410 final exam - ATI questions

a nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. which of the following statements by the guardian indicates an understanding of the teaching? 1. my child can resume usual activities since this was just an outpatient surgery 2. my child will be able to drink the chocolate milkshake I promised to get fro them tonight 3. I will notify the doctor if I notice my child is swallowing more frequently 4. I will have my child gargle with warm salt water to relieve their sore throat

I will notify the doctor if I notice my child is swallowing more frequently

a school nurse is providing an in-serivice for faculty about improving education for students who have ADHD. which of the following statements by a faculty member indicates an understanding of the teaching? 1. I will plan to increase the amount of homework I assign to students who have ADHD 2. I will give students who have ADHD the same amount of time as other students to complete tests 3. I will allow students who have ADHD one rest break throughout the day 4. I will teach challenging academic subjects to students who have ADHD in the morning

I will teach challenging academic subjects to students who have ADHD in the morning meds are most effective in the morning, they tire easily in p.m.

a nurse is assessing a newborn following a circumcision. which findings should the nurse identify as an indication that the newborn is experiencing pain? decreased HR chin quivering pinpoint pupils slowed respirations

chin quivering

a nurse is providing anticipatory guidance to the parent of a toddler. which of the following expected behavior characteristics of toddlers should the nurse include? 1. controls impulsive feelings 2. understands right from wrong 3. easily separates from parents for long periods of time 4. expresses likes and dislikes

expresses likes and dislikes

a nurse is planing care for a client who is in labor and is to have an amniotomy. which of the following assessments should the nurse identify as the priority? O2 saturation temperature BP urinary output

temperature infection risk

a nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? 1. use sterile scissors to remove the dressing from the site 2. irrigate each lumen weekly with 10 mL of NS solution when not in use 3. access the site using a noncoding angled needle 4. use a semipermeable transparent dressing to cover the site

use a semipermeable transparent dressing to cover the site

a nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. which of the following instructions should the nurse include? 1. stay home from school for 1 week following the procedure 2. follow a diet that is low in fiber for 1 week 3. wait 3 days before taking a tub bath 4. apply a pressure dressing to the site for 3 days

wait 3 days before taking a tub bath should keep site clean and dry for 3 days to reduce risk of infection. Avoid immersion in water during that time.

a nurse is teaching a new parent about newborn safety. which of the following instructions should the nurse include in the teaching? 1. you can share your room with your baby for the next few weeks 2. cover your baby with a light blanket while sleeping 3. check the temperature of your baby's bath water with your hand 4. your baby can nap in the car seat during the daytime

you can share your room with your baby for the next few weeks

a nurse is assessing the pain level of a 3 year old toddler. which of the following pain assessment scales should the nurse use? 1. FACES 2. Numeric 3. CRIES 4. Visual analog

FACES

a nurse is teaching a client who is in preterm labor about terbutaline. which of the following statements by the client indicates an understanding of the teaching? I will get injections of the medication once daily until my labor stops my blood sugar may be low while I'm on this medication I will have blood tests because my potassium might decrease my BP may increase while I'm on this medication

I will have blood tests because my potassium might decrease adverse effect is hypokalemia

a nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. after calling for assistance, which action should the nurse take next? 1. place a rolled towel beneath one of the clients hips 2. apply internal upward pressure to the presenting part using two gloved fingers 3. admin oxygen to the client via a nonrebreather was at 10 L/min 4. increase the IV infusion rate

apply internal upward pressure to the presenting part using two gloved fingers

nurse is caring for a client who in labor and whose fetus in the right occiput posterior position. the client is dilated to 8 cm and reports back back. which of the following actions should the nurse take? 1. apply sacral counterpressure 2. perform transcutaneous electrical nerve stimulation (TENS) 3. initiate slow-paced breathing 4. assist with biofeedback

apply sacral counterpressure

a nurse is caring for a newborn undergoing phototherapy to treat hyperbilirubinemia. which actions should the nurse take? 1. cover the newborns eyes while under the phototherapy light 2. keep the newborn in a shirt while under the phototherapy light 3. apply a light moisturizing lotion to the newborns skin 4. turn and reposition the newborn every 4 hr while undergoing phototherapy

cover the newborns eyes while under the phototherapy light

a nurse is planning care for a client who is 2 hr postpartum. which interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? discuss contraceptive options with the client and her partner repeat information to ensure client understanding listen to the client and her partner as they reflect upon the birth experience demonstrate to the client how to perform a newborn bath

