ATI Comprehensive final

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 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?

-Diaphoresis, dizziness, -anxiety, impending doom, -nausea, and vomiting Nausea, vomiting, and epigastric distress are common manifestations of MI. Diaphoresis (sweating), dizziness, fatigue, and anxiety are common manifestations of MI. Anxiety and feelings of doom and fear are common manifestations of MI.

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 -useergonomically designed computer keyboard Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain.

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 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 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?

A companyto his room The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect the client from injury due to wandering.

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 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.

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 major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express his fear of the unfamiliar medical equipment in the hospital. The nurse encourages the child to touch the equipment to decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.

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 One-on-one observation requires constant supervision of the client. The client might wake up and engage in self-injurious behavior while the newly licensed nurse is caring for the other client.

A nurse in an urgent care center is reviewing laboratory results for several clients who have benefit stations of influenza. Which of the following clients should the nurse report to the provider in mediately?

An infant who is wbc count is 24,000

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?

And 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 With the child sitting up and breathing through his mouth, the nurse should apply continuous pressure with her thumb and forefinger to the soft lower area of the nose for 10 min. Most bleeding from the nose stops within that period.

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 Warm packs or warm soaks, such as in a bath or hot tub, are often effective for relieving arthritic pain. The nurse should encourage the client to avoid temperatures hot enough to cause burns. She should plan for a temperature just a little warmer than body temperature for optimal comfort.

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 Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury.

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 Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled regurgitation, whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which is an indication of aspiration. Infection

A nurse is observing a client who has schizophrenia and is in the day room when another client asks him if two items of clothing match. He replies a match. 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 statements as which of the following speech alterations?

Associative looseness The nurse should identify that this client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts that lead from one to another.

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 Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.

A nurse is reinforcing discharge teaching with a client who had a 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 to pregnancy?

Breast tenderness

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 The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and the use of silence are actions that promote trust which encourages the client to speak more openly about issues and concerns.

A nurse is beginning her shift and reviewing the medication administration records for her clients. She notes a dosage of 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 After collecting data from the client to check for adverse effects of the medication, the nurse should notify the provider of her observations to determine the next action.

A nurse response 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 reinforcing teaching with an assistive personnel about dietary restrictions for a client who is taking phenelzine to treat depression. The APs selection of which of the following foods for the clients lunch indicates an understanding of the instructions?

Chicken salad Phenelzine is an MAOI. Clients taking MAOIs must avoid foods that contain tyramine due to a dangerous food-drug interaction. Foods high in tyramine include those that are processed and aged, such as luncheon meats and cheeses. This menu selection does not contain food high in tyramine; therefore, it is the best choice.

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 Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. They also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects.

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 The charge nurses should apply the nursing process priority-setting framework. The nurses can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, he must first collect adequate data. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the charge nurses should collect data about the situation by gathering the staff's input, and collaborate about implementing the change smoothly and efficiently.

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 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 assisting with the admission of a client to the medical unit and ask him if he has advanced directives. The client states I have a document with me the name of someone who can make healthcare decisions for me I am not able to. Should identify that the client is referring to which of the following documents?

DPA A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

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 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the priority finding for the nurse to report to the provider is a decreased hemoglobin level. Zidovudine can cause severe anemia and neutropenia from bone marrow suppression resulting in hematologic toxicity.

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 Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With the cleft in the palate, these infants could develop poor speech habits.

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 Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require that any staff who will have contact with the client's environment don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client, and a mask and goggles if secretions from the infected area could spray into the worker's face. Delivering the tray would require contact with the environment; therefore, the dietary assistant must wear gloves.

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 Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should take actions to prevent aspiration, such as elevating the head of the bed, prior to initiating the feeding.

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

Erratic Behavior The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to the client is the development of neuropsychiatric effects that can progress to depression and suicide. Therefore, the highest priority finding is erratic behavior.

A nurse is discussing the fire safety with newly hired nurses. Which of the following identify as the priority if a fire occurs in the health care facility?

Evacuate clients from the unit

A nurse is talking with a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include?

Extended periods of immobility increase your risk for osteoporosis

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

Hematocrit 55%

A nurse is reinforcing teaching with a client about how to use an albuterol MDI. 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?

Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds

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 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 female client who has we currency Cystitis asked the nurse about preventing future episodes. Which of the following statements should the nurse provide for the reinforcement of teaching?

I prefer tub baths to showering Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women who are at risk for UTIs should avoid tub baths because they increase the risk for infection. The nurse should remind the client to take showers instead of tub baths.

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 The client may initially require self-catheterization every 2 to 3 hr with the frequency eventually increasing to every 4 to 6 hr. A longer interval can result in bladder distention and increased risk for urinary tract infection.

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 The parent should check the child's blood glucose every 3 hr during an illness because it tends to rise, even if the child eats less food.

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

Prednisone to treat persistent arthritis exacerbations

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 Warfarin is an anticoagulant that prevents thrombus formation in susceptible clients. The INR measures its effectiveness. For most clients taking warfarin, an INR of 3.0 indicates effective therapy.

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 Raising all four side rails can put the client at greater risk for injury. He might try to climb over the side rails, which could result in a fall or injury.

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?

In the unit medication room Nurses should only discuss clients' information in areas where no one else can overhear the discussion. A unit medication room is a nonpublic area where nurses can privately discuss client information that pertains to the client's care.

A nurse is 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 Clients whose thyroid hormone levels are high have increased protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with an increased appetite, it is often difficult to meet energy demands, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake.

