2023 PEDS ATI Proctored Exam
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing a to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? Place the steps in order of performance.
1) B- turn off the IV pump 2) C- occlude the IV tubing 3) A- remove the tape securing the catheter 4) D- apply pressure over the catheter insertion site
A nurse in the emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as mcburney's point?
A is correct. The nurse should identify the lower right quadrant of the abdomen between the umbilicus and the anterior iliac crest as the location of Burney's point.
A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the inter professional team to evaluate the client for dysphasia? A) A speech-language pathologist B) Social worker C) Physical therapist D) Occupational therapist
A) A speech-language pathologist
During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager, identify as an acceptable place for discussing clients information? A) Areas with no public access B) Outside the door of a clients room C) In the cafeteria during break D) In the hallway near the nurses station
A) Areas with no public access
A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the follow interventions should the nurse include?
A) Avoid IM injection
A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?"
A) Clients level of comfort and ability to participate in the interview
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?
A) Consult the medication reference book available on the unit
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status?
A) Daily weight
A nurse is reviewing the laboratory values of a client who has a positive Chvosteks sign. Which of the following laboratory findings should the nurse expect? A) Decreased calcium B) Decreased potassium C) Increased potassium D) Increased calcium
A) Decreased calcium
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?
A) Encourage the client to listen to soft music
A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A) Establish client outcomes B) Collect information about past health problems C) Determine whether the client has met specific goals D) Identify the clients specific health problem
A) Establish client outcomes
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
A) Evaluate pedal pulses
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A) Increased blood pressure B) Decreased blood glucose C) Acute Decreased oxygen use D) Increased gastrointestinal motility
A) Increased blood pressure
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?
A) Inspection
A nurse is a rehabilitation facility is observing an assistive personal (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task
A) Locking the brakes on the bed and the wheelchair before moving the client
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A) Renew the prescription for the use of restraints within 24 hours B) Secure the restraints with the buckle side next to the clients skin C) Ensure 4 fingers can be inserted under the secured restraint D) Remove the restraint every 3 hours
A) Renew the prescription for the use of restraints within 24 hours
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
A) Sit at the bedside while feeding the client
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
A) Test for the presence of the clients gag reflex
A nurse is preparing to administer a unit of packed RBC to a client. Which of the following pieces of information must the nurse verify with another nurse prior to administration? (SATA) A) The clients ID number B) The clients room number C) The clients name D) ABO compatibility E) Rh compatibility
A) The clients ID number B) The clients name D) ABO compatibility E) Rh compatibility
A nurse is receiving change-of-shift Report on for children. Which of the following children should the nurse assesses first?
A- A toddler who has a concussion and an episode of forceful vomiting; When using the urgent vs. no urgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.
A nurse is creating a plan of care for a preschooler who has Wilms tumor and is scheduled for surgery. Which of the following interventions should the nurse include?
A- Avoid palpating the abdomen when bathing the child before surgery; The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site.
A nurse is providing teaching to the parent of a school-age child who has oral candidiasis and is to begin taking oral Nystatin. Which of the following instructions should the nurse include?
A- Check the medication prior to Administration; The nurse should instruct the parent to shake the medication prior to administration in order to disperse the medication evenly within the suspension.
A nurse is creating an educational plan to teach parents about protecting their children from sun burns. Which of the following instructions should the nurse plan to include?
A- Choose a waterproof sunscreen with an SPF of at least 15; The nurse should instruct parents to apply a waterproof sunscreen with an SPF of at least 15 forchildren. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.
A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following one week of treatment, which of the following clinical manifestations indicate to the nurse that the medication is effective?
A- Decrease edema; A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, decreasing edema.
A nurse is assessing the pain level of a three-year-old toddler. Which of the following pain assessment scales should the nurse use?
A- FACES Pain rating scale; The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts the current level of pain. The nurse can then determine the need for pain management.
The nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
A- Hematocrit 28%; The nurse should recognize that this hematocrit level is below the expected reference range fora school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygencarrying capacity.
