ATI CBC Level 4 Practice A
A nurse is teaching a client who had an organ transplant about cyclosporine therapy. Which instruction should the nurse include in the teaching?
"Avoid drinking grapefruit juice when taking this medication." -Grapefruit juice can decrease the metabolism of cyclosporine, which can cause an increase in serum levels and increase the risk for toxicity
A nurse is providing teaching to a client who has a halo device applied to prevent further cervical spinal cord injury following a diving accident. What info should the nurse include?
"Avoid leaning forward when attempting to stand." -the weight of the halo device can alter balance. leaning forward could cause the client to fall.
A nurse is providing discharge teaching to a client who has hepatitis. Which of the following information should the nurse include?
"Avoid sexual intercourse until the antibody test is negative" -The nurse should inform the client to avoid sexual intercourse until the antibody testing results are negative
A nurse is teaching a newly licensed nurse about degenerative disk disease. Which of the following statements by the newly licensed nurses indicates understanding of the teaching?
"Clients who have this disease should participate in muscle-strengthening exercises" -Clients who have degenerative disk disease or osteoarthritis should participate in muscle strengthening exercises to increase mobility and decrease joint discomfort -Clients who have osteoporosis can lose 5 to 7.5 cm (2 to 3 inches) in height. Clients who have osteoarthritis do not lose bone density.
A nurse is teaching a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which statement by the client indicates an understanding of the teaching?
"I should inspect my skin daily for cuts and rashes" The client who has SLE should inspect her skin daily for cuts and abrasions and report them to her provider. The client who has SLE should wear sunscreen with a sun protection factor (SPF) of 30 or higher when in sunlight. The client who has SLE should apply lotion to her skin to protect it from dryness. The client who has SLE should avoid using tanning beds or prolonged exposure to sunlight.
A nurse is providing teaching to a client following a kidney transplant from a cadaver donor. Which of the following statements by the client indicates an understanding of the teaching?
"I will need to continue hemodialysis until my new kidney is functioning well" The client will need to continue hemodialysis following kidney transplant surgery until the new kidney is functioning properly on its own. The client should weigh himself daily following surgery to monitor renal function. The client should expect blood pressure to decrease following surgery as chronic renal failure resolves. The client will be on immunosuppressant therapy for the lifetime of the transplanted kidney.
A nurse is teaching a client who has AIDS about preventing infections. Which of the following statements by the client indicates an understanding of the teaching?
"I will report a temperature higher than 100-degrees Fahrenheit to my doctor" A fever can be an indication that the client has an infection
A nurse is providing discharge teaching for a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
"Lie down when you take this medication" -nitroglycerin is a vasodilator that can cause hypotension. Other adverse effects include headache, flushing, and tachycardia
A nurse is teaching a group of community members about emergency preparedness planning. Which of the following statements by a community member indicates an understanding of the teaching?
"My children should be involved in developing our family disaster plan" -Entire families should be involved to ensure everyone understands the plan and knows what actions to take in the event of a disaster -The family should check the disaster kit for expired items at least every 6 months. -The family should keep hard copies of important documents in the disaster kit, which will ensure that these documents are available in the event of a power outage. -The family should store at least 3 days' worth of food and water for the family in the event of a disaster.
A nurse is providing dietary teaching to a client who has CKD and is undergoing hemodialysis. Which dietary information should the nurse include?
"Take an iron supplement daily" -Clients who have CKD can experience anemia from limited protein in their diets and a decreased production of erythropoietin. Daily iron supplements can prevent anemia
A nurse is teaching about preventing a vasovagal attack for a client who has bradydysrhythmia. Which of the following information should he nurse include?
"Use an arm reacher to grab items that are on the top shelf" -This will help prevent a vasovagal attack, which can further decrease the client's HR The nurse should instruct the client to avoid bearing down to prevent causing a vasovagal attack. The nurse should instruct the client to avoid using cold compresses and applying any pressure to her eyes to prevent a vasovagal attack. The nurse should instruct the client to avoid brushing her tongue, which stimulates the gag reflex, to prevent a vasovagal attack.
A nurse is teaching a client who has a new prescription for carvedilol following a myocardial infarction. What information should the nurse include?
"You should check your pulse before taking this medication" -The client should withhold his med and notify his provider if his heart rate is less than 60/min
A nurse case manager is providing discharge teaching to a client who is scheduled to receive home health visits. Which of the following statements should the nurse include in the teaching?
"Your initial home health visit will include family and caregivers assisting with your care at home" -during this visit, the nurse will develop a treatment plan
A nurse is preparing to administer nitroglycerin topical ointment to a client who had a myocardial infarction. Which action should the nurse plan to take? (move steps in order)
1) Cleanse the client's skin and allow it to dry 2) Apply a thin layer of medication ointment to the dosing paper. 3) Spread the medication over a 6.4 by 8.9 cm area of skin 4) Cover the medication site with plastic wrap 5) Remove the medication in 6 hr.
