ATI Nursing Concepts Advanced Test
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?
"It is the responsibility of the provider to obtain express consent."
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?
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 has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication?
Excessive vomiting Due to loss of acid from the body
A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?
Hypoglycemia Betamethasone causes hyperglycemia in the mother which predisposes the neonate to hypoglycemia in the first hours after delivery
A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?
Lethargy Rationale: bc lethargy occurs when pressure is placed on the reticular activating system within the brainstem
A nurse at a long-term care facility is participating in a quality improvement project to reduce the 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?
Outcome audit This is conducted to determine the actual result a specfic nursing intervention has had on client outcomes
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?
stop the infusion Rationale: bc it prevents further damage to vessel and minimizes any additional harm to the client
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?
supine with head of the bed (HOB) elevated to 30 degrees Rationale: the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing bloodflow to the brain
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?
"I can have 1-2 alcoholic beverages a week." Rationale: Buspirone is an anxiolytic medications used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, it does not interfere with CNS depressants, such as benodiazepines, alcohol, or barbiturates, and it is acceptable to have 1-2 alcoholic beverages each week.
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?
"I will have my husband wear a condom during intercourse." NO SEX with PROM
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?
"Let's discuss some strategies you can use when this happens again."
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?
Determine respiratory status Rationale: The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening therefore, the nurse should first determine the clients respiratory status.
A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? (Select all that apply.)
Dietitian Physical therapist Social Work
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?
Elevated temperature
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?
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 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?
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 therefore. experience a reduced bleeding time as a result of a transfusion of platelets.
A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first?
Take an ABG specimen to laboratory Rationale: because ABGs are kept on ice and should be transported immediately to the labratory or the specimen will deteriorate
A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign?
an adolescent who is 2 days post operative following an appendectomy Rationale: The care of an adolescent who is 2 days postoperative following an appendectomy requires postoperative care including education, infection prevention, and medications that require fundamental nursing skills and knowledge; therefore it is appropriate to assign this client to the nurse who has floated from the labor and delivery unit
A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching?
cue client by providing cards that portray common needs
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?
discuss risks associated with leaving
