Comprehensive Final ATI

A nurse is reinforcing teaching with the parents of an infant who has a cleft palate. The parents ask the nurse how long they should wait before he should have corrective surgery. The nurse should explain what the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes?

Difficulty with language acquisition

A nurse is caring for a client who has a methicillin-resistant staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting

A nurse is assisting with the care of a client who has Addison's disease and come to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse should expect that the provider will prescribe which of the following medications?

Hydrocortisone

A nurse is caring for a client who is taking warfarin. Which of the following lab values should the nurse recognize as an effective response to the medication?

INR 3.0

A nurse is collecting data from a client who has tuberculosis and a prescription for ethambutol. The nurse should inform the client that he is likely to develop which of the following alterations as an adverse effect of this medication?

Loss of red/green color discrimination

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse recommend for the client's plan of care?

Offering the client a diet high in fluid and fiber

A nurse is reinforcing teaching with the parents of a child who has a new prescription of lamotrigine for a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?

Rash

A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make?

The client has had an exposure to tuberculosis.

A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask?

"Does anyone smoke around or in the same house as your child?"

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause for the client's sleeping difficulties?

"I often have a cup of coffee with my dessert before going to bed."

A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following statements should the nurse provide further reinforcement of teaching?

"I prefer tub baths to showering."

A nurse is reinforcing teaching with the parent of a child who has type 1 diabetes mellitus how to manage the child's disorder during illness, such as colds. Which of the following statements by the parent indicates an understanding of the teaching?

"I'll check his blood glucose more often."

A nurse is reviewing the use of side rails with an assistive personnel (AP). which of the following statements by the AP indicates further instruction is required?

"If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself."

A nurse is caring for a client who takes warfarin to treat chronic atrial fibrillation and has early manifestations of alzheimer's disease. The client's partner asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?

"It is likely that ginkgo biloba will interfere with the effectiveness of his other medications."

A nurse is reinforcing teaching with a family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions?

"It will help our child if we structure our daily routine."

A nurse at a long-term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions?

"It's almost time for your appointment..Let me do your hair for you and brush your teeth."

A nurse is reinforcing teaching with a school-age child who has just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse reinforce with the child and his parents about care during the first 48 hr?

"Keep the cast above the level of your heart."

A nurse is collecting data from a 66-year-old client during a routine physical examination at her first clinic visit and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since i had any immunizations." Which of the following responses should the nurse make?

"Let's go ahead with giving you this immunization"

A nurse is reinforcing teaching with a client who is going to have an EEG in the morning. Which of the following information should the nurse provide the client?

"Shampoo your hair before the procedure, and don't put any styling products on it afterward."

A nurse is reinforcing teaching with a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following information should the nurse reinforce with the client?

"Your risk for ectopic pregnancy increases with an IUD."

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day.

A nurse is assisting with the admission of a client to the medical unit and asks him if he as advance directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document

A nurse is reinforcing discharge teaching with a client who has a new prescription for metoprolol. Which of the following instructions should the nurse include? (Select all)

"Do not stop taking this medication abruptly." "Count your radial pulse daily." "Change positions slowly."

A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?

"Tell me about your favorite video game."

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make?

"Tell me what concerns you the most about being hospitalized."

A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make?

"The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common."

A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?". Which of the following responses should the nurse make?

"This must be so difficult for you."

A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?

"Use a stable, relaxing routine, such as a bath and story time, before bed."

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse make?

"You don't have to give up pasta; just adjust the amount you eat."

A nurse is reinforcing teaching with a client who is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include?

"Your procedure will only take 10 or 15 min. for each eye."

A nurse is reinforcing teaching with a client about how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?

1. "Hold the mouthpiece 1-2 inches in front of your mouth" 2. "Tilt your head back slightly and open your mouth wide." 3. "Depress the canister while taking a slow deep breath." 4. "Hold your breath for 10 seconds."

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization?

A 10-piece wooden puzzle

A community health nurse is contributing to the plan of care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for the first?

A 4-day-old newborn who has an elevated bilirubin level and requires photo-therapy

A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?

A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL

A nurse in a long-term care facility for a group of clients. One of the client's is walking in the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take?

Accompany the client back to his room.

A nurse on a pediatric unit is assisting with the plan of care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parent's presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan because it offers which of the following benefits?

Allows the child to manipulate toy medical equipment

A nurse in an urgent care center is reviewing lab results for several clients who have manifestations of influenza. Which of the following clients should the nurse report to the provider immediately?

An infant whose WBC count is 24,000/mm3

A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?

An irregularly shaped brown lesion with light blue areas on the neck

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?

Apply continuous pressure to the lower part of the child's nose

A nurse is caring for a client who has a platelet count of 50,000 /mm3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take?

Apply pressure to the catheter removal site for 10 min.

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding?

Arm cast for a spiral fracture of the forearm

A nurse is assisting with developing a plan of care for a client who has gasteroesophageal reflux disease (GERD). The nurse should suggest monitoring the client for which of the following complications?

Aspiration

A nurse is observing a client who has schizophrenia and is in the dayroom when another client asks him if two items of clothing math. He replies, "A math. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these these statements as which of the following speech alterations?

Associative looseness

A nurse is assisting with the admission of a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After the admission history is complete, which of the following actions should the nurse reccommend?

Attach a latex allergy alert identification band

A nurse is caring for a client who has deep partial and full- thickness burns and requires a topical antimicrobial drug. The nurse should reinforce with the client that the goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth

A nurse is reinforcing discharge teaching with a client who had a transient ischemic attack (TIA). The nurse should instruct the client to monitor which of the following parameters at home?