A nurse in an emergency department is caring for four clients. Which of the following clients should the nurse identify as requiring mandatory reporting?
A child who is accompanied by a parent to be treated for patterned burns on the arms -mandatory reporting for suspected physical abuse
A triage nurse is prioritizing clients following a mass casualty disaster. Which of the following clients should the nurse treat first?
A client who is exhibiting manifestations of shock. -a client exhibiting manifestations of shock requires immediate intervention for survival. A client who has extensive full-thickness burns to 85% of her body has a minimal chance of survival, even with intervention. Therefore, the nurse should treat another client first. A client who has an open distal fibula fracture does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should treat another client first. A client who has multiple abrasions to the chest and lower extremities does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should treat another client first.
A risk manager is reviewing incident reports. Which of the following incidents should the risk manager identify as a sentinel event
A nurse discovers an IV extravasation of a vesicant medication -this can cause high local concentrations resulting in infection, pain, and loss of mobility -A sentinel event results in significant harm to the client. A client leaving the facility against medical advice places the client at risk for harm, but it is not a sentinel event. -A sentinel event results in significant harm to the client. A nurse administering an antihypertensive medication 3 hr late is a medication error, but it is not a sentinel event. -A sentinel event results in significant harm to the client. A nurse documenting client care information in the wrong medical record is a documentation error, but it is not a sentinel event.
A charge nurse is educating unit nurses about the ethical principle of nonmaleficence. Which example should the nurse include in the teaching?
A nurse uses a mechanical lift to move a client from a bed to a chair. -prevents harm to the client
A nurse is caring for a client who has sepsis and has developed disseminated intravascular coagulation (DIC). Which of the following actions should the nurse take?
Administer anticoagulants to the client -to limit clotting -The nurse should avoid using glycerin swabs due to their drying effects on the mucosa, which increases the risk for bleeding. -The nurse should monitor the client's breath sounds at least every 2 to 4 hr to assess for crackles and other manifestations of fluid overload.
A nurse is working on an interprofessional collaboration plan of care for a client who has a stage 3 pressure ulcer. Which action should the nurse recognize as the. role of the licensed practical nurse (LPN)?
Administer pain medication
A nurse manager is teaching a group of nurses about professional negligence. Which of the following situations should the nurse manager include as an example?
Administering heparin to a client who is undergoing a lumbar puncture. -A nurse who administers heparin to a client who is undergoing a lumbar puncture is an example of negligence. Anticoagulant medication can cause bleeding in the lumbar area. -A nurse should withhold metformin and any type of antidiabetic medication from a client who has diabetic ketoacidosis. Therefore, this is not an example of negligence. -A nurse should administer potassium IV bolus at a rate of no greater than 10 mEq/hr. Therefore, this is not an example of negligence. -Digoxin 0.25 mg is within the expected dosage range. Therefore, this is not an example of negligence.
A nurse manager is teaching a unit nurse about case management. What information should the nurse manager include in the teaching about the role of the nurse as a case manager?
Advocates for services the client needs -A nurse case manager's role is to advocate for services needed and available resources to meet the client's needs.
A nurse is teaching about managing care with the family of a client who has Parkinson's disease and takes dopamine. Which information should the nurse include in the teaching?
Allow the client to perform ADLs -promotes and maintains independence for as long as possible -The nurse should instruct the family to monitor the client for orthostatic hypotension, which can be caused by the client's dopamine. The nurse should include that hallucinations and confusion are other adverse effects of this medication.
A nurse who works on a med-surg unit is asked to float to the maternal newborn unit due to short staffing. Which professional organization protects the nurse if she refuses the assignment?
American Nurses Association (ANA)
A nurse is teaching a client who has deep-vein thrombosis and is receiving heparin injections. The nurse should instruct the client to report which of the following manifestations as an adverse effect of this medication?
An increase in nosebleeds -increase in nosebleeds or bruising can be indications of a hemorrhage, which is an adverse effect of heparin An increase in sleeplessness is not an adverse effect of heparin. A decrease in urinary output is not an adverse effect of heparin. A decrease in appetite is not an adverse effect of heparin.
A nurse is caring for a client who has an adrenal gland disorder. Which of the following actions should the nurse take?
Apply a pressure-reducing overlay on the client's mattress -The nurse should apply a pressure-reducing overlay on the client's mattress because the edema across the client's sacrum can result in a pressure ulcer. The edema is caused by hypercortisolism that leads to fluid retention
A nurse is caring for a client who is 6hr post-op following a total knee replacement. Which action should the nurse take to prevent a pulmonary embolism?