demonstrate to the client how to perform a newborn bath

a nurse is caring for a client who becomes unresponsive upon delivery of the placenta. which actions should the nurse take first? determine respiratory function increase IV fluid rate access emergency medications from the cart collect a maternal blood sample for coagulopathy studies

determine respiratory function

a nurse in assessing a school-age child who has an infratentorial brain tumor. which of the following findings should the nurse identify as a manifestation of ICP? 1. hypotension 2. reports insomnia 3. difficulty concentrating 4. tachycardia

difficulty concentrating

a charge nurse is preparing to make a room assignment for a newly admitted school-age child. which of the following considerations is the nurse's priority? 1. length of stay 2. treatment schedule 3. disease process 4. self-care ability

disease process transmission of infectious disease would require rooms with negative pressure and/or PPE precautions

a nurse is preparing to admin oxytocin to a client who is postpartum. Which findings is an indication for the admin of the medication? (SATA) flaccid uterus cervical laceration excess vaginal bleeding increased afterbirth cramping increased maternal temperature

flaccid uterus excess vaginal bleeding

a nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. the nurse should secure the sensor to which of the following areas on the infant? 1. wrist 2. great toe 3. index finger 4. heel

great toe

a nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? 1. have the adolescent sign a consent form for treatment 2. instruct the adolescent to return with a guardian 3. obtain consent from the adolescents guardian over the phone 4. treat the adolescent without a consent form

have the adolescent sign a consent form for treatment

a nurse is assessing a newborn for manifestations of hypoglycemia. which of the following findings should the nurse expect? jitteriness hypertonia abdominal distension mottling

jitteriness

a nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? 1. reports an absence of nausea and vomiting 2. reports experiencing onset of lose stools within 15 min of admin 3. serum potassium level 4.1 mEq/L 4. BP of 86/52

serum potassium level 4.1 mEq/L treats hyperkalemia

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 1. urine specific gravity 1.045 2. sodium 155 mEq/L 3. blood glucose 45 mg/dL 4. urine output 35 mL/hr

sodium 155 mEq/L

a nurse is teaching a new mother how to use a bulb syringe to suction her newborns secretions. which instructions should the nurse include? insert the syringe tip before compressing the blub suction each of the nares before suctioning the mouth insert the tip of the syringe into the center of the newborns mouth stop suctioning when the newborns cry sounds clear

stop suctioning when the newborns cry sounds clear

a nurse in the emergency department is assessing a 3 month old infant who has rotavirus and 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? 1. HR 124/min 2. increased tear production 3. sunken anterior fontanel 4. cap refill 2 seconds

sunken anterior fontanel

a nurse is assessing a client who is at 30 weeks gestation during a routine prenatal visit. Which finding should the nurse report to the provider? swelling of the face varicose veins in the calves non pitting 1+ ankle edema hyperpigmentation of the cheeks

swelling of the face

nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. which of the following lab results should the nurse report to the provider? Hct 39% serum albumin 4.5 g/dL WBC 9,000/mm3 platelets 50,000/mm3

platelets 50,000/mm3 below expected range, can indicate disseminated intravascular coagulation.

a nurse is caring for a preschooler who has congestive heart failure. the nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. which of the following prescriptions should the nurse clarify with the provider? 1. furosemide 2. captopril 3. regular insulin 4. potassium chloride

potassium chloride CHF can develop electrolyte imbalances like hyper/hypo kalemia

a nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. which of the following actions should the nurse take to minimize the infant's pain? 1. use a manual lancet to obtain the heel blood sample 2. apply an ice pack to the infant's heal prior to obtaining the sample 3. allow the mother to breastfeed while the sample is being obtained 4. apply a topical lidocaine cream prior to obtaining the sample

allow the mother to breastfeed while the sample is being obtained breastfeeding, non-nutritive sucking, or pacifier can provide pain relief for infants