Blood pressure

A nurse in a prenatal clinic is collecting data from several clients. Which of the following client reports should the nurse identify as an expected physiologic adaptation of pregnancy?

Breast tenderness

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage.

A nurse is collecting data from a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection?

Candidiasis

A nurse responds to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first?

Check airway patency

A nurse is reinforcing teaching with a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client to report which of the following manifestations to the provider?

Chest pain

A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?

Collard green

A health care facility's leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first?

Collect the staff's input about planning and implementing the change

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's beside and preform which of the following verification procedures?

Compare the medical record number and name on the MAR with the client's identification band.

A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus (SLE) and is to begin medication therapy. Which of the following types of medications should the nurse expect to administer?

Corticosteroids

A nurse is reviewing the medical record of a client who is requesting a prescription for sildenafil citrate. Which of the following data in the client's record should the nurse identify as a contraindication for the use of this medication?

Current use of nitroglycerine to treat heart failure

A nurse is contributing to the plan of care for a client who had a stroke and is to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend to take prior to initiating each feeding?

Elevate the head of the bed

A nurse is collecting data from a client who is taking varenicline for smoking cessation. Which of the following finding is a nurse's priority?

Erratic behavior

A nurse is reviewing the laboratory data of a client who reports manifestations that suggest systemic lupus erythematosus (SLE). The nurse should expect an increase in which of the following parameters for a client who has SLE?

Erythrocyte sedimentation rate (ESR)

A nurse is discussing fire safety with newly hired nurses. The nurses should identify which of the following actions as the priority if a fire occurs in the healthcare facility?

Evacuate clients from the unit

A nurse is caring for an older adult client who has in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound?

Excessive wax in the ear canal

A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?

Explain that it is against policy to share access codes and refer the resident to his supervisor

A nurse participating in a community health fair is providing information to a client who has BP of 150/90 mmHg during a blood pressure screening. Which of the following actions should the nurse take?

Give the client a written record of his BP to bring to his provider

A nurse is caring for a client who has dehydration. Which of the following lab values should the nurse expect for this client?

Hct 55%

A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider?

Hyperkalemia

During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing client's information?

In the unit medication room

A nurse i reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?

Increase her caloric intake with meals

A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority?

Initiate airborne precautions

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process?

Instruct clients who are able to ambulate to leave

A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client?

Lateral

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make?

Maintain the head of the bed at 30 degrees

A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurse's priority to collect?

Measure the client's weight daily

A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?

Meperidine

A nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of the following finds should the nurse report to the provider as indication of impending airway obstruction?

Nasal Flaring

A nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter

A nurse is assisting with the care of a client who had precipitous delivery. The nurse should identify the collection of which of the following data as the priority during the fourth stage of labor?

Palpating the client's fundus

A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is teh nurse's priority?

Performing hand hygiene before and after contact with the client

A nurse is reinforcing teaching with a client who has a new prescription for doxycyclin. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication?

Photo-sensitivity

A nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation?

Post a large calendar on the bulletin board

A nurse is assigned to care for several clients who are postoperative. The nurse should identify the client taking which of the following medications is at risk for delayed would healing?

Prednisone to treat persistent arthritis exacerbations

A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?

Pulse oximetry of 85%

A nurse is review the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

Reading the newspaper

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)?

Record urinary output after emptying the indwelling urinary catheter.

A nurse is reinforcing discharge teaching with a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include?

Reduce dietary sodium

A newly licensed nurse in an urgent care center is caring for a child who has bruises that the nurse suspects are due to child abuse. Which of the following actions should the nurse take?

Report the suspected abuse to local authorities.

A nurse is reinforcing teaching about self-administration of NPH insulin with a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include?

Rotate injection sites within the same area

A charge nurse in a long-term care facility notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the charge nurse plan to take?

Send an e-mail to each non-adherent employee that includes a link to upcoming educational sessions.

A charge nurse in a skilled nursing facility notes several recent conflicts among staff on different shifts. Which of the following strategies should the charge nurse plan to use to resolve these conflicts?

Set up a series of meetings for all staff members to attend to discuss issues.

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior?

Speak to the client with clear, calm, caring statements

A nurse is collecting data from a school-age child who has celiac disease. Which of the following findings should the nurse expect?

Steatorrhea

A nurse is reinforcing teaching with a client who has a new prescription for sertraline. The client asks the nurse if he should continue to take St. John's wort for depression. Which of the following instructions should the nurse give the client?

Stop taking the herbal supplement while taking the medication.

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction?

Stop the infusion

A nurse is collecting data from a client who is receiving clozapine to treat schizophrenia. The nurse should identify that an increase in which of the following parameters is an early indication of agranulocytosis?

Temperature

A nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse recommend to include?

The importance of colonoscopy screening starting at age 50 years old.

Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18-month-old infant who has Pneumocystis carinii pneumonia indicate that she is HIV positive. When assisting with planning care, the nurse should consider which of the following factors?

The infant's mother is likely HIV positive

A nurse is assisting to prepare for the transfer of a client from the postanesthesia care unit (PACU) following a subtotal thyroidectomy. Which of the following equipment should the nurse have available at the client's bedside?

Tracheostomy tray

A nurse is reinforcing teaching with a client about treatment options for profound sensorinerual hearing loss. The nurse should include which of the following information about the function of the cochlear implants?

Transmits impulses directly to auditory nerve endings nerve endings

A nurse is preparing to administer 10 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take?

Use separate syringes for administering insulin glargine and NPH insulin

A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for this client?

Walking with a staff member

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which of the following actions indicate to the nurse the AP understands how to perform this task?

locks the brakes on the bed and the wheelchair before moving the client