A nurse is providing teaching about car seat use to the mother of a six-monthold infant. Which of the following statements by the mother indicates an understanding of the teaching?
A- I should secure the car seat using lower anchors and tethers instead of the seat belt; Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back-rest for the car seat. Therefore, if this system is available, the seatbelt does not have to be used.
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?
A- Nasal flaring; When using the airway, breathing, circulation approach to client care, the nurse should place the priority on nasal flaring. Nasal flaring indicates that the infant is experiencing acute respiratory distress.
A nurse is caring for a school-age child who has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?
A- Palpate the dorsum of the child's feet; The nurse should palpate the dorsum of the feet by pressing her fingertip against a bony prominence for 5 seconds to assess for peripheral edema.
A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?
A- Provide the child with a book about Adventure; The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age.
A nurse is assessing a client who has a new diagnosis of celiac disease. Which of the following clinical manifestations should the nurse expect?
A- Steatorrhea; The nurse should realize that clients who have celiac disease are unable to digest gluten. This will cause damage to the cells in the bowel, leading to malabsorption, steatorrhea, and diarrhea.
A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Prescriptions: -tuberculin skin test (TST) -measles mumps rubella vaccine -inactivated influenza vaccine -diphtheria, tetanus, and pertussis (DTaP vaccine) Vital signs -respiratory rate 24/minute -heart rate 115/minute -temperature 37.4 degrees Celsius or 99.3 degrees Fahrenheit History and physical -Age 12 months 9 days -height 71.1cm/28-in allergies neomycin - anaphylactic reaction caregiver reports: -rhinitis with clear nasal drainage for 2days -occasional non productive cough for 2 days -history of asthma
A- Withhold the measles mumps and rubella MMR vaccine; The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication to receiving the MMR vaccine. Clients who have a severe allergy to eggs orgelatin should not receive this vaccine.
A nurse is providing dietary teaching to the parent of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
A- You should offer your child high protein meals and snacks throughout the day; The parent should provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients in order to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.
A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Eriksons developmental task for her age group?
B) "I think I have done a good job with my children since they are all independent now."
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?
B) "It modulates the transmission of the pain impulse"
A nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?
B) 2
A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?
B) Antagonistic
A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A) Placing an unused portion of the medication in a sharps box B) Asking another nurse to observe the disposal of an unused portion of the medication C) Counting the inventory of the available narcotic after administering the medication D) Ensuring that another nurse signs the control inventory form after disposal of an unused portion of medication
B) Asking another nurse to observe the disposal of an unused portion of the medication
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates the clients death is imminent? A) Urinary retention B) Cold extremities C) Hypertension D) Tachycardia
B) Cold extremities
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment (SATA)
B) Dry, brittle hair D) Spoon-shaped nails E) Poor wound healing
A. Ruse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A) Redness at the infusion site B) Edema at the infusion site C) Warmth at the infusion site D) Oozing of blood at the infusion site
B) Edema at the infusion site
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration A) Irrigate the tubing with 30ml of sterile water B) Elevate the head of the bed to 30 degrees or 45 degrees C) Suggest changing the feeding to lactose - free formula D) Warm the enteral formula to room temperature before feeding
B) Elevate the head of the bed to 30 degrees or 45 degrees
A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following places the client at risk of impaired skin integrity?
B) Faint pedal pulse
A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take?
B) Keep the clients bed linens dry
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choose for the nurse to use to decrease skin irritation? A) Abdominal binder B) Montgomery straps C) Hypoallergenic tape D) Plastic tape
B) Montgomery straps
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
B) Nausea D) Urticaria E) Stridor
A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?
B) Position the client for drainage of secretions by gravity
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following clinical manifestations should the nurse expect? Select all that apply.
B- Ankle clonus C- exaggerated stretch reflexes E- contractures; Ankle clonus is correct. A child who has spastic cerebral palsy will exhibit ankle clonus which isa rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes is correct. A child who has spastic cerebral palsy will exhibit spasticity or exaggerated stretch reflexes. Contractures is correct. A child who has spastic cerebral palsy will exhibit contractures due tothe tightening of the muscles.
