ATI-Knowledge and clinical judgement(Advanced)

0.75 mEq/L

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy? A.0.25 mEq/L B.0.75 mEq/L C.1.5 mEq/L D. 2.25 mEq/L

Sputum culture of acid fast bacillus

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis? A. Tuberculin test B. Chest X-Ray C. ELISA test D. Sputum culture of acid fast bacillus

Assist the client to a side laying position

A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate? A. Assist the client to a side laying position B. Remove 10mL from the sunction control chamber C. Apply a padded clamp on the tubing for 1-2 min D. Move the drainage system above the level of the clients heart

25-35lbs

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? A. 10-15lbs B.15-20lbs C.25-35 lbs D.35-45lbs

Slurred speech

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority? A. Hematocrit 32% B. WBC 16/mm3 C. Slurred speech D. Yellow Sclerae

Warm refrigerated drops to room temperature prior to instillation

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops? A. Place the child on the effected side for several minutes upon completion of instillation B. Warm refrigerated drops to room temperature prior to instillation C. Pull the pinna of the ear upward and back during instillation D. Massage the area posterior to the ear after instillation

A client who is recovering from cardiac catheterization

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement? A. A client who is recovering from cardiac catheterization B. A client who is in stage 4 of Parkinsons disease C. A client who has anorexia and hypotension D. A client who has a temperature of (39.1 C) 102.4F and is shivering

"I will use my chromoly inhaler before using my albuterol inhaler"

A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? A " I be be sure to rinse my mouth out after using my cromolyn inhaler" B. " I can't use my cromlyn inhaler for sudden asthma attacks" C. "its will be several weeks before I notice an improvement in my asthma" D. "I will use my chromoly inhaler before using my albuterol inhaler"

Toast with peanut butter

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? A.Toast with peanut butter B.Apple juice C. Yogurt with fruit D. Beef broth

Advocacy

A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? A. Deontology B. Morality C. Principlism D. Advocacy

Assigning staff members on each shift the same password for accessing medical records

A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information? A. Requiring that client information be sent to providers using pre-saved numbers on the speed dial of the fax machiene. B.Assigning staff members on each shift the same password for accessing medical records C.Allowing nurses to complete electronic documentation on a client while at the clients bedside D. discussing a clients financial hardship at an interdisaplinary team meeting

"What part of your mothers care concerns you?"

A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy? A. "Its quite simple, ill make sure colostomy bag is clean before she leaves and you should have no problems" B."Is the colostomy care the only reason your mother is going to be living with you?" C. "A home health nurse will be stopping by tomorrow. If you have any questions you can ask her." D. "What part of your mothers care concerns you?"

Abdominal Distension

A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention? A. Vesicular rash B. RR 54/min C. Abdominal Distension D. HR 142/min

Headaches

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication? A. Hypothermia B. Polyuria C. Headaches D. Seizures

NG tube to suction

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia? A. Nephrostomy tube to drainage bag B. Indwelling catheter to gravity C. Chest tube to water seal D. NG tube to suction

A written prescription from the provider

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)? a. a written prescription from the provider b. signed documentation from the client c. family support of the decision d. admission to hospice for palliative care

2.5 mL

A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?

WBC 2,800/mm3

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication? A. Weight loss B. WBC 2,800/mm3 C. HR 54/min D. Insomnia

Dark urine

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? A. Rapid weight gain B. Tar-colored stools C. Lethargy D. Dark urine

A client who has rubella

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? A. A client who has rubella B. A client who has measles C. A client who has hepatitis A D. A client who has rocky mountain spotted fever