ATI comp test

The nurse continues to care for the client. Nurses' Notes Day 1, 0915: The client's adult child reports the client has not slept for 2 days and has become obsessed with cleaning the house and hosting parties. At times the client is overly joyous and has a very elevated sense of self- confidence. The adult child states that the client has also demonstrated very impulsive spending habits and expresses concern about the client giving away large sums of money to others. The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time they ate. 1.Encourage the client to avoid napping during the day. Anticipated 2. Place the client in a room away from the nurses' station. Contradicted 3. Weigh the client each day. Anticipated 4. Provide the client with high-calorie fluids every hour. Contradicted

1.Encourage the client to avoid napping during the day. Anticipated 2. Place the client in a room away from the nurses' station. Contradicted 3. Weigh the client each day. Anticipated 4. Provide the client with high-calorie fluids every hour. Contradicted

20. A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES )?

A 24-year-old male who has a casted femur fracture

12. A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care?

A client who has agonal respirations

1. A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

A client who has difficulty swallowing

2. A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching?

A general anesthetic is administered prior to ECT treatments

19 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose?

Alanine aminotransferase (ALT )

6. A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client's sibling comes visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time?

Allow the sibling to wave at the client through the window or door

9. A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first?

Arrange a meeting with teenage mothers who are high school students in the community

5. A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected . Which of the following actions is appropriate for nurse to take?

Ask the charge nurse to assign an experienced nurse to act as a resource

15. A nurse is about to administer an injection to a client who states, "I don't want that injection. The last time I got that I was sore for a week." The nurse goes ahead and administers the injection against the client's wishes. The nurse committed which of the following?

Battery

16. A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left- sided heart failure?

Bilateral lung crackles

11. A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate?

Covering insertion site with a transparent dressing

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis. Exhibit 2 Nurses Notes Day 1,0915 The client's adult child reports the client has not slept for 2 days and has become obsessed with cleaning the house and hosting parties. At times the client is overly joyous and has a very elevated sense of self-confidence. The adult child states that the client has also demonstrated very impulsive spending habits and expresses concern about the client giving away large sums of money to others. The client's speech is very pressured, disorganized and loud. Client unable to recall the last time they ate. Hallucinations: Psychosis Lack of Sleep: Mania Excessive spending habits: Mania Disorganized thought process: Psychosis Pressured speech: Mania

Hallucinations: Psychosis Lack of Sleep: Mania Excessive spending habits: Mania Disorganized thought process: Psychosis Pressured speech: Mania

8. an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs . Which of the following clients should the nurse plan to assess ?

Head injury HR 60

A nurse is caring for a client who is taking disulfiram for alcohol -use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor ?

Headache

4.A nurse is caring for a client following an open colectomy . Which of the following findings places the client at risk for delayed wound healing ?

Hyperemesis

a nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

I will avoid crushing this medication

A 52-year-old client brought to emergency department by adult child. Client is alert and oriented to person and time but does not know where they are. No history of substance use according to client's adult child. Client exhibits constant movements and poor concentration. Hair and clothing are unclean. Appears to be listening to unseen others. Skin turgor poor. Condition: Mania Client Finding: Euphoric mood

Mania, euphoric mood

A nurse is caring for a client who is postoperative following a mitral balloon valvuloplasty. Which of the following areas should the nurse auscultate to assess for mitral areas of the heart? (you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Mitral Valve

10. After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first?

Place an NPO sign on the door of a client scheduled surgery

7. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy . Which of the following interventions should the nurse include ?

Place the newborn 45 cm (18 in) from the light source

A nurse is caring for a client who is in the latent phase of Labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated two centimeters, 25% effaced and -2 station. Which of the following interventions should the nurse implement?

Request the provider prescribe a pudendal nerve block

17. A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous -central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer's lactate at 150 mL per hr . prior to starting the infusion, which of the following actions should the nurse take?

Review the chest x-ray report

A Nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend ?

Scrambled eggs

13. A nurse is planning to provide community education about viral hepatitis . Which of the following should the nurse plan to include in the teaching?

Series of four hepatitis vaccines is recommended to prevent viral hepatitis

. A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome

Tachypnea /irritability /tremors

18. A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrelipase . Which of the following should the nurse include in the teaching ?