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching?
B- Encourage the child to perform independent self-care; The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility.
A Nurse is teaching the parents of a school-aged child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?
B- My child will receive antibiotics for several weeks; The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is assessing a school-age child immediately post-operative following a perforated appendix repair. Which of the following findings should the nurse expect?
B- absence of peristalsis; The nurse should expect absence of peristalsis in the immediate postoperative period, until thebowel resumes functioning.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
B- apply topical analgesic cream to the site one hour prior to the procedure; The nurse should apply a topical analgesic to the lumbar site 60 min prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.
A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. which of the following instructions should the nurse include in the teaching?
B- award the child with a sticker when he sits on the potty chair; The child with a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.
A nurse is providing teaching to the parents of a preschooler who has heart failure and who is to begin taking Digoxin twice-daily. Which of the following instructions should the nurse include in the teaching?
B- brush the child teeth after giving the medication; The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.
A nurse in the emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take?
B- monitor the child's oxygen saturation; The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment.
A nurse is assessing a three-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
B- respiratory rate 45/min; A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider immediately.
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify which of the following laboratory values indicates effectiveness of the current treatment?
B- sodium 140; The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?
B- sodium 155; A child who has a head injury can develop diabetes insipidus as a result of pituitary hypo function leading to a deficiency of antidiuretic hormone. Under excretion of antidiuretic hormone leads to polyuria and polydipsia and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following clinical manifestations should the charge nurse include as suggestive of potential physical abuse?
B- symmetric Burns of the lower extremities; The nurse should include in the teaching that symmetric burns of the lower extremities are a suggestive clinical manifestation of physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse included in the teaching? A) "Support the majority of your weight on the axillae" B) "Keep your elbows extended" C) "Bear weight on both of your legs" D) "Move both crutches forward at the same time"
C) "Bear weight on both of your legs"
A newly admitted client who has major depressive disorder states to the nurse, "I'm a failure, I can't even cope with the little things anymore." Which of the following responses should the nurse provide?
C) "Do you feel like you don't deserve to feel good about yourself?"
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?
C) "I keep having night,ares about my upcoming surgery"
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care
C) "Let's set up a meeting time with the doctor to discuss your options for home care."
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
C) "What do you think caused the onset of your pain?"
A nurse is preparing to assess the function of the clients trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?
C) Cotton wisps
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?
C) Decreased cardiac output
A nurse is assisting a client who is eating at mealtime. Suddenly the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first A) Place an oxygen mask on the client B) Check the clients pulse C) Determine whether the client is able to breathe D) Wrap arms around the client from behind
C) Determine whether the client is able to breath
A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A) Supine B) Lateral C) Fowlers D) Trendelenburg
C) Fowlers
A nurse is caring for a client who has a fecal impact ion. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A) Carminative B) Hypertonic C) Oil retention D) Sodium polystyrene sulfate
C) Oil retention
A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A) Deltoid B) Ventrogluteal C) Vastus lateralis D) Dorsogluteal
C) Vastus lateralis
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
C)Raise the level of the bed
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. the nurse should identify that which of the following menu items has the highest amount of iron?
C- 1/2 cup raisins; The nurse should encourage the adolescent to eat raisins because they contain the highest amount of non-heme iron.
The nurse is providing discharge teaching to the parent of an 18-month old toddler who has dehydration as a result of acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?
C- I will monitor my child's number of wet diapers; The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is the best way for the parent to monitor adequate output and hydration status.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?
C- The Adolescents serum potassium level is 4.1; The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
C- administer an analgesic to the child; Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
The nurse is preparing to administer an immunization to a four-year-old child. Which of the following actions should the nurse plan to take?
C- administer the immunization using a 24-gauge needle; The nurse should administer an immunization for a 4-year-old child using a 24- gauge needle to minimize the amount of pain experienced by the toddler.
