HCC 2-Comfort ATI Test

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

-"Your husband should decide when more medication is needed."

A nurse is preparing to administer meperidine 75 mg IM to a client who reports postoperative pain. Available is meperidine 100 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

-0.8

A community health nurse is preparing a presentation about complementary and alternative therapies. Which of the following therapies should the nurse describes as a means of manipulating a series of channels to re-establish the flow of vital energy within the body?

-Acupuncture

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

-Adjust the thermostat so that the environment is warm.

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

-Administer opioids for pain.

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?

-Administer pain medication.

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

-Apply an ice pack to the affected area.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

-Apply the bag for 30 min at a time.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

-Ask the client to rate her pain on a scale from 0 to 10.

A nurse is is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply)

-Assist the client to cough and deep breathe every hour. -Administer PRN analgesics as needed. -Give the client a back massage. -Teach the client relaxation techniques.

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

-Avoid prolonged sitting. -Sleep in a side-lying position with flexed knees. -Try padded shoe insoles.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?

-Cellular hypoxia

A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take?

-Check the display on the PCA pump.

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?

-LDL 172 mg/dL

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

-Leg pain at rest.

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

-Massage the client's back.

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?

-Naloxone

A nurse is preparing to administer morphine IV to a client. Which of the following medications should the nurse plan to have available?

-Naloxone

A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?

-Observe for indications of hypokalemia.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

-Obtain a pair of slipper-socks for the client.

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

-Offer the client a back rub. -Remind the client to use incisional splinting. -Identify the client's pain level. -Change the client's position.

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

-Orthostatic hypotension

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

-Pain

A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?

-"Avoid eating tree nuts, such as almonds."

A nurse is teaching a client who has kidney stones. Which of the following instructions should the nurse include?

-"Filter your urine each day."

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicated an understanding of the teaching?

-"I am going to take a stress management class."

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

-Edema

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)

-Pain level and pain tolerance can be assessed using a scale from 0 to 10. -Each client's expression of pain may be different and individualized. -Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

-Respiratory rate

A nurse is caring for a client on the medical-surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to take: -Prepare to administer IV heparin -Prepare client for ultrasound doppler of the lower extremity. Potential Condition: -Arterial thrombosis Parameters to Monitor: -aPTT -Platelet count

A nurse is caring for a 7-year-old child. The nurse is reviewing the assessment findings and diagnostic results. For each assessment finding, click to specify if the finding is consistent with leukemia, sickle cell anemia, or hemophilia. Each finding may support more than one disease process.

Leukemia: -Temperature -Bruising -Bleeding -WBC count -Pain Sickle Cell Anemia: -Temperature -WBC count -Pain Hemophilia: -Bruising -Bleeding -Pain

A nurse is assessing a 24-year-old female client. Drag words from the choices below to fill in each blank in the following sentence.

The client is exhibiting clinical manifestations of --Deep vein thrombosis-- and --Pulmonary embolism--.

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

-"I will call for pain medication before the previous dose wears off."

A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. Which of the following statements by the client indicates an understanding of the teaching?

-"I will need to increase my fluid intake while taking this medication."

A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching?

-"Use the pain scale to determine if you need to self-administer."

A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?

-"Yes, I understand that you feel better wearing your bracelet."

A nurse is teaching a client who has a new prescription for codeine. Which of the following instructions should the nurse include in the teaching?

-"You should change positions slowly."

A nurse is teaching a client about using a PCA device for postoperative pain management. Which of the following statements should the nurse make?

-"You will have control of administering your own pain medication."

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

-Asking the client to rate the pain.

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

-Stop the treatment if the client's skin becomes red.

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

-Take the medication with food.

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

-"It's unfortunate that I have to be in the hospital for this treatment."

A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include?

-"Monitor for muscle pain."

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?

-"Offer fluids to your child multiple times every day."

A nurse is providing dietary teaching to a client who has calcium oxalate kidney stones. Which of the following statements indicated an understanding of the teaching?

-"I may eat a banana with my breakfast."

A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching?

-"I should tell the nurse if I can't control my pain with this device."

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

-"I will apply heat."

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

-"Use elastic stockings."

A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?

-"I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it."

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?

-"I don't eat shellfish because it gives me hives."

A nurse is caring for a 5-year-old child in the acute care setting. Which of the following assessment findings require additional action by the nurse? Click to highlight the assessment findings which require additional action by the nurse? To deselect a finding, click on the finding again.

-Child is uncooperative and agitated. -Child reports chest pain and joint pain as a 4 on the Faces Scale. -Nasal flaring and moderate subcostal and substernal retractions are noted. -Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

-Dehydration

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

-Determine the location of the pain.

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

-Drink 3 L of fluid every day.

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

-Encourage intake of at least 3 L of fluids per day.

A nurse is caring for a 2-month-old infant who is postoperative following a surgical repair of a cleft lip. Which of the following actions should the nurse take?

-Encourage the parents to rock the infant.

A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?

-FLACC

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

-Family history

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

-Fetal position is persistent occiput posterior.

A nurse is preparing an in-service about the various supplements clients might use. Which of the following herbal supplements should the nurse include as potentially increasing the anticoagulant effects of aspirin and other oral anticoagulants?

-Feverfew

A nurse is caring for a 6-month-old infant. Which of the following findings indicated to the nurse that the infant may be experiencing pain?

-Furrowed brow

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.)

-Have a parent stay with the child during procedures. -Perform the procedures as quickly as possible -Allow the child to keep a toy from home with her.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

-Impaired tissue perfusion

A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?

-Increased crying episodes

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

-Increased heart rate

A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?

-Initiate the use of a PCA pump for pain control.

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

-Intermittent claudication

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

-It facilitates the client's deep breathing.

A nurse is planning care for an adolescent client. Which of the following actions should the nurse plan to take? (Select all that apply.)

-Perform passive range-of-motion exercises. -Administer IV fluids. -Obtain consent for a blood transfusion. -Encourage bedrest.

A nurse is caring for a client who is postoperative following an abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

-Respiratory rate

A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

-Respiratory rate 8/min

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.)

-Restlessness -Grimacing -Clenching

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

-Self-report of pain

A nurse caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain?

-Semi-Fowler's with a pillow under her knees.

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

-The client developed a tolerance to the medication.

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

-The client has a paralytic ileus.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

-The client's self-report of pain severity.