2-ATI (Nursing Concepts)(Adv Test)

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? a) Cue the client by providing picture cards that portray common needs. b) Increase the volume of the voice when speaking to the client. c) Encourage the client to limit hand gestures when communicating. d) Vary the use of phrases and terminology in discussions.

a)

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? a) Reduced bleeding time b) Decreased plasma globulins c) Improved activity tolerance d) Increased immune functioning

a) The formation of a platelet plug then triggers the more formal process of blood coagulation. 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 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? a) Increased appetite b) Elevated temperature c) Bradycardia d) Drowsiness

b) An elevated temperature is a finding associated with acute alcohol delirium.

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? a) Tachycardia b) Sternal retractions c) Hypoglycemia d) Hypothermia

c) Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

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? a) Prone with head of the bed flat b) Dorsal recumbent with head of the bed elevated to 15° c) Supine with head of the bed elevated to 30° d) Side-lying with head of the bed elevated to 45°.

c) Following a supratentorial craniotomy, the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain. Positioning the client supine with the head of the bed elevated to 30° is appropriate

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? a) Administer epinephrine (Adrenaline). b) Elevate the lower extremities. c) Determine respiratory status. d) Apply oxygen via non-rebreather mask.

c) The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.

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? a) Provide a toy doctor's kit to play with. b) Keep all syringes and needles out of sight until needed. c) Use an approach that is firm but direct. d) Allow the child to manipulate the medical equipment.

d) 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? a) Hyperkalemia b) Severe diarrhea c) Atelectasis d) Excessive vomiting

d) Metabolic alkalosis is a potential complication of excessive vomiting because of the loss of acid from the body.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? a) Take an ABG specimen to the laboratory. b) Transport a client to the radiology department for an x-ray. c) Obtain a clean catch urine sample from a newly admitted client. d) Pass fresh water to clients.

a) ABG samples are kept on ice and should be transported immediately to the laboratory or the specimen will deteriorate, which will cause inaccurate and meaningless results. This is the task the nurse should instruct the AP to perform first.

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? a) "I will have my husband wear a condom during intercourse." b) "I will check my temperature every 4 hours." c) "I will wipe from front to back after bowel movements." d) "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."

a) The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of the increased risk for infection

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? a) Facial edema b) Urinary frequency c) Acid indigestion d) Breast leakage

a) Facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.

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.) a) Dietician b) Physical therapist c) Hospice nurse d) Social worker e) Respiratory therapist

a, b, d Dieticians have expertise related to dietary contributions to maintaining health and treating disease and can offer the team suggestions that promote wound healing and muscle repair. Physical therapists have expertise related to the musculoskeletal system and implements therapeutic treatments that will rebuild and improve strength, teach new skills, and regain mobility Social workers have expertise in working with clients and families to resolve issues that arise due to health problems and can link the client with community resources, assist with developing the discharge plan, and resolve conflict.

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? a) "I will only be on this medication 4 to 6 months because it can lead to physical dependence." b) "I can have 1 to 2 alcoholic beverages each week." c) "I will need to stop taking Xanax two weeks before I can begin taking this medication." d) "I can have 6 to 8 ounces of grapefruit juice each day."

b) Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching.

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? a) Prospective audit b) Outcome audit c) Process audit d) Structure audit

b) n outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.

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? a) "I know this must be difficult, but your mother will calm down soon." ​b) "Let's discuss some strategies you can use when this happens again." c) "Individuals near death are ready to let go toward the end." d) "Have you determined why she is crying and saying she is ready to die?"

b) This response by the nurse offers to provide information, which can reduce anxiety and enhance decision-making. This response by the nurse creates a safe and secure environment, fosters trust and respect, and is appropriate.

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)? Pupil dilation Ataxia Lethargy Bradycardia

c) Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP.

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? a) "It is necessary to have written consent for invasive procedures." b) "Implied consent is appropriate for some aspects of nursing care." c) "It is the responsibility of the provider to obtain express consent." d) "Informed consent should be obtained separately for each surgical procedure."

c) Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching

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? a) Assign a security guard to stay at the client's door. b) Request a prescription from the provider for soft restraints. c) Discuss the risks associated with leaving with the client. d) Remove the telephone from the client's room.

c) The content of this question emphasizes the concept of professionalism by determining the legal actions of the nurse when a client leaves a facility against medical advice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Discussing the risks associated with leaving the facility against medical advice with the client is a priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician-prescribed discharge.

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? a) Notify the provider. b) Obtain a chest x-ray. c) Flush the catheter. d) Stop the infusion.

d) Stopping the infusion is the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. This prevents further damage to vessel and minimizes any additional harm to the client.

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? a) A preschooler with a hip spica cast who is being discharged today b) An infant scheduled for a surgical repair of a ventricular septal defect tomorrow c) A toddler with a fractured femur who has been in Bryant's traction for 5 days d) An adolescent who is 2 days postoperative following an appendectomy

d) 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.