A school nurse is assessing a school-age child blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?
C- assist the child to a side-lying position on the floor; The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to floor in a side-lying position immediately. This position enables the child's secretions to drain from the mouth, preventing aspiration, and maintaining a patent airway.
A nurse in the emergency department is caring for a toddler who has partial thickness burns on his right arm. Which of the following actions should the nurse take?
C- cleanse the affected area with mild soap and water; The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A school nurse is assessing an adolescent who presents with multiple Burns in various stages of healing. Which of the following behaviors should the nurse identify as suggestive of possible physical abuse?
C- denies discomfort during assessment of injuries; The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.
A nurse at an urgent care clinic is assessing an adolescent client who has an upper respiratory tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis?
C- dry, hacking cough; The nurse should recognize that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
The nurse is caring for a 15 year old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion SIADH?
C- mental confusion; A child who has a head injury can develop SIADH as a result of altered pituitary function, leadingto an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration.
A nurse is preparing to collect a sample from a toddler for a sickle turbidity test. Which of the following actions should the nurse plan to take?
C- perform a finger stick; The nurse should perform a finger stick on a toddler as a component of the sickleturbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include?
C- pulmonary function test will be performed every 12 to 24 months toC- pulmonary function test will be performed every 12 to 24 months to evaluate how your child is responding to therapy evaluate how your child is responding to therapy; The nurse should inform the parent that her child will need pulmonary function tests every 12to 24 months tC- pulmonary function test will be performed every 12 to 24 months to evaluate how your child is responding to therapy evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their symptoms can improve or decline and treatment needs to change accordingly.
A nurse in an Emergency Department is assessing a three-month-old infant who has rotavirusand is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?
C- sunken anterior fontanel; The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? Click the audio button to listen.
C- tachypnea; The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.
A nurse is assessing the vital signs of a 10 year old child following a burn injury. Which of the following clinical manifestations indicate early septic shock?
C- temperature 39.1 degrees Celsius or 102.4 degrees Fahrenheit; The nurse should expect a child who has early septic shock to have a fever and chills.
A nurse in a provider's office is caring for a school-age child who has varicella. The parent ask the nurse when her child will no longer be contagious. Which of the following responses should the nurse make?
C- when your child lesions are crusted, 6 days after they appear; The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.
While in the hospital , a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?
D) "Tell me more about how you feel about dying"
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?
D) "Would you like to talk about how you feel?"
A nurse is preparing to insert an indwelling urinary catheter for s female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A) Swallow water B) Prepare for a painful sensation C) Hold her breath D) Near down gently
D) Bear down gently
A nurse in a providers office is assessing a client who has heart failure. The client has gained weight since her last, and her an,les are edematous. Which of the following findings is another clinical manifestation of fluid volume excess
D) Bounding pulse
A nurse is caring for a client who is unstable and has vital sign measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?
D) Disconnect the machine and measure the blood pressure manually every 15 min
A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety
D) Disulfiram
A nurse is auscultating a clients lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A) Limit the clients fluid intake B) Assist the client into a supine position C) Administer oxygen at 2 L/min D) Encourage the client to cough
D) Encourage the client to cough
A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?
D) Gait
A nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
D) Halo of erythema on the surrounding skin
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A) Tenderness when touched B) Pink, shiny tissue with a granular appearance C) Serosanguineous drainage D) Halo of erythema on the surrounding skin
D) Halo of erythema on the surrounding skin
A nurse is caring for a client who is 48 hours post op following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A) Blood loss B) NPO status after surgery C) Nasogastric tube suctioning D) impaired peristalsis of the intestines
D) Impaired peristalsis of the intestines
A nurse is preparing a plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invoice decides should the nurse expect the client to have?
D) Jackson-Pratt drain
A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?
D) Lentils
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include.
D) Limit drinking liquids with food
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?
D) Lower back discomfort
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications
D) Plasma volume expanders
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the clients medical record?
