationale: It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed.

A nurse is caring for a client who has been recently diagnosed with cancer. The client says, "I would rather be dead than go through the treatment for cancer." Which of the following responses should the nurse make? A. That wouldnt be fair to your family, would it B how can you feel that way when you have so much to live for C why dont we talk about the success you have in your life D what is it that concerns you about cancer treatment

"What is it that concerns you about the cancer treatment?"*This is a therapeutic response because the nurse is asking a broad question that allows the client to explore thoughts and feelings.

A nurse is reinforcing teaching with a client about how to perform personal ileostomy care prior to discharge. The client says " I dont think i am going to be able to take care of this myself" which of the following responses should the nurse make? A. in time, you will become better at this than i am B dont worry about it. Most clients feel like that at first C What part of the ileostomy care are you having trouble with? D I agree this is a difficult process

"What part of ileostomy care are you having trouble with?" rationale: The nurse is demonstrating acceptance of client's feelings and seeking clarification of client's concerns

The adult child of a client has come to take his parents home from the facility following a colon resection. The son tells the nurse, "I don't know how I am going to take care of my mom now." Which of the following responses should the nurse make? A. A home health nurse will be stopping by tomorrow. If you have any questions, you can ask then. B. what part of your mother's care are you concerned about? C. It is quite simple. Ill make sure that the colostomy bag is clean before your mother leaves. D Your mother has been taught to care for the colostomy independently

"What part of your mother's care are you concerned about?"*This is a therapeutic response because the nurse is using clarification to address the son's immediate concerns about caring for his parent.

A nurse is caring for a client who has recently found out that she is pregnant. The client says "I dont think I should tell my partner about the pregnancy." Which response should nurse make? A"Why wouldn't you want to tell your partner?" B "you seem uncertain about telling your partner." C. I am sure he will be happy when you tell him D. You are in disbelief. You should be thrilled

"You seem uncertain about telling your partner."*This is a therapeutic response because the nurse is reflecting on the client's statement.

An assistive personnel is bathing a client who is unconscious and is talking to him about current events and the weather. The client's partner says to the nurse " why does the assistive personnel talk to my husband? He's unconscious." which of the following responses should the nurse make? A. Ill speak to them about it. your husband should not be stimulated like that B why do you care if they talk with your husband C your husband is unconscious but still may be able to hear D The assistive personnel must not realize that your husband cannot hear

"Your husband is unconscious but might still be able to hear" rationale: they may be able to hear even if unable to respond and require an appropriate level of stimulation

a nurse in a ped office is conducting a telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. the mother states her son has a yellow discharge around his penis and asks the nurse what she should do. what is an appropriate response from the nurse

"do not attempt to remove it"the yellow exudate covers the penis 24 hr after the circumcision and will persist for 2-3 days. this is an expected finding and should not be removed

A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern? A. A client who is 26 weeks of gestation and reporting leukorrhea. B. A client who is 10 weeks of gestation and reporting urinary frequency. C. A client who is 37 weeks of gestation and reporting perineal discomfort. D. A client who is 34 weeks of gestation and reporting abdominal tenderness

A client who is 34 weeks of gestation and reporting abdominal tenderness Rationale: Abdominal or uterine tenderness is an early clinical finding associated with abruption placenta, which could lead to an unstable status.

A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A. A client who has cystic fibrosis and has a paroxysmal cough. B. A client who is prescribed cromolyn sodium (Crolum) and has a peak expiratory flow rate of 79%. C. A client who has celiac disease and abdominal distention. D. A client who is prescribed digoxin (Lanoxin) and has 3 episodes of vomiting.