Apply compression stockings to both o the client's legs The nurse should apply compression stockings to both of the client's legs to prevent the formation of a pulmonary embolism. The nurse should avoid placing a pillow under either of the client's knees, as this can constrict blood flow, which can result in a pulmonary embolism. The nurse should avoid massaging either of the client's legs, as this can dislodge a clot that has already developed, which can result in a pulmonary embolism. The nurse should instruct the client to avoid holding his breath during turning because this will result in a Valsalva maneuver, which can dislodge a clot that has already developed and result in a pulmonary embolism.
A nurse is teaching an educational session about reducing health care-associated infections. Which instruction should the nurse include?
Bathe the clients daily with chlorhexidine wipes
A chief nurse officer (CNO) is comparing the quality of health care at her facility to the best-performing facilities nationwide to determine if quality improvement is required. Which of the following processes should the CNO plan to use as a comparison tool?
Benchmarking -Benchmarking measures products, services, and practice against top-performing organizations. Facilities use this as a tool for developing desired standards of organizational performance
A nurse is caring for a client who has Addison's disease and is receiving an infusion of 0.9% sodium chloride. The client develops acute adrenal insufficiency. Which action should the nurse take?
Check the client's blood glucose level -hypoglycemia is a manifestation of acute adrenal insufficiency. Glucose should be monitored hourly -The nurse should maintain the IV infusion of 0.9% sodium chloride to prevent hyponatremia. -The nurse should implement a decreased-potassium diet for a client who has hyperkalemia, which is a manifestation of acute adrenal insufficiency. -The nurse should avoid administering potassium-sparing diuretics to a client who has hyperkalemia, which is a manifestation of acute adrenal insufficiency.
A nurse is caring for a client who has acute respiratory distress syndrome and is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent the client from acquiring ventilator-associated pneumonia?
Check the client's need for suctioning every 2 hours -this is to prevent aspiration and ventilator-associated pneumonia -The nurse should perform mouth care for the client every 2 hr to prevent aspiration and ventilator-associated pneumonia. -The nurse should maintain the head of the client's bed at 30° to prevent aspiration and ventilator-associated pneumonia. -The nurse should turn the client every 2 hr to prevent aspiration and ventilator-associated pneumonia.
A nurse is caring for a client who is 24 hr postop following lumbar spinal surgery to treat degenerative disk disease. Which of the following findings should the nurse report to the provider as a possible complication of the surgery?
Clear drainage on dressings -The clear drainage on or around the client's dressings can indicate a cerebral spinal fluid leak. The nurse should place the client flat and immediately report this finding to the provider
A nurse is providing preoperative teaching to a client who does not speak the same language as the nurse. Which action should the nurse take?
Contact a trained interpreter to translate the teaching for the client
A nurse is caring for a client who has hepatic encephalopathy and is receiving lactulose. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication?
Decreased ammonia level -this med decreases ammonia levels by producing a laxative effect. Another effect of this med is decreased confusion
A charge nurse is facilitating conflict resolution between two coworkers regarding a client assignment. Which of the following conflict management strategies should the charge nurse use first?
Determine how each coworker manages personal conflicts -determining how each coworker handles conflict are the first steps to successfully resolving the conflict -Evidence-based practice indicates the charge nurse first needs to understand the conflict management style of each coworker. Respecting each other's feelings about the conflict and realizing that everyone handles conflicts differently are the first steps to successfully resolving the conflict. -The nurse should listen to the concerns of each coworker to understand both sides of the situation. However, evidence-based practice indicates that the nurse should perform another action first.
A nurse is the change agent for instituting a new facility policy. After gathering data related to the change, which of the following steps of change theory should the nurse take next?
Determine the level of staff motivation for the change -this reduces stress and helps facilitate the change
A nurse in risk management is evaluating a sentinel event. Which of the following actions should the nurse take?
Develop a plan to reduce the risk for client injury -the nurse should develop a plan to reduce the risk for negligence and prevent another sentinel event from occurring
A nurse manager is teaching a newly licensed nurse about the Emergency Medical Treatment and Active Labor Act (EMTALA). Which of the following information should the nurse include?
EMTALA requires that all clients are stable prior to discharge or transfer -this act also prohibits refusing to care for clients who are indigent or uninsured
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take first?
Elevate the client's legs -ABCs approach to client care; elevating the legs promotes venous return of blood to the heart. This makes it easier for the client to breathe and increases BP and cardiac output -The nurse should obtain the client's ABG levels to monitor her pH level. However, there is another action the nurse should take first. -The nurse should administer a vasopressor medication to the client to vasoconstrict the client's blood vessels, which increases the client's blood pressure. However, there is another action the nurse should take first. -The nurse should measure the client's temperature to monitor for hypothermia as a possible result of receiving IV replacement fluids too rapidly. However, there is another action the nurse should take first.