D) The client threw the medication on the floor
A nurse is preparing to administer an IM injection to a young adult client. Which of the following injection sites is the safest to this client? A) Vastus lateralis B) Dorsogluteal C) Deltoid D) Ventrogluteal
D) Ventrogluteal
A nurse is obtaining a capillary blood sample to determine a clients blood glucose level. The nurse prepares and punctures the clients finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? A) Smear the small amount of blood onto the testing strip B) Hold the finger above heart level C) Massage the clients fingertip D) Wrap the clients finger in a warm washcloth
D) Wrap the clients finger in a warm washcloth
A nurse is teaching the parents of a newborn about ways to prevent sudden infant death syndrome SIDS. Which of the following instructions should the nurse include?
D- Give the infant a pacifier at bedtime; The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping. A- The nurse should instruct the parent to place the infant in a supine
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the Adolescent indicates an understanding of the teaching?
D- I should I seal my non washable shoes in plastic bags for a couple of weeks; Sealing non-washable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not recommended for tinea pedis.
A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
D- administer IM epinephrine to the child; When using the urgent vs no urgent approach to client care, the nurse determines that the priority action is administering IM epinephrine to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency becauseultimately it causes decreased blood return to the heart.
A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome mcns and 3 + pitting edema. Which of the following interventions should the nurse include in the plan?
D- administer corticosteroids to the toddler; The nurse should recognize that corticosteroids are the treatment of choice for providers caring for children who have MCNS. Therefore, the nurse shouldD- administer corticosteroids to the toddler- place include administration of prescribed corticosteroids in the plan of care for this toddler.
A nurse is providing teaching to the parents of a toddler about the administration of a prescribed eye drops and eye ointment. Which of the following instructions should the nurse include?
D- administer the eye drops 3 minutes before the ointment; The nurse should instruct the parents to administer the eye drops first and then wait 3 min before administering the eye ointment. This action provides adequate time and spacing for each separate medication to work.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?
D- an infant who is 8 months old and is not yet making babbling sounds; The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for more extensive evaluation of hearing.
A nurse is providing discharge teaching to the parents of a three-month-old infant following acheiloplasty. which of the following instructions should the nurse include?
D- apply a thin layer of antibiotic ointment on your babies' suture line daily for the next three days; The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.
The nurse is providing anticipatory guidance to the mother of a toddler. Which of the following expected Behavior characteristics of toddlers should the nurse include in the teaching?
D- expresses likes and dislikes; The nurse should teach the mother that her toddler will begin to express her likes and dislikes. This is the time in life when a toddler is developing autonomy and self-concept. She will try to assert herself and frequently refuse to comply. The parent should allow the child to have some control but also set limits in order for her to learn from her behavior and learn to control her actions.
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the Adolescent in droplet precautions?
D- for 24 hours following initiation of antimicrobial therapy; The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is nolonger contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.
A nurse is creating a plan of care for an infant who has an epidural hematoma with a skull fracture. Which of the following actions should the nurse include in the plan?
D- implements seizure precautions for the infants; The nurse should implement seizure precautions for an infant who has an epidural hematomas' a safety measure.
The nurse is providing teaching about Social Development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
D- playing dress-up; The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.
The nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods tote child?
D- rice pudding; The nurse should instruct the parent that the child will remain on a lifelong glutenfree diet. The child cannot consume oats, rye, barley or wheat, and sometimes lactose deficiency can be secondary to this disease. The nurse should recognize that rice pudding is a gluten-free food.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. which of the following actions should the nurse plan to take?
D- schedule the toddler for a yearly screening; The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
A nurse in an emergency department is performing a physical assessment on a 2-week old male infant. Which of the following manifestations is the priority for the nurse to report to the provider?
D- substernal retractions; When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the infant is experiencing acute respiratory distress and increased respiratory effort, which could quickly progress to respiratory failure.
A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few hours while another relative stay with the child. Which of the following statements should the nurse make to explain to the child when her mother will return?
D- your mommy will be back after you eat; Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.