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 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client, and in this case, to other clients and staff. When there are several risks to safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat. Clients who have or might have tuberculosis require airborne isolation precautions immediately because of the highly communicable nature of the infection. Airborne precautions prevent transmission of pathogens that remain infectious in the air, including Mycobacterium tuberculosis, the bacterium that causes tuberculosis.

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 Clients who are able to ambulate should leave first in an evacuation process because it quickly reduces the number of clients who require evacuation assistance.

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 reinforcing teaching with the 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 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 When a client who has dementia has periods of confusion, the AP should allow the client additional time to complete activities that she is able to perform independently. Insisting on completing the task for her, or attempting to hurry her, can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or needs it.

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 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 Many cultures have beliefs about food that the nurse should respect. Discussing nonanimal protein sources can help the client identify those that do not conflict with her religious and cultural beliefs.

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 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° The nurse should recommend that the client's head of the bed remain elevated at 30 to 45 degrees to decrease the risk for ventilator-acquired pneumonia.

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

Measure the clients weight daily The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical for infants and children because fluid accounts for a greater portion of body weight.

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 Opioids are more effective for residual limb pain rather than phantom limb pain; additionally, meperidine is not recommended for chronic pain because using it long-term can cause accumulation of a toxic metabolite.

A nurse is talking with the parent of a four month old infant about growth and development. Which of the following statements indicates that the parent needs further instruction?

My baby loves to play with pillows in her crib Parents should never place pillows in their infant's crib. They pose a suffocation hazard.

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?

Nasal cannula

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

Nasal flaring Acute laryngotracheobronchitis, or croup, causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions.

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 Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language.

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 client who is immobile is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function.

A nurse is reinforcing teaching with the parent of a client 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 to the parent?

Oral glucocorticoids are more likely to slow linear growth in children Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (the client's airways), resulting in a decreased risk for adrenal suppression.

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 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery is one that follows labor of less than 3 hr. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage.

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 The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores spread easily by contact with body fluids and inanimate objects. The greatest risk to this client, as well as to the nurse and others, is injury from infection transmission; therefore, the priority intervention is hand hygiene.

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

Photosensitivity An adverse effect of doxycycline, a tetracycline antibiotic, is photosensitivity. The skin reacts abnormally to light, especially ultraviolet radiation or sunlight. Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.

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 Posting a large calendar in a central location will assist this client with orientation.

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% Clients who have had abdominal surgery should have an oxygen saturation above 95%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention.

A nurse is reinforcing teaching with the Parent 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 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to this client is injury from Stevens-Johnson syndrome or toxic epidermal necrolysis, which are life-threatening reactions that manifest initially as a rash in the first 2 to 8 weeks of treatment with lamotrigine. The nurse should instruct the parents to report a rash immediately to the provider.

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

Reduce dietary sodium

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 The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement.

A nurse is collecting data from a client who has an acute visual disturbance and describes it as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?

Retinal detachment The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.

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 To prevent lipodystrophy, the client should rotate injection sites, making them about 2.5 cm (1 in) apart, within the same anatomical area.

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

Send an email to each nonadherent employee that includes a link to upcoming educational sessions E-mail provides a simple yet efficient way for the charge nurse to inform nonadherent employees about options they have for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates adherence by helping each employee identify an upcoming session that coordinates with his work schedule.

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

Set up a series of meetings for all staff members to discuss issues The charge nurse is using the conflict resolution strategy of collaboration by involving the staff to communicate and work together to devise and implement win-win solutions.

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 the clients behavior?

Speak to the client with clear calm caring statements To remain in control of the situation, the nurse should use clear, calm statements that are nonthreatening to the client. The nurse should also set limits for clients who exhibit potentially violent behavior.

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 asked the nurse if we should continue to take St. John's wort for depression. Which of the following instructions should the nurse to give the client?

Stop taking the herbal supplement while taking the medication Taking the antidepressant sertraline and the herbal supplement St. John's wort together puts the client at risk for serotonin syndrome.

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 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. For this client, it could be a life-threatening event such as circulatory collapse. Therefore, the first action the nurse should take is to stop the infusion to prevent any further administration of blood.

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?

Tell me about your favorite videogame The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication.

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 Clients who have borderline personality disorder have a difficult time identifying their feelings. The nurse uses open-ended therapeutic communication with this response which allows the client to focus on concerns about hospitalization and encourages verbalization of feelings.

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 Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.

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 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 This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she is requesting.

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 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 infants mother is likely HIV positive

A nurse is reinforcing teaching with the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include?

The tubes should stay in place until they fall out on their own

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 With the laryngeal edema that is common post thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk for hemorrhage by increasing tension on the incision during insertion. The nurse should have a tracheostomy tray available for this client.

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 bedtime story before bed Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime. They also provide for parental-child interaction prior to bed.

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 at a family planning clinic is preparing to give a presentation to clients about to use a diaphragm. Which of the following information should the nurse plan to include in the session?

Use spermicidal jelly whenever you use your diaphragm A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device.

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 The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff.

Ours in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse can I vote in the upcoming presidential election? Which of the following responses should the nurse make?

We can work together to find out how you can get a mail in ballot The nurse provides a therapeutic response by suggesting collaboration and formulating a plan of action that will result in giving the client information and addressing the client's need.

A nurse is reinforcing teaching with a client who is scheduled for LASIK surgery which of the following information should the nurse include?

Your procedure will only take 10 to 15 minutes per eye

A nurse is reinforcing teaching with the client who has come to the family planning clinic requesting an IUD. Which of the following information should the nurse reinforced with the client?

Your risk for ectopic pregnancy increases with an IUD An IUD is a family planning device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.