A client who is prescribed digoxin (Lanoxin) and has 3 episodes of vomiting. Rationale: Vomiting, slow heart rate, and anorexia are clinical findings associated with digoxin toxicity which is an acute condition.

a nurse is reviewing lab results of 4 clients. which should be reported to provider immediately? A. a client who has diabetes mellitus with fasting blood glucose of 150 mg/dL B. A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L C. A client who is prescribed oxygen therapy and albuterol (Proventil) with a PCO2 of 50 mm Hg D. A client who has urosepsis with a WBC count of 15,000 mm3

A client who is prescribed digoxin and furosemide with potassium of 3.1 mEq rationale: this value is below expected range of 3.5-5.0 indicating client has hypokalemia. this is a complication with use of loop diuretics such as furosemide and increases risk of digoxin toxicity

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. tenderness when touched B. Pink, shiny tissue with a grainy appearance C. Serosanguineous drainage D. A halo of erythema on surrounding skin

A halo of erythema on the surrounding skin rationale: indicates possible underlying infection

A nurse working the 7 pm to 7 am shift on ped unit has received report on 4 post op clients. Which of the following requires immediate intervention? A. An adolescent who is post op following an appendectomy and has refused to ambulate for past 8 hr. B. school age child who is post op following a herniorrhaphy with an infiltrated peripheral IV that has been clamped. C. Preschooler who is postop following a tonsillectomy and is experiencing frequent swallowing. D. infant who is post op following a cleft palate repair with a heart rate of 146/min and a respiratory rate of 28/min.

A preschooler who is postop following a tonsillectomy and is experiencing frequent swallowing. Rationale: potential bleeding placing client at risk for hemorrhage.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction catheter back 1 cm (0.5 in ) if the client starts coughing. B. allow 30 seconds between suctioning passes C. hyperventilate the client with 50% oxygen for 30 seconds. D. Perform a maximum of 4 passes with the suction catheter.

A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. Rationale: This will remove the catheter from the mucosal wall of the trachea prior to suctioning.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. Provide breaths with a manual resuscitation bag. C. Administer oxygen. D. Establish an airway

A. Start chest compressions Rationale: The greatest risk to the client is loss of adequate circulation to the tissues; therefore, following the sequence of cardiopulmonary resuscitation, the nurse should first initiate chest compressions. The following steps include opening the airway and breathing for adults and ped clients because evidence indicates there is a greater survival rate when chest compressions are started before a breath is initiated.

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level. B. Discuss the adverse effects of pain medication with the client. C. Obtain the client's vital signs. D. Check the client's allergies.

A. use the pain scale to determine the client's pain level. Rationale: The first action the nurse should take is to begin pain management by asking the client to describe her pain.

A nurse is caring for a client following a fetal demise. The client is crying and says, "I tried to get pregnant for so long. My partner and I wanted this baby so much. Now what will we do?" Which of the following responses should the nurse make? A. why do you think this continues to happen to you B You can have another baby soon C i think you should look into adoption D are you feeling overwhemed?

Are you feeling overwhelmed?"*The nurse is using the techniques of clarification to gain a better understanding of the client's thoughts and is expressing understanding with this therapeutic response.

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that of which of the following medications has the potential to reduce the antihypertensive effect of captopril? A. Aspirin (Bayer) B. Acetaminophen (Tylenol) C. Guaifenesin (Robitussin) D. Diphenhydramine hydrochloride (Benadryl)

Aspirin Rationale: Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE Inhibitor.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A. Place the soiled linens on the chair while making the bed. B. Hold the linens away from the body and clothing. C. Place the linens on the floor until able to place it in a linen bag. D. Shake the clean linens to unfold.

B. Hold linens away from body and clothing Rationale: The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following action should the nurse take? A. Maintain suction while removing the NG tube. B. Instill 100 mL of air into the NG tube before removal. C. Pinch the NG tube while removing the tube. D. Instruct the client to breathe in and out during the removal of the NG tube.

C. Pinch the NG tube while removing the tube Rationale: decrease the risk of aspiration of any gastric contents

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is skin traction. The client reports pain of 6 on a scale of 0-10 under the traction bandage. Which of the following actions should the nurse take? A. Administer an analgesic. B. Assist the client to shift positions. C. Check pedal Pulse. D. Distract the client with music therapy.