Take with meals

14. A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity?

The nurse explains the potential risks of treatment

A new nurse in an acute mental health facility is teaching a client about potential adverse effects of transcranial magnetic stimulation . The nurse tells the client that he might not feel light -headed but that it should not affect his memory . The nurse is demonstrating which of the following ethical principles ?

a Beneficence

A nurse is teaching a client who is pregnant and has genital herpes simplex virus (HSV). Which of the following statements should the nurse include in the teaching? a. "You will need to have a cesarean birth if there are any visible lesions." b. "You can apply a cortisone cream to the lesions twice each day." c. "You should take 600 milligrams of ibuprofen every 8 hours for discomfort during an outbreak d. "Your baby's cord blood will be tested to determine if she has contracted HSV

a. "You will need to have a cesarean birth if there are any visible lesions."

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has a hip fracture and a new onset of tachypnea b. A client who has epidural analgesia and weakness in the lower extremities c. A client who has sinus arrhythmia and is receiving cardiac monitoring d. A client who has diabetes mellitus and an HbA1c of 6.8%

a. A client who has a hip fracture and a new onset of tachypnea

A nurse is monitoring a client who is receiving a transfusion of packed RBC's. The client reports chills, headaches, low back pain, and a feeling of tightness in his chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

a. Acute hemolytic

A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? a. Administer nitroglycerin 0.4 mg SL. 30 min before the procedure. b. Draw blood specimens for culture and sensitivity. c. Obtain a CBC with differential. d. Transport the client to radiology for a CT scan.

a. Administer nitroglycerin 0.4 mg SL. 30 min before the procedure.

A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home which of the following instructions should the nurse include?

a. Apply cold compresses too painful areas

A nurse is teaching a client who is pregnant about non-stress testing. Which of the following statements by the client indicates an understanding of the teaching?

a. During this test, I will punch a button if the baby moves

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority? a. Dysphagia b. Excoriation of the skin on the neck and chest c. Xerostomia d. Client reports a pain level of 6 on a scale from 0 to 10

a. Dysphagia

A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?

a. Empty your ostomy pouch when it is half full

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (Select all that apply.) a. Encouraging clients to seek further information from the provider b. Honoring family requests to withhold medical information c. Addressing client needs when providing resources d. Making decisions about health care on clients behalf e. Promoting health care access

a. Encouraging clients to seek further information from the provider c. Addressing client needs when providing resources e. Promoting health care access

A nurse is planning care for a client who is experiencing benzodiazepine toxicity . The nurse should plan to administer which of the following medications ?

a. Flumazenil

A nurse is assessing a child who is post-operative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

a. Frequent swallowing

A nurse is caring for a client Exhibit 1 History and Physical Day 1, 0900 A 52-year-old client was brought to the emergency department by an adult child. Client is alert and oriented to person and time but does not know where they are. No history of substance use according to the client's adult child. Clients exhibit constant movements and poor concentration. Hair and clothing are unclean. Appears to be listening to unseen others. Skin turgor poor, The nurse is assessing the client. Select the 4 findings that require immediate follow-up. a. Hallucination b. Heart rare c. Sleep pattern d. Skin turgor e. Hygiene

a. Hallucination b. Heart rare d. Skin turgor e. Hygiene

A nurse is teaching about Safe Handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching?

a. I should boil tap water for 2 minutes and call it before mix it with powdered formula

A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching ?

a. I will wear a yellow wristband, so everyone knows I'm at risk for falling

A nurse is teaching a class about providing pare within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

a. Irrigation of the external ear canal

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm of the ventilator sounds. Which of the following actions should the nurse take?

a. Look for a leak in the tubes cuff

A nurse is planning to administer packed RBC's to an older adult client who has a low hemoglobin level . Which of the following actions should the nurse plan to take?

a. Monitor Vital Signs every hour throughout the transfusion

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take ?

a. Observe the client for 1 hour after meals

A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit . Which of the following referral should the nurse anticipate for the client?