A nurse is reviewing the lab results of a client who has severe burns from a home fire that occurred 6 hr ago. Which of the following findings should the nurse expect?
Elevated Potassium level -the nurse should anticipate a client who had a severe burn within the last 12 hr to have fluid shifts that result in an elevated K+ level, which occurs as a result of cellular injury due to hypovolemia -The nurse should anticipate a client who had a severe burn within the last 12 hr to have increased hemoglobin and hematocrit levels as blood osmolarity increases from vascular dehydration.
A nurse is reviewing the diagnostic test results of a client who is suspected of having Cushing's disease. The nurse should identify that which of the following findings supports this diagnosis?
Elevated salivary cortisol level -Cushing's disease, also known as hypercortisolism, has clinical manifestations of elevated salivary cortisol levels -The nurse should expect a client who has Cushing's disease to have an increased sodium level. -The nurse should expect a client who has Cushing's disease to have an increased urine glucose level. -The nurse should expect a client who has Cushing's disease to have a decreased lymphocyte count.
A nurse is caring for a female client who has an indwelling urinary catheter. Which action should the nurse take to minimize the risk for catheter-related infection?
Evaluate the client daily for the necessity of continued catheterization. -increased dwelling time increases the client's risk for infection. Catheter should be DC'd as early as possible
A nurse is caring for a client who has a new diagnosis of heart failure. Which of the following actions should the nurse take first?
Evaluate the client's breath sounds -ABCs approach to client care
A nurse manager is informed that the family of a client is preparing to file a malpractice lawsuit. The nurse should identify which of the following situations as potential malpractice?
Failure to identify an infiltrated IV
A nurse manager is teaching about the failure to communicate during a staff educational session. Which of the following examples should the nurse manager include?
Failure to report elevated blood pressure during change of shift report -Failure to communicate involves failing to report accurate information in a timely manner.
A nurse is teaching a client who has HIV about zidovudine. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication
Fever -This can indicate an infection caused by bone marrow suppression
A nurse is caring for a client who is post-op following a craniotomy to remove a brain tumor. The nurse should notify the provider about which of the following findings?
Fixed an nonreactive pupils to light -This is an indication of a neurological deficit due to a herniation of the brain
A nurse is preparing to conduct research regarding catheter-related infections for a performance improvement initiative. Which of the following activities should the nurse identify as components of the research process? (SATA)
Formulate the research problem is correct. This action allows the nurse to define the purpose of the study and determine the type of research design she will use. Review literature from any available web-based resources is incorrect. The nurse should review reliable sources concerning the research problem, including systematic reviews, pre-appraised literature, and studies from peer-reviewed journals. The nurse should evaluate the quality of web-based materials on the internet prior to including the information in the research. Obtain approval from the American Nurses Association (ANA) is incorrect. The nurse does not need to obtain approval from the ANA to conduct the research. The nurse can contact the ANA for research funds, as the ANA can award small research grants through the American Nurses Foundation. Conduct a pilot study is correct. The nurse should conduct a pilot study, which can assist the nurse to identify the strengths and limitations of a planned larger-scale study. It can also assist with the assessment of the design and methodology of the research. Communicate the conclusions of the study is correct. The nurse should communicate the conclusions of the pilot study and the research conducted. Once the outcomes are disseminated, the new evidence-based practice can be incorporated into the daily practice of the facility.
A nurse manager is discussing Medicare reimbursement with a group of staff nurses. The nurse should identify that Medicare will deny reimbursement for which fo the following events?
Fractured hip from a fall while ambulating postoperatively -Medicare denies reimbursements for "never events". These events are considered preventable and include HAIs, injuries resulting from a client fall, and surgery performed to an incorrect site
A nurse caring for a client identifies an ethical dilemma concerning the client's treatment. Which of the following actions should the nurse take next?
Gather relevant information -The nurse should gather relevant information including who is involved with the problem and information about the client's health
A nurse is caring for a client who is in the active phase of labor and has an amniotic fluid embolus. Which action should the nurse take?
Give O2 via nonrebreather mask at 10L / min -additionally, the nurse should prepare for intubation and mechanical ventilation
A nurse is assessing a newborn. Which of the following findings should the nurse identify as a manifestation of sepsis?
Grunting -grunting, nasal flaring, retractions, apnea, tachycardia, hypotension, lethargy, pallor, petechiae, hypoglycemia, hypotonia, and/or decreased oxygen saturations are other symptoms of sepsis
A nurse is caring for a client who has cirrhosis. The client has an ammonia level of 120 mcg/dL, slurred speech, and is disoriented to person and place. The nurse should identify that these findings possibly indicate which of the following complications of cirrhosis?
Hepatic encephalopathy -elevated ammonia level, slurred speech, and mental status changes are early manifestations of hepatic encephalopathy
A nurse is monitoring a client who had a stroke. The nurse should identify which of the following findings as an indication of increased intracranial pressure (ICP)?
Hypertension -Other indications include a widened pulse pressure and bradycardia -The nurse should monitor for widened pulse pressure as an indication of increased intracranial pressure. -The nurse should monitor for an increased body temperature, because a fever can extend the area of damage in the brain following a stroke.
A nurse is caring for a client who has CKD and is taking hydrochlorothiazide. The nurse should monitor the client's lab values for which of the following findings?
Hypokalemia -The nurse should monitor the client's lab values for a decrease in potassium while the client is taking a thiazide diuretic due to the client's increased excretion of water and electrolytes
A nurse is assessing a client who has heart failure and reports chest pain and difficulty breathing. The nurse should identify that which of the following manifestations indicate the client is experiencing cardiogenic shock? SATA
Hypotension Agitation Tachypnea MY ANSWER Hypotension is correct. The nurse should identify that hypotension is a manifestation of cardiogenic shock. Agitation is correct. The nurse should identify that agitation is a manifestation of cardiogenic shock. Dry skin is incorrect. The nurse should identify that cool, clammy skin, rather than dry skin, is a manifestation of cardiogenic shock. Tachypnea is correct. The nurse should identify that tachypnea is a manifestation of cardiogenic shock. Polyuria is incorrect. The nurse should identify that a urine output of less than 0.5 to 1mL/kg/hr, rather than polyuria, is a manifestation of cardiogenic shock.
A nurse is caring for a client who has sepsis. Which manifestation should indicate to the nurse that this client might be progressing to septic shock?
Hypothermia -This is due to the body's inability to compensate for the infection The nurse should recognize that a client who is progressing to septic shock can experience tachycardia as a result of the body's attempt to preserve organ function. The nurse should recognize that a client who is progressing to septic shock can experience hypotension as a result of the body's inability to compensate for the infection. The nurse should recognize that a client who is progressing to septic shock can experience decreased urine production as organ failure occurs.
A nurse is assessing an infant who has meningitis. Which manifestation should the nurse expect?
Hypothermia -other manifestations can include vomiting, seizures, and nuchal rigidity -The nurse should expect an infant to have marked irritability and restlessness. -The nurse should expect the infant to have a bulging or tense fontanel.
A nurse is teaching a group of nurses about the role of a case manager. What information should the nurse include in the teaching?
Identifies cost-effective equipment
A charge nurse is preparing an education session for newly licensed nurses about the purpose of incident reports in a blameless culture. Which of the following information should the charge nurse include?
Incident reports are used to reduce future preventable adverse events
A nurse is planning care for a child who has cystic fibrosis. Which intervention should the nurse include?
Increase the child's daily fat intake to 40% of total calories -due to impaired intestinal absorption of fat
A nurse is caring for a client who has Parkinson's disease. Which of the following actions should the nurse take to promote the client's mobility?
Instruct the client to perform range-of-motion exercises -exercising and walking help to delay the progression of the disease
A community health nurse is concerned about the lack of health care services available to low-income communities. Which of the following actions should the nurse take to act as an effective healthcare legislation adovcate?
Join a professional nursing organization -this can allow nurses to have a collective voice when advocating for legislative policies
A nurse is developing a plan of care for a client who has a traumatic brain injury after a fall. Which of the following medications should the nurse expect to administer to the client to reduce ICP?
Mannitol -Mannitol is an osmotic diuretic that decreases cerebral edema
A nurse is caring for a group of postpartum clients. Which task should the nurse delegate to an assistive personnel?
Measure the urine output of a client who is receiving magnesium sulfate
A nurse is planning care for a client who has viral encephalitis and is starting to take IV acyclovir. Which of the following interventions should the nurse include in the plan?
Monitor kidney function studies after infusing this medication -acyclovir can precipitate in the renal tubules and cause kidney damage
A nurse is caring for a client who has a partial-thickness burn and a prescription for a silver sulfadiazine cream. Which intervention should the nurse take?
Monitor the client's WBC. -A drop in the WBC count can be an indication of an allergic reaction to the silver sulfadiazine cream The nurse should clean the client's wound with mild soap and water before applying the silver sulfadiazine cream. The nurse should apply the medication to the client's wound once or twice daily. The nurse should monitor the client's kidney function studies and liver enzymes because silver sulfadiazine cream can cause systemic adverse reactions that can lead to kidney or liver damage.
A nurse is caring for a client who has CKD. Which of the following actions should the nurse take to manage the client's fluid volume?