Check pedal Pulse Rationale: Pressure on peroneal nerve can occur when skin traction is applied to lower extremities which can result in foot drop.

a nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked. B. Palpate the bladder. C. Obtain a prescription to irrigate the catheter with 0.9 % sodium chloride. D. Encourage the client to drink more fluids.

Check to determine if catheter tubing is kinked.

A nurse is reinforcing teaching with a caregiver who has aphasia. The nurse should include which of the following communication strategies in the teaching? A. Cue the client by providing picture cards that portray common needs. B. Increase the volume of the voice when speaking to a client. C. Encourage the client to limit hand gestures when communicating. D. Vary the use of phrases and terminology in discussions.

Cue the client by providing picture cards that portray common needs. Rationale: Using picture cards enhances communication. The nurse should include this communication strategy in the teaching.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Speak directly into the client's impaired ear. B. Exaggerate lip movements. C. Speak loudly. D. Face the client when speaking

D. Face the client when speaking Rationale: Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is most important for the nurse to monitor? A. Diplopia B. Loss of bladder control C. paresthesias D. Decreased respiratory effort.

Decreased respiratory effort Rationale: Myasthenia gravis affects neuromuscular transmission of voluntary muscles of body. Progressive weakness of the diaphragmatic and intercostal muscles can produce respiratory distress.

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? A. Increased appetite B. Elevated Temperature C. Bradycardia D. Drowsiness

Elevated Temperature Rationale: The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? A. Evaluate level of consciousness. B. Place client on bed rest. C. Encourage increased fluid intake. D. Initiate continuous ECG monitoring.

Evaluate level of consciousness Rationale: A change in level of consciousness is earliest manifestation of fat embolism syndrome.

A nurse is caring for a client who has radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? A. Promote adequate intake of calcium. B. Evaluate neurovascular status. C. Elevate the extremity above the heart. D. Apply ice intermittently for the first 24 hours.

Evaluate neurovascular status Rationale: neurovascular compromise is a manifestation of compartment syndrome and must be detected in early stages to avoid permanent damage.

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A. facial edema b. urinary frequency c. acid indigestion d. breast leakage

Facial edema rationale: facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.

A nurse is caring for a client who has suscpected brain tumor and is scheduled for a computerized axial tomography scat (CAT). When the procedure is explained, the client expresses fear about entering the enclosed space of the scanner. Which of the following statements should the nurse make? A. I think you should request a magnetic resonance image instead. B let me review some breathing exercise with you C It is scary to go into an enclosed space D this is a routine test, so there is no reason to worry

Let me review some breathing exercises with you Rationale: To help minimize anxiety, the nurse should encourage the use of relaxation techniques, such as breathing exercises, prior to the procedure

A nurse is caring for a client who has leukemia. The client says " the doctor told me that my condition is too severe to be treated successfully. I guess I dont have long to live." Which of the following responses should the nurse make? A. Having a positive attitude can help you. B. Lets talk about how you are feeling about this information. C Have you considered getting a second opinion D things get worse before they get better

Lets talk about how you are feeling about this information rationale: This is the exploring technique which allows the client the opportunity to express his feelings regarding the prognosis.

A nurse is preparing to insert an indwelling catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

Lower abdomen Rationale: or upper thigh. this will decrease tension and trauma to the urethra.

A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse. A. Administer nebulized epinephrine (racemic epinephrine) B. Ensure adequate hydration C. Obtain an oxygen sat level D. Encourage parents to comfort the client.

Obtain oxygen sat level Rationale: laryngotracheobronchitis can result in impaired airway clearance because of upper airway swelling and increased respiratory effort.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food. B. Offer the client tart or sour foods first. C. Tilt the client's head backward when swallowing. D. Turn on the television

Offer the client tart or sour foods first rationale: this stimulates saliva production, which helps with chewing and swallowing.

A nurse is assessing a client who is postop following a gastric bypass. which of the findings indicates the client could be experiencing an anastomotic leak? A. Lethargy B. Neuralgia. C. Bradycardia D. Oliguria

Oliguria Rationale: When a gastric bypass is performed, the stomach, duodenum, and part of jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria is a finding consistent with peritonitis and can indicate client is experiencing anastomotic leak.

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? A. Bathe a client who is scheduled for physical therapy at 9 am. B. Perform fingersticks for glucose levels on a client who have diabetes. C. Stock procedure rooms. D. Distribute clean linens.

Perform fingersticks on clients with diabetes mellitus. Rationale: To attain accurate readings, these levels should be attained prior to eating breakfast.

A nurse is assisting with care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? A. wrap the cord in a towel saturated with 0.9% sodium chloride. B. Apply oxygen via face mask. C. Place client in knee-chest position. D. increase IV fluid rate.

Place client in knee-chest position. Rationale: This will aid in keeping pressure of presenting part of the fetus off the cord.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl. B. Transfer the specimen to a sterile container. C. Refrigerate the collected specimen. D. Place the stool specimen collection container in a biohazard bag.

Place the stool specimen collection container in a biohazard bag Rationale: The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification, and to prevent contamination with microorganisms.

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is the priority concern of the nurse? A. Enhancing self-esteem B. Preventing injury C. encouraging problem solving D. Promoting usefulness

Preventing injury

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A. Promoting oxygenation B. Management of pain C. Maintaining hydration D. Preventing infection

Promoting oxygen Rationale: Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling has been linked to severe hypoxia and can be fatal. Rest should be encouraged to decrease expenditure of oxygen and energy.

a nurse is collecting data on a client who has appedicitis. where should the nurse palpate to determine the presence of tenderness at McBurney's point

RLQ

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? A. reduced bleeding time B. decreased plasma globulins C. improved activity tolerance D. increased immune functioning

Reduced bleeding time rationale: Platelets are responsible for triggering the process of blood clotting. Clients who have leukemia are prone to bleeding because of low platelet counts and should experience a reduced bleeding time as a result of a transfusion of platelets.

A nurse is caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for TPN is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations? A. Hypertension and crackles B. Excessive thirst C. Shakiness and diaphoresis. D. Twitching muscles

Shakiness and diaphoresis Rationale: These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below prescribed amount.

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? A. Notify the provider B. Obtain a chest x-ray C. Flush the catheter. D. Stop the infusion.

Stop the infusion Rationale: This prevents further damage to vessel and minimizes any additional harm to the client

A nurse has assigned four tasks to an assistive personnel. Which of the following should the nurse instruct the AP to perform first? A. take an ABG specimen to the lab. B. Transport a client to the radiology department for an xray. C obtain a clean catch urine sample for a newly admitted client D pass fresh water to clients

Take an ABG specimen to the lab rationale: ABG samples are kept on ice and should be transported immediately to the lab or the specimen will deteriorate.

A nurse in a rehab center is caring for a client who just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? A. Temperature 37.6 C (99.8 F) B. Blood glucose level 144 mg/dL C. dry mouth D. headache

Temperature 37.6 C (99.8 F) rationale: sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower, medial quadrant of the buttock near the coccyx. B. The side hip between the iliac crest and anterior iliac spine C. the tissue of the posterior upper arm D. The lower, inner thigh, 2 finger widths above the patella.

The side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder? A. Grandiose sense of self importance B. Reckless disregard for safety of others C. unstable interpersonal relationships D. Lack of empathy

Unstable interpersonal relationships rationale: Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? A. initiate a bladder training schedule B. Administer solifenacin (Vesicare) C. Insert an indwelling urinary cath D. Perform intermittent cath.

initiate a bladder training schedule Rationale: least invasive