a. Physical therapist

A nurse is assessing a client who is at 37 weeks of gestation and reports sudden , severe abdominal pain with moderate vaginal bleeding and persistent uterine contraction . The client's blood pressure is 88 over 50 mmhg and her abdomen is rigid . The nurse should identify these findings as indicating which of the following complications ?

a. Placenta abruption

A nurse is preparing to insert an indwelling urinary catheter for a client . Which of the following actions should the nurse take first?

a. Position the sterile drape leaving the perineum exposed

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use? a. Rectal b. Tympanic c. Axillary d. Oral

a. Rectal

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take? a. Report the infection to the state department of health b. Administer ceftriaxone via intermittent IV bolus c. Schedule the client for retesting in 1 week. d. Instruct the client to abstain from sexual intercourse for 1 month.

a. Report the infection to the state department of health

A nurse is preparing to administer medication to a client. What are the following identifiers should the nurse use to identify the client?

a. Room number

A nurse at the health department is providing anticipatory guidance to a parent of a one month or a year-old infant . The nurse should inform the parent that the infant should receive which of the following immunizations at the age of two months ?

a. Rotavirus

a nurse is assessing a client who is receiving enteral feeding via an Ng tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's findings ?

a. Switch to a lactose -free formula.

A community health nurse is providing education to a group of older adults about immunizations . Which of the following immunizations should the nurse recommend ?

a. Tdap

The nurse is continuing to care for the client. Provider prescriptions Day 1, 1100: Lithium carbonate 600 mg PO BID Nurses' Notes Day 1, 0915: The client's adult child reports the client has not slept for 2 days and has become obsessed with cleaning the house and hosting parties The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply. a. The client engages in quiet activities in their room. b. The client slept 5 hr the previous night c. The client consumes 8 oz of high-calorie fluids each hour d. The client takes 2 short naps during the day. e. The client appears to listen to unseen others

a. The client engages in quiet activities in their room. b. The client slept 5 hr the previous night c. The client consumes 8 oz of high-calorie fluids each hour d. The client takes 2 short naps during the day.

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a seated position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension ?

a. The clients systolic blood pressure decreases by 25 mmHg

A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using Progressive relaxation?

a. Tighten the muscle group, then release tension and move to the next one

A home health nurse is planning care for an older adult client who has a vision loss and takes medication throughout the day . Which of the following actions should the nurse include in the plan?

a. Use container Lids of different shapes to indicate times of Administration

A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care? a. Wash the penis from the scrotum to the tip using a spiral motion. b. Use water with no soap to prevent skin irritation c. Discard the washcloth after cleansing the urethral meatus. d. Don sterile gloves to prevent infection

a. Wash the penis from the scrotum to the tip using a spiral motion.

A nurse is planning care for a client who has a history of urinary tract infections UTIs and requires placement of an indwelling catheter. Which of the following actions should the nurse take to help minimize the client's risk of acquiring a UTI?

a. Whoop the tubing so that is lower than the collection bag b. keep urine a bag at bladder level when ambulating . secure the catheter to the client's thigh d obtain urinary samples by disconnecting the tubing connections

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching?

a. You should wear a snug fitting bra continuously for 72 hours

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism? a. "I'm so glad I've retired because the work was making me sick and depressed." b. "Since I retired, I have entered many gardening competitions." c. "There were lay-offs at my company, so I journaled about what I accomplished during my career." d. Thad to retire because my boss didn't like me."

b. "Since I retired, I have entered many gardening competitions."

A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include? a. Cheesecake b. Air-popped popcorn c. Milkshake made with whole milk d. Baked potato chips

b. Air-popped popcorn

A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a prescription for pain medication. b. Collect blood cultures c. Transport the child to obtain a CT scan. d. Initiate seizure precautions,

b. Collect blood cultures

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Take pancrelipase b. Complete oral hygiene. c. Eat a meal. d. Use an albuterol inhaler.

b. Complete oral hygiene.

A nurse is discussing discharge plans with an older client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss? a. Reviewing information about support groups for individuals who have had a stroke b. Obtaining an alert system to get help in case of a fall c. Providing information about available transportation resources d. Choosing an agency to provide home physical therapy

b. Obtaining an alert system to get help in case of a fall

A nurse is reviewing the medical history of a client who asks about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication? a. Recent myocardial infarction b. Recent eye surgery c. Breast cancer d. Thrombophlebitis

b. Recent eye surgery

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. There is a loop of tubing below the drainage system b. The system is working properly c. The tubing is partially obstructed by clots. d. The lung has re-expanded

b. The system is working properly

The nurse is continuing to care for the client. History and Physical Day 1,0900: A 52-year-old client brought to emergency department by adult child. Client is alert and oriented to person and time but does not know where they are. No history of substance use according to client's adult child. Client exhibits constant movements and poor concentration. Hair and clothing are unclean. Appears to be listening to unseen others. Skin turgor poor. Select the 3 statements the nurse should include. a. Blurred vision is an expected adverse effect of this medication. b. will take at least a week before this medication reaches a therapeutic level c. This medication can cause nausea and drowsiness." d. "You will be placed on a low sodium diet while taking this medication." e. "This medication can cause weight gain."

b. will take at least a week before this medication reaches a therapeutic level c. This medication can cause nausea and drowsiness." d. "You will be placed on a low sodium diet while taking this medication."

A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. "We should discuss resources to implement in your daily life." b. "Let me show you simple relaxation exercises to manage stress." c. "We should establish our roles in the initial session." d. "Let's talk about how you can change your response to stress."

c. "We should establish our roles in the initial session."

A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? a. Exclude nutritional supplements from the list of medications the client reports. b. Include any adverse effects of the medications the client might develop c. Compare new prescriptions with the list of medications the client reports d. Encourage the client to make his own list after he returns to his home

c. Compare new prescriptions with the list of medications the client reports

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago. Which of the following manifestations indicates that the client might be experiencing hypoglycemia? a. Hot, dry skin b. Acetone breath c. Confusion d. Polydipsia

c. Confusion

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? a. Noting changes in the treatment plan in the client's medical record b. Recording the client's progress in the nurses' notes c. Having interdisciplinary team meetings for the client on a regular basis d. Posting swallowing precautions at the head of the client's bed

c. Having interdisciplinary team meetings for the client on a regular basis

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care? a. Provide a tracheostomy tray at the bedside. b. Place the client in supine position. c. Insert an IV saline lock d. Place a plastic tongue depressor at the client's bedside.

c. Insert an IV saline lock

A nurse is caring for a client Medical History Client is receiving chemotherapy for treatment of colon cancer Laboratory Results Week 1: WBC count 8,000/mm³ (5,000 to 10,000/mm³) Platelets 350,000/mm³ (150,000 to 400,000/mm³) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2: WBC count 3,800/mm³ (5,000 to 10,000/mm) Platelets 150,000/mm³ (150,000 to 400,000/mm³) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Vital Signs Week 2: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 102/min Respiratory rate 24/min Oxygen saturation 93% on room air A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up? Select all that apply. a. Potassium level b. Breath sounds c. WBC count d. Temperature e. Blood pressure

c. WBC count d. Temperature e. Blood pressure

A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make? a. "Use of a petroleum-based lubricant with a condom increases the condom's effectiveness." b. "Condoms are equally effective for birth control with or without the use of vaginal spermicides. c. "When using implanted contraceptive methods, condoms should also be used to protect against STDs." d. "Ensure that the condom fits snugly over the tip of the penis."

d. "Ensure that the condom fits snugly over the tip of the penis."

A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who has narcissistic personality disorder and is mocking others during group therapy b. A client who has obsessive-compulsive disorder and is upset about a change in daily routine c. A client who has depressive disorder and requires assistance with ADLS d. A client who is taking clozapine to treat schizophrenia and reports a sore throat

d. A client who is taking clozapine to treat schizophrenia and reports a sore throat

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? a. Leaving a nasogastric tube clamped after administering oral medication b. Documenting communication with a provider in the progress notes of the client's medical record c. Placing a yellow bracelet on a client who is at risk for falls d. Administering potassium via IV bolus

d. Administering potassium via IV bolus

A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? a. Both fontanels are the same size. b. Both fontanels show molding c. The posterior fontanel is open. d. The anterior fontanel is open.

d. The anterior fontanel is open.