Monitor the client's blood pressure every 4 hr. -THe nurse should monitor the client's blood pressure at least every 4 hr. An elevated BP can indicate fluid volume overload, so the nurse should report this finding to the provider According to research-based care, the nurse should assess the client for manifestations of fluid volume overload, including the presence of dependent edema, decreased urine output, and decreased oxygen saturation, at least every 4 hr.
A nurse is preparing to provide wound care on a client who has a stage 1 pressure ulcer. Which of the following characteristics should the nurse expect the ulcerative skin area to have?
Non-blanchable and reddened
A nurse in an emergency department is assessing a toddler and notes linear bruising across her buttocks. The guardian reports that the child was disciplined with a wooden spoon by a day care worker. Which fo the following actions should the nurse take?
Notify the local authorities of suspected abuse -all nursing personnel are required to notify local authorities of suspected abuse and child maltreatment.
A charge nurse is planning care for a group of clients. Which task should the nurse delegate to the LPN?
Obtain a blood glucose level from a client who has type 1 diabetes mellitus.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take?
Offer fluid via oral syringe to the infant every 10 minutes. -The nurse should offer 5-10 mL of fluid every 10 minutes to maintain hydration; infants who have RSV have difficulty feeding due to increased secretions
A nurse manager is facilitating conflict resolution between two nurses who disagree about the need to make a referral to a social worker. Which conflict management strategies should the nurse manager use?
Offer self to constructively facilitate communication. -The nurse manager will be the impartial third party in this communication
A community health nurse is planning a public health presentation aimed at minimizing health care disparities. Which of the following age groups should the nurse identify as the priority for increasing health literacy?
Older Adults -Older adults have the lowest level of health literacy compared to other age groups
A community health nurse is teaching a newly licensed nurse about the types of psychiatric health care settings available in the community. Which should the nurse identify as a primary care setting?
Outpatient counseling clinic -primary care setting clinics provide strategies for clients to prevent or delay mental health issues -Partial hospitalization programs provide clients with short, intensive mental health treatments similar to inpatient treatments. However, patients are allowed to return home each day. Typically, the program lasts 5 to 6 hr per day. -Day treatment programs provide clients with behavioral regulation and social skills development. However, patients are allowed to return home each day.
A nurse in a provider's office is caring for an older adult client who recently had a TKA. The client requires short-term rehabilitation in a skilled nursing facility. Which of the following parts of medicare should the nurse expect to cover the majority of the cost of treatment?
Part A -Medicare Part A covers acute care, short-term rehabilitation in a skilled nursing facility, rehab in the client's home, and most of the cost of hospice care Medicare Part B provides insurance coverage for many services provided to clients on an outpatient basis, such as office visits to primary providers. Medicare Part C, also called the Medicare Advantage Plans, supplements Medicare Parts A and B and might provide a cost savings to clients. Nonprimary care without a referral is not covered, and all costs are out-of-pocket. Medicare Part D provides prescription drug benefits. It is an elective plan with out-of-pocket premiums and copayments. All clients who have Medicare are eligible to enroll.
A public health nurse is teaching an educational session about emergency preparedness. The nurse should include that which of the following actions is part of the preparedness phase of the disaster management cycle?
Participate in mass casualty exercises -The nurse should include in the teaching that participating in mass casualty exercises is part of the preparedness phase of the disaster management cycle. Participating in these exercises tests the effectiveness of the disaster plan.
A nurse is assessing a client who has thrombocytopenia. Which of the following findings should the nurse expect?
Platelets 130,000/mm^3 -normal range is 150,000 to 450,000
A nurse is performing an admission assessment on a client who has meningitis. Which finding should the nurse expect?
Positive Kernig's Sign -this is expected due to meningeal irritation. When Kernig's sign is present, the client can't fully extend her leg when lying supine with her thigh flexed toward her abdomen A positive Trousseau's sign is an expected finding of hypocalcemia. A positive Cullen sign is an expected finding of acute pancreatitis. A positive Chvostek's sign is an expected finding of hypocalcemia.
A nurse manager identifies that the number of client medication administration errors on the unit has increased. When creating a cause-and-effect chart, which of the following information should the nurse manger include?
Possible reasons for the medication errors
A nurse is reviewing the lab values of a client who has Addison's disease. Which finding should the nurse expect?
Potassium 6.2 mEq/L -A high potassium level is due to lack of cortisol concentration levels, which leads to a f&e imbalance.
A nurse is teaching a group of newly licensed nurses about different levels of care. Which of the following should the nurse use as an example of primary care?
Prenatal care -Primary care focuses on preventive care and health education. Examples include prenatal care, nutrition counseling, exercise classes, and immunizations
A nurse is planning care for a client who has acute viral hepatitis. Which of the following interventions should the nurse include in the plan?
Provide the client with a high-carbohydrate diet -The nurse should plan to provide the client with a high-carbohydrate and high-calorie diet with moderate fat and protein to promote healing
A nurse is caring for a client who has had a myocardial infarction and suspects cardiogenic shock. The nurse should monitor for which of the following manifestations?
Pulmonary Congestion -Pulmonary congestion is a result of decreased cardiac output due to damage to the cardiac muscle
A nurse is assessing a client who has sepsis with systemic inflammatory response syndrome (SIRS). Which of the following findings should the nurse expect? (SATA)
Pulse 100/min is correct. The nurse should expect the client to have an accelerated heart rate of greater than 90/min. WBC 14,000/mm3 is correct. The nurse should expect the client to manifest a WBC greater than 12,000/mm3, which can indicate systemic infection. Systolic blood pressure 150 mm Hg is incorrect. The nurse should expect the client to have a systolic blood pressure of less than 90 mm Hg due to a compensatory response that causes vasodilation. Platelet count 70,000/mm3 is correct. The nurse should expect the client to have a platelet count of less than 100,000/mm3 due to formation of microthrombi consuming much of the available platelets and clotting factors. Hyperactive bowel sounds is incorrect. The nurse should expect the client to have absent bowel sounds due to decreased circulation, cell anoxia, and cell death leading to organ failure.
A nurse suspects that a client is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?
Raise the head of the client's bed -ABCs approach to client care; raising the head of the bed allows for ease of breathing and better oxygenation -Obtain the client's blood pressure in both arms. The nurse should obtain the client's blood pressure in both arms to assess his cardiac status and adequacy of perfusion. However, there is another action the nurse should take first. -The nurse should check the client for sacral edema to assess for fluid retention or bleeding in the body. However, there is another action the nurse should take first. -The nurse should prepare the client for a chest x-ray to diagnose the presence of a pulmonary embolism in his lung. However, there is another action the nurse should take first.
Following a mass casualty disaster, a nurse is assigning a triage tag to a responsive client who has a major burn injury covering 15% of his body surface area. Which triage category should the nurse assign to the client?
Red -This is a significant injury that requires immediate treatment The nurse should assign a yellow tag to a client who has a significant injury that does not require immediate treatment. The nurse should assign a black tag to a client who has extensive injuries and a minimal chance of survival. The nurse should assign a green tag to a client who has a minor injury that does not require immediate treatment.
A nurse manager suspects that a nurse is chemically impaired. Which fo the following actions should the nurse manager take first?
Remove the nurse from the work environment -the greatest risk in this situation is a potentially chemically impaired nurse causing injury to clients
A nurse is assessing a client who has a DNR order and has stopped breathing. The family asks the nurse to resuscitate the client. Which action should the nurse take?
Respect the client's preferences.
A nurse is caring for a client who has a referral for occupational therapy. The nurse should identify on the referral form that the client needs assistance with which of the following?
Self-grooming activities -The occupational therapist can assist and teach the client to become independent with ADLs such as grooming, bathing, dressing, and eating
A nurse manager is teaching a group of nurses about OSHA. What information should the nurse include?
Sets standards for hazardous exposures in the workplace.
A nurse manager is attempting to resolve a conflict by asking the nurses to focus on the positive, rather than the negative, aspects of the situation. Which of the following conflict resolution strategies is the charge nurse using?
Smoothing -Smoothing occurs when conflicting parties are asked to focus on positive, rather than negative, aspects of a situation. Accommodating occurs when one party sacrifices his beliefs and allows the other party to win. The underlying conflict is not resolved. Competing occurs when one party pursues a goal regardless of the cost to others. This strategy causes anger and frustration in the losing party. Collaborating occurs when all conflicting parties put aside their original goals and work as a team to establish a common goal.
A nurse is assessing a client who has sepsis. For which of the following findings should the nurse notify the rapid response team?
Systolic blood pressure 88 mm Hg -The nurse should notify the rapid response team if the client's systolic blood pressure is less than 90 mm, which can be an indication of progression to sepsis with SIRS
A nurse is reviewing the ECG strip of a client who is experiencing angina. Which characteristic should the nurse expect to find?
T-wave inversion -The nurse should identify that an inverted T-wave indicates ischemia of the heart as a result of angina
A nurse is caring for a client who has a new diagnosis of esophageal cancer. The client's family tells the nurse that they do not want the client to know the diagnosis. Which of the following actions should the nurse take to uphold client autonomy?
Tell the family the client has the right to know about her health -The nurse is demonstrating the ethical principle of autonomy by respecting the client's right to make decisions about her health
A nurse is reviewing the medical record of a male adult client who was admitted with angina. Which finding should indicate to the nurse the client might have experienced a myocardial infarction?
