ADN ATI practice questions

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. which of the following statements by the client indicates an understanding of the teaching?

"I can expect this medication o turn my skin orange" Why? -The nurse should instruct the client to expect the skin & urine to turn a reddish-orange color while taking rifampin. -Take on an empty stomach. Take with isoniazid with a B-complex vitamin.

A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment likely will involve which of the following procedures?

Colonoscopy Why? A colonoscopy requires the insertion of a flexible scope into the rectum. The provider advances the scope carefully until it enters the colon. It can provide direct visualization of the inside of the colon & helps the provider identify the exact cause and location of bleeding.

A nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect?

Hyponatremia Why? Due to excessive release of ADH. As a result the client retains water, which causes dilutional hyponatremia. -Client will retain water which leads to decreased urine output and client will be hydrated.

A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take?

Instruct the child to use a soft-sponge toothbrush when brushing her teeth. Why? -A regular toothbrush may cause further irritation to the mucosal ulcers. -Don't take viscous lidocaine, it depressed the gag reflex, increases risk of aspiration. -Don't nt use hydrogen peroxide due to drying effects on mucosa. -Avoid lemon glycerin swabs with mucosal ulcerations due to irritation.

A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should then nurse include in the plan?

Monitor the child for increase temperature. Why? -To monitor child for a fever. -Maintain best rest for child who has decreased RBCS. -Administer oxygen to child who has decreased RBS & low oxygen saturation. -Monitor child who has low platelet level for bleeding. Normal platelet level 150,000-450,000

A nurse is assessing a client whose sister recently died in a motor vehicle crash. The nurse should identify that which of the following factors indicates an increased risk of complicated grief reaction?

The sudden occurrence of the death. Why? -A sudden, unanticipated death can complicate the mourning process & lead to a complicated grief reaction. Other factors include death from a lengthy illness, the loss of a child, or the perception that death was preventable.

A nurse is admitting a child whop has Wilms' tumor. Which of the following actions should the nurse take?

Put a "no abdominal palpation" sign over the child's bed. Why? Palpation isn't necessary to confirm diagnosis & could prompt metastasis. Wilms' tumor-Most common type of kidney cancer in children.

A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the following actions should the nurse take?

Warm the dialysate solution prior to administration. Why? To prevent pain and abdominal cramping. -Cleanse -Place drainage bag below level of clients abdomen. -Apply sterile gloves & use 3 cotton swabs soaked in povidone-iodine to cleanse the catheter site. (destroys bacteria & prevents infection)

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery." Why? Nightmares 7 sleep disturbances are manifestations of anxiety & PTSD. These indicate a risk of experiencing psychological distress.

A nurse is present at the time of a child's death following a terminal illness. Which of the following statements should the nurse make to the child's parent?

"I will miss your child's infectious laugh; it always made me smile." Why? -Expressing personal feelings about the loss of the child can convey empathy and support the grieving parent. Describing the positive impact the child has, such as making others smile, is a way to share positive memories with the patient.

A nurse is caring for a client who is post-op rhinoplasty. Which of the following findings should the nurse report to the surgeon?

Frequent swallowing. Why? It indicates posterior nasal bleeding & possible hemorrhage. Edema of nose, eyes & face are expected findings. Mouth breathing & Ecchymosis of the nose eyes & face are expected findings.

A nurse is assessing a client who is post-op following a craniotomy and has a urine output of 600 ml/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to asses for DI?

Specific gravity Why? Diabetes insipidus is caused by damage to the hypothalamus or pituitary gland as a result of cranial surgery, infection or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.

A nurse in the ER is caring for a client who has a snakebite on her arm. Which interventions should the nurse implement?

a. Immobilize the limb at the level of the heart. Why? To limit the spread of venom. Any constructive clothing or jewelry should be removed before swelling worsens & the affected limb should be immobilized at the level of the heart. Tourniquets, incising the wound & ice is no longer accepted treated and is now contraindicated.

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

History of anorexia nervosa Why? Inadequate protein intake can lead to decreased bone density, increasing the risk of fractures.

A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurses priority?

a. Paresthesia b. Alopecia c. Stomatitis d. Constipation -Paresthesia. Why? -Apply safety and risk reduction setting framework. Client safety is highest priority. -Vincristine, a cell-cycle specific chemotherapy agent, interrupts cellular reproduction at mitosis and can cause neurotoxicity.

A nurse is providing discharge teaching to a client who has a pulmonary embolism. Which of the following statements indicates that the client understands the information?

"Ill call the doctor if I see any blood in my urine. Why? Bleeding precaution are essential for clients who has a pulmonary embolism because they take an anticoagulant. The should report any signs of bleeding and leg swelling or tenderness. The vena cava filter remains in place until provider determines there isn't a high risk for clot formation or permanently. Clients who has a pulmonary embolism typically require anticoagulant therapy for weeks to years after the acute event.

