ATI comprehensive final

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first?

Initiate bag-valve-mask ventilation

The charge nurse is coordinating the evacuation of clients from the 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

Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. The nurse has limited experience with children. Which of the following actions should the nurse manager take?

Assign a unit nurse to act as a resource for the medical-surgical nurse.

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 five years since I've had any immunizations. Which of the following responses should the nurse make?

Let's go ahead with giving you this immunization

A nurse is assessing 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 is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home?

"I'll stick with foods for now"

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 providing discharge teaching to parents whose infants has had a ventriculo-peritoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching?

"We will notify the doctor right away if he has a fever."

A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client.

1. Remove the cap 2. Shake the canister 3. Hold the mouthpiece 2 to 4 cm or 1 to 2 inches from the mouth 4. Tilt your head back slightly and open your mouth wide 5. Depress the medication canister I'll taking a slow deep breath to facilitate delivery of the medication through the airway 6. Hold your breath for 10 seconds, then resume usual breathing pattern

A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child?

12 months old

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

A Client in DKA and a blood glucose of 375

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

A four day old newborn who has elevated Bilirubin level and requires photo therapy

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse?

A leak within the ventilator's circuitry

A nurse is assisting with the plan of care for a client who is post operative following a hip arthroplasty. In the clients medical record, the nurse notes a history of COPD. Which of the following oxygen delivery method should the nurse recommend to use this client?

A nasal cannula

A nurse is caring for a client who is taking acarbose to treat type two diabetes. Which of the following should the nurse monitor for adverse effects?

Diarrhea

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

Accompany the client back to his room

A nurse On the pediatric unit is assisting with the plan of care for a preschooler who will have a surgical procedure in the morning. The child has been crying despite his parents 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 is assisting with developing a plan of care for a client who has GERD. The nurses should suggest monitoring the client for which of the following complications?

Aspiration

A nurse is assisting with the admission of a client who has a urinary tract infection and a history of Myelomeningocele. After the admission history is complete, which of the following actions should the nurse recommend?

Attach a latex allergy alert identification band

a nurse is teaching a client who has extensive deep partial-and full-thickness burns and requires a topical antimicrobial medication. the nurse should explain to the client that the goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth

A nurse is discussing medication administration for an older adult client with a newly licensed nurse. The nurse should identify that, due to physiological changes of aging, older adult clients might need dosage adjustments due to an increase in which of the following parameters?

Body fat

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 to pregnancy?

Breast tenderness

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 the list of calcium sources for this client?

Collard greens

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

Candidiasis

A nurse in the ED is caring for a client who report s pain in her left leg following a motor-vehicle crash. The nurse notes that her left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first?

Check neurovascular status distal to the injury.

The healthcare facilities 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 input about planning and implementing the change

A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus 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 has requesting a prescription for sildenafil citrate. Which of the following data in the clients record should the nurse identify as a contradiction for the use of this medication?

Current use of isosorbide to treat heart failure

A nurse is collecting data from a client who has aids and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider?

Decreased hemoglobin

A nurse is reinforcing teaching with the parents of an infant who has a cleft palette. The parents asked the nurse how long they should wait before he should have corrective surgery. The nurse should explain that 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 MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the clients 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 assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)

Headache

A nurse in an acute care facility is implementing the facility's disaster plan following a flood in the community. Which of the following actions should the nurse take?

Identify stable clients in the ICU to transfer to the medical surgical units.

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

If the patient seems confused, I will raise all four side rails so that he doesn't hurt himself

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

Obtain the services of an interpreter

A nurse is reviewing 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 post operative care of a client following an appendectomy. Which of the following actions should the nurse assigned to an assistive personnel?

Record urinary output after emptying the indwelling urinary catheter

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following findings should indicate to the nurse that the AAA is expanding?

Report of sudden severe back pain

A newly licensed nurse in an urgent care center is caring for a client 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 caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first?

Stop the medication infusion.

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 most about being hospitalized

A nurse is reinforcing teaching with a client who has type two diabetes. 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 providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia?

patch the unaffected eye.

A nurse is reinforcing teaching with the Parent of a child who has a new prescription of iamotrigine 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 delegates newly Licensed nurse to provide one on one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching?

Ambulates the client's roommate while the client sleeps

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

Give the client a written record of his blood pressure to bring to his provider

A nurse in a substance use disorder program is interacting with the client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?

I have read that problems with substance can have a variety of predisposing factors

A nurse in the providers office is talking with an older adult client reports having trouble sleeping. Which of the following statements should the nurse identify as a possible causes for the patients sleeping difficulties?