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? 1. an 18 month toddler who has unintelligible speech 2. 3 month old infant who has an exaggerated startle response 3. 4 year old preschooler who prefers playing with others rather than alone 4. an 8 month old infant who is not yet making babbling sounds

an 8 month old infant who is not yet making babbling sounds

a nurse on an antepartum unit is caring for four clients. which client should the nurse identify as the priority? client who has gestational diabetes and a fasting blood glucose of 120 mg/dL a client who is 34 weeks gestation and reports epigastric pain a client who is 28 weeks gestation and has an Hgb of 10.4 g/dL a client who is at 39 week gestation and reports urinary frequency and dysuria

a client who is 34 weeks gestation and reports epigastric pain

a nurse is receiving a change-of-shift report for four children. which of the following children should the nurse assess first? 1. a toddler who has a concussion and an episode of forceful vomiting 2. an adolescent who has infective endocarditis and reports having a headache 3. an adolescent who was placed into halo traction 1 hr ago and reports pain as a 6 on a scale of 0-10 4. a school-age child who has acute glomerulonephritis and brown-colored urine

a toddler who has a concussion and an episode of forceful vomiting indication of increasing ICP

a nurse is planning discharge for a client who is 3 days postpartum. which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression? place warm, moist packs on the breasts apply cabbage leaves to the breasts wear a loose-fitting bra put green tea bags on the breasts

apply cabbage leaves to the breasts plant sterols help relieve swelling and discomfort from breast engorgement

a nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? 1. I will offer my child small amounts of juice frequently 2. I will avoid giving my child solid foods until the diarrhea has stopped 3. I will monitor my childs number of wet diapers 4. I will give my child polyethylene glycol daily for 7 days

I will monitor my childs number of wet diapers

a nurse is caring for client who is at 41 weeks gestation and has a positive contraction stress test. for which of the following diagnostic tests should the nurse prepare the client? 1. percutaneous umbilical blood sampling 2. amnioinfusion 3. biophysical profile (BPP) 4. chorionic villus sampling (CVS)

biophysical profile (BPP)

a nurse is teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. which of the instructions should the nurse include? 1. use a kitchen teaspoon to measure the medication 2. brush the child's teeth after giving the medication 3. double the next dose if the child misses a dose 4. repeat the dose if the child vomits

brush the child's teeth after giving the medication sweetened liquid medication can cause tooth decay

a nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. which of the following actions should the nurse take? restrict hourly fluid intake to 150mL/hr have calcium gluconate available assess DTR's every 6 hrs monitor I/O every 4 hrs

have calcium gluconate available

a nurse is teaching a client who is at 35 weeks gestation about potential pregnancy complications to report to the provider. which manifestation should the nurse include? shortness of breath when climbing stairs swelling of feet and ankles at end of day headache that is unrelieved by analgesia Braxton hicks contractions

headache that is unrelieved by analgesia

a nurse is assessing an 8 year old child who has early indications of shock. after establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? 1. insert an indwelling catheter 2. measure weight and height 3. initiate IV access 4. maintain ECG monitoring

initiate IV access

a nurse is caring for a client following an amniocentesis at 18 weeks gestation. which of the following should the nurse report to the provider as a potential complication? 1. increased fetal movement 2. leakage of fluid from the vagina 3. upper abdominal discomfort 4. urinary frequency

leakage of fluid from the vagina

a nurse is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? 1. obtain a throat culture from the child 2. monitor the child's oxygen saturation 3. put a warm mist humidifier in the childs room 4. place the child in the supine position

monitor the child's oxygen saturation

a nurse is assessing an infant who has pneumonia. which of the following findings is the priority for the nurse to report to then provider? 1. nasal flaring 2. WBC count 11,300/mm3 3. diarrhea 4. abdominal distension

nasal flaring (ABC's priority framework)

a nurse is caring for a school-age child who has peripheral edema. the nurse should identify that which of the following assessments should be performed to confirm peripheral edema? 1. palpate the dorsal of the child's feet 2. weight the child daily using the same scale 3. assess the childs skin turgor 4. observe the child for periorbital swelling

palpate the dorsal of the child's feet

a nurse is caring for an infant who is receiving IV fluids for the treatment of metrology of fallout and begins to have a hyper cyanotic spell. which of the following actions should the nurse take? 1. place infant in knee-chest position 2. admin a dose of meperidine IV 3. D/C admin of IV fluids 4. apply O2 at 2 L/min via nasal cannula

place infant in knee-chest position

a nurse is assessing a 6 month old child during a well child visit. which of the following should the nurse report to the provider? 1. prescience of a central incisor tooth 2. presence of strabismus 3. presence of an open anterior fontanel 4. presence of external cerumen

presence of strabismus

a nurse is planing activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take? 1. provide the child with a book about adventure 2. arrange frequent visits from family members and peers 3. give the child a large-piece puzzle 4. use puppets to entertain the child

provide the child with a book about adventure

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? 1. you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing 2. you should monitor your childs weight weekly while they are receiving inhaled corticosteroid therapy 3. pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy 4. when using the peak expiratory flow meter, record your child's average of 3 readings

pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy