ATI STUFF
A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client indicates understanding of the teaching?
"I should wear elastic stockings on both of my legs." (The purpose of the stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery)
A nurse is caring for a client who has schizophrenia and states, "my doctor is trying to kill me." Which of the following responses should the nurse make?
"It must be frightening to feel that your doctor is trying to kill you." (When a client is experiencing a delusion the nurse should empathize with the feelings behind the clients delusions)
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
"Sit on the toilet 30 minutes after eating a meal."- (Increased peristalsis occurs after food enters the stomach. Siting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. The nurse should instruct the client to consume a minimum of 1,500mL of fluid to prevent constipation. The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods. The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.)
A nurse is caring for an adolescent client who is overweight. The adolescent tells the nurse that classmates tease him about his weight. Which of the filling responses should the nurse make?
"Tell me how you feel when your classmates tease you." (This response encourages the client to express his feelings)
A nurse is caring for a client who is postoperative following an amputation of the left lower leg. The client states, "I can't believe this has happened to me. I don't deserve this." Which of the following responses should the nurse provide?
"Tell me what you're feeling about what has happened." (This therapeutic communication encourages the client to talk further about personal feelings and perceptions)
Toddlers who are 2 years old should consume how many calories per day?
1,000 calories
A nurse is assessed a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure?
Abdominal distention (can indicate the presence of peritonitis due to the draining of CSF or a postoperative ileus)
The nurse should assess the client for which of the following manifestations of pneumothorax?
Absence of breath sounds
A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the prover? Bun 8 mg/dL Uric acid 3.0 mg/dL Creatinine 0.9 mg/dL Urine specific gravity 1.010
Creatinine 0.9 mg/dL (the expected reference range for a toddler is a creatinine level of 0.3-0.7 mg/dL. the expected reference range for a toddler is BUN 5-18 mg/dL. the expected reference range for a toddler is a uric acid level of 2.0-5.5 mg/dL. the expected reference range for a toddler is a urine specific gravity of 1.001-1.030)
A nurse is administering brimonidine eye drops to a client who has glaucoma. Which of the following ocular effects should the nurse expect?
Decreased intraocular pressure (because brimonidine decreases IOP by reducing aqueous humor production)
A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of the following is the PRIORITY for the nurse to report to the provider Elevated BP Weight gain Muscle twitching 2+ peripheral edema * THINK ABC's
Elevated blood pressure (elevated BP increases the risk of a hypertensive crisis that can result from taking an MAOI like phenelzine)
A nurse is caring for a client who is having a PTCA with stent placemat. Which of the following actions should the nurse anticipate in the post-procedure plan of care?
Monitor for bleeding (because bleeding is a post procedure complication of the procedure because of the administration of heparin during the procedure and the removal of the femoral sheath). The client should also remain on bed rest until homeostasis is assured.
A nurse on a pedi unit is admitting a 4 year old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play?
Plastic stethoscope (providing a stethoscope allows the child to engage in therapeutic play. Imitating health care personnel may ease the child's fear of unfamiliar equipment)
Lamotrigine primary adverse affects to report to provider
RASH (because it is an inital signs of SJS or Toxic Epidermal Necrolysis which are lofe threatening reactions that manifest initially as a rash in gbe first 2-8 werks of tx with lamotrigine)
A nurse is preparing to administer a Mantoux skin test to a client. What is the purpose of a mantoux skin test using purified protein derivative (PPD)
To identify if a client has been infected with Mycobacterium tuberculosis (The mantoux skin test is used to identify individuals who have been infected with mycobacterium tuberculosis. It can't differentiate between active and latent)
A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40mg daily. The client reports taking extra doses to promote weight loss. Which of the following findings should indicate to the nurse that the client is dehydrated?
Urine specific gravity 1.035 (oliguria, an increased urine concentration, and an increased urine specific gravity greater than 1.030 are expected findings in clients who are dehydrated)