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

A nurse is caring for a client who takes more friend to treat chronic a fib and has early manifestations of Alzheimer's disease. The clients partner asked 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 going to medical surgical unit is caring for a client who developed deep, rapid respirations. Arterial blood gas Analysis: pH 7.25, PaCO2 morning 40, HCO3 18. Which of following should a nurse identify and report to the provider?

Metabolic acidosis

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 clients level of orientation?

Post a large calendar on the bulletin board

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?

Prolonged Q-T intervals

A nurse is teaching a client who has chronic kidney disease about predialysis dietary recommendations. The nurse should include information about restricting his intake of which of the following nutrients?

Protein

A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the following assessments is the nurses priority?

Pulmonary function

A nurse is providing teaching to 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 medications.

A nurse is providing teaching to a client who has come to the family planning clinic requesting an IUD. Which of the following information should the nurse provide the client?

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

A nurse in an urgent care center is collecting data from a group of clients who all have in odor Of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse?

A client who is difficult to arouse and is unable to respond to questions

A nurse in the labor and delivery suite is planning care for a group of four clients. Which of the following clients should the nurse see first?

A client who is in active labor and has late decelerations on the fetal heart monitor's strip.

A nurse in an acute care clinic is talking with the client reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss nonpharmacological approaches that will relieve her pain. Which of the following interventions should the nurse suggest?

Apply warm compresses to sore joints

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 on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client?

Build trust with the client by sitting quietly with him

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

Hematocrit 55%

A community health nurse is preforming client triage while participating in a disaster drill. The nurse should recommend that which of the following clients receives treatment first?

Hemothorax

A nurse is reviewing the laboratory report for a client who has CDK. The nurse finds the following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, and phosphate 4.8. Which of the following findings is the priority for the nurse to report to the provider?

Hyperkalemia

A nurse is reinforcing teaching with a client who has a spinal cord injury and will need to perform intermittent urinary self catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?

I will perform intermittent self catheterization every 2 to 3 hours

A nurse is reinforcing teaching with the parent of a child who has type one diabetes how to manage the child's disorder during illness, such as cold. 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 caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication?

INR 3.0

A provider tells a client who reports practicing Hinduism that at 12 weeks gestation she needs more protein in her diet and suggest eating more meat. After the provider leaves examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?

Let's discuss other foods that are also high in protein that you could substitute for meat

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

Meperidine

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

Offer the client a diet high in fluid and fiber

A nurse is teaching the parent of a child who has severe reactive airway disease about glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it orally. Which of the following information should the nurse provide the parent?

Oral glucocorticoids are hazardous during times of stress.

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

Palpating the clients fundus

A nurse is caring for a client who has a pseudomembranous colitis do to CDIff. Which of the following interventions is the nurses priority?

Performing hand hygiene before and after contact with the client

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 ox of 85%

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

Rotate injection sites within the same area

A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include?

Sit with your back supported, keep your knees at hip level, use an ergonomically designed computer keyboard

A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following finding should the nurse identify as an indication of an acute intravascular hemolytic reaction?

Sudden oliguria

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 evaluating the injection site for a client who had a Mantoux skin test 48 hours 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 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 clients insomnia?

The client watches television in her bed during the day

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 assisting to prepare for the transfer of a client from the post anesthesia care unit following a sub total thyroidectomy. Which of the following equipment should the nurse have available at the patient's bedside?

Tracheostomy tray

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

Walking with a staff member

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 information?

Areas with no public access

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

Initiate airborne precautions

A nurse at a long-term care facility hears an 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 assisting with the care of a client who has Addison's disease and comes to the emergency department reporting nausea, vomiting, diarrhea, and of abdominal pain. To prevent addisonian crisis, the nurse should expect that the provider will prescribe which of the following medications?

HydroCortisone

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

Keep the cast above the level of your heart

A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction. Which of the following manifestations should the nurse identify as indications Of a myocardial infarction?

Nausea and vomiting Diaphoresis and dizziness Anxiety and feelings of doom

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include?

"You might need glasses after the surgery."

a nurse on an oncology unit receives report at the beginning her shift about four clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an stony bag full of bright red, bloody drainage.

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 spent the past several minutes mumbling about being doomed to die and is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurses priority?

Attempt to reduce environmental stimuli

A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home?

Blood pressure

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse finds that the client has absent breath sounds on the left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client.

Chest tube insertion

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record to the clients bedside and perform which of the following verification procedures?

Compare the medical record number and name on the medication administration record with the clients identification band

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 the conversation?

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