A nurse is providing counseling for a couple experiencing infertility issues. Which of the following statements by the nurse is appropriate?

"You might want to join our support group for couples who are experiencing similar problems." Why? -An invitation to join a support group will promote emotional, social and spiritual growth. Many positive results from peer support can occur.

A nurse is caring for a child who has leukemia and is receiving chemotherapy. The child's parent is upset and says "I just cant believe my child is going to lose her beautiful hair!" Which of the following responses should the nurse make?

"You're feeling a sense of loss right now." Why? -This response offers a general lead to the parent and encourages further discussion.

A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a client. Which of the following findings should the nurse report to the provider?

Color variation within a lesion. Why? -The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for evolving or changing in any feature of the lesion. A-Asymmetric B-Border irregularity C-Color variation D-Diameter >6mm E-Evolving

A nurse is monitoring a client who has graves disease for the development of thyroid storm. The nurse should report which of the following findings to the provider?

Hypertension. Why? A client experiencing a thyroid storm will have an exaggerated condition of hyperthyroidism associated with the development of a fever, hypertension, abdominal pain & tachycardia. Graves disease is a common cause of hyperthyroidism, which is an imbalance of metabolism caused by overproduction of thyroid hormone.

A school nurse is providing care to a student who is angry and states, "My parents don't know i am gay, so i cant visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing?

Disenfranchised grief Why? Disenfranchised grief occurs when social expectations restrict an individuals ability to cope with grief in an expected way. Can occur when the social relationship between the client & another person cannot be openly recognized. Client has no social support.

A nurse is planning care for a 6-year old child who is receiving chemotherapy., The child has a hightlight platelet count of 20,000m^3. Based on the lab value, which of the following interventions should the nurse include in the plan of care?

Encourage quiet play. Why? The client is a risk for excessive bleeding due to his LOW platelet level. Quiet play will lessen the clients risk of injury, thereby reducing the chance of hemorrhage.

A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones?

Parietal Why? -The parietal bones from the larger part of the upper and side wall of the cranium. -Sphenoid bone forms part of the face. -Occipital bone is in back of skull. -Frontal lobe is in front of skull.

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial. -Islamic faith-bod of deceases is washed, wrapped then buried ASAP. -Hindu faith-place body with head facing north. Cremation rather than burial. -Buddihst faith-Male family memebers prepare the body following death.

A nurse is preparing to provide self-care teaching to a client who is 4 days post-op following the creation of a colostomy & refuses to look at the stoma. Which of the following actions should the nurse take?

Postpone any teaching with the client at this point. Why? Refusal to look at the stoma indicates the client is in the denial stage of grief and might not be able to learn anything further at this time about self-care of the colostomy.

A nurse in an acute mental healthy facility is participating in a group therapy session during which clients enact realistic situations to help process past events. Which of the following types of group therapy is occurring?

Psychodrama group. Why? In psychodrama group, members actually take parts & act out a clients past experiences in the present time. It allows a client to process & gain insight into past experiences that the client has identified as a significant emotional issue.

A nurse in a providers office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations?

Regurgitation, Nausea, Belching & Heartburn.

A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take?

STOP in infusion Elevate the extremity Notify the provider Remove the IV line. Why? -Extravasation is the infusion of vesicant solutions or medications into the surrounding tissues. After observing extravasation, the nurse should FIRST stop the infusion. -The IV line is not removed until the providers prescriptions have been initiated.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client?

Sitting while leaning forward over the bedside table. Why? -This position maximizes the space between the clients ribs and allows aspiration of accumulated fluid and air.

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes as a shallow crater in the epidermis of the clients sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages?

Stage 2 Why? A stage 2 pressure ulcer involves partial-thickness skin loss of the epidermis & the dermis. The ulcer is visible & superficial & can look like an abrasion, blister or shallow crated. Edema persists, & the ulcerr might become infected. The client might report pain, & there might be a small amount of drainage.

A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states she does not understand how she will be alright without her gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder?

Storing bile. Why? The primary function of the gallbladder is to store bile. Because this organ is only for storage, the clients liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum, where it will preform various functions.

A nurse in an ER is caring for a client who sates, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the clients medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take?

Talk to the client about making a safety plan. Why? -It is important to support the client 7 take actions such as counseling the client about making a safety plan. The nurse should understand local laws regarding intimate partner violence & should report the incident as required.

A nurse is assessing the dynamics of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider?

The child has several unexplained scars &n bruises. Why? Child maltreatment is suspected when child has multiple unexplained scars and bruises.