Temperature -Client's elevated temp can be an indication of a MI. An elevated temp for several days following the infarction b/c this is the body's inflammatory response to myocardial necrosis
A nurse is teaching a family member of a client who has a new diagnosis fo DIC. The nurse should include that DIC is a disorder that alters which of the following?
The blood-clotting process -Widespread clotting of the blood vessels and major organs can result in depletion of clotting factors and cause hemorrhage
A nurse is having a disagreement with a coworker about a client assignment. When following the chain of command, which of the following individuals should the nurse contact to discuss the conflict?
The charge nurse -the charge nurse is the nurse's immediate supervisor
A charge nurse is delegating client care assignments for a group of nurses. The charge nurse should identify that which of the following factors is the priority when making assignments?
The level of intensity of care -Acuity level is a categorization of client care needs and the degree of care needed. The higher the acuity level, the more intense and complex the client care is
A nurse in a substance use treatment facility is caring for a group of clients. Which action by the nurse demonstrates the ethical concept of fidelity?
The nurse keeps a promise to take a walk outside with a client after group therapy -The nurse kept a promise made to a client.
A nurse is caring for clients on a med-surg unit. Which of the following actions by the nurse demonstrates the professional characteristics of human dignity?
The nurse treats each of his assigned clients with equal respect -This action by the nurse is an example of the professional characteristic of human dignity, which includes treating all clients equally regardless of medical history or background. - stopping dialysis is a professional characteristic of autonomy
A client asks are nurse how to apply for Medicaid services. The nurse should refer the client to which of the following agencies?
The state welfare office -The client should be referred to the state welfare office to get information about applying for medicaid services. Medicaid funds are distributed to states to provide assistance for older adults, individuals with disabilities, and families who have dependent children -The nurse should refer the client to the local health department for programs such as Women, Infants, and Children (WIC). -The nurse should refer the client to the state insurance department for assistance with obtaining private insurance. -The nurse should refer the client to the local Social Security Administration office for information regarding Medicare.
A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which action should the nurse plan to take?
Transfuse the platelets through a small filter -this removes the white blood cells -The nurse should administer the platelets to the client immediately without warming to prevent platelet clumping. -The nurse does not need to match the client's blood type to the platelets because the platelets are pulled from multiple donors and have no antigens.
A nurse is developing a plan of care for a client who has sustained burns to the lower half of his body and is to receive hydrotherapy. Which action should the nurse include in the plan?
Use forceps and scissors to remove the loose, dead tissue from the client's wound - The nurse should use scissors and forceps to remove loose, dead tissue from the client's wound during hydrotherapy to promote healing. -The nurse can leave small blisters intact to serve as a protective barrier that promotes healing. However, the nurse should open large blisters and thoroughly clean the area with mild soap and water. -The nurse should perform hydrotherapy by placing the client on a special shower table and washing small areas of the client's wound. Immersion in a whirlpool or tub is no longer performed due to the increased risk for infection. -The nurse should plan to perform hydrotherapy one to two times daily to clean and debride the wound.
A nurse is discussing the prevention of encephalitis at a community health fair. The nurse should recommend which of the following actions to prevent ecephalitis?
Use insect repellent that contains DEET -West Nile virus is a cause of encephalitis
A nurse is caring for a client who has a pressure ulcer. Which action should the nurse take when cleaning the client's wound?
Warm the cleansing solution to the client's body temperature -this prevents the solution from lowering the wound temperature and promotes healing
A nurse is staging pressure ulcers on a client's foot. Which of the following areas should the nurse identify as a stage III pressure ulcer?
Wound on the r/lateral side of foot (underneath pinky toe) A is incorrect. The nurse should identify that this is a stage I pressure ulcer, which has intact skin, is reddened, does not blanch, and the tissue is firm or boggy to touch. B is incorrect. The nurse should identify that this is a stage II pressure ulcer, which does not have intact skin and has partial-thickness skin loss of the epidermis or dermis with a superficial ulcer or blister. C is incorrect. The nurse should identify that this is an unstageable pressure ulcer due to the blackened eschar in the center of the wound. D is correct. The nurse should identify that this is a stage III pressure ulcer, which involves full-thickness skin loss but does not extend past the underlying fascia, bones, or tendons.
A nurse manager notices that he has exceeded the amount of money allocated for labor costs for the quarter. Which action should the nurse manager take?
involve staff nurses in budge planning. -this promotes awareness of the costs of staffing a unit and encourages cost-effective care.
A nurse is reviewing the lab values of a client who is in hypovolemic shock. Which of the following findings should the nurse expect?
pH level 7.25 The nurse should expect the client's laboratory values to reflect metabolic acidosis. The client's pH level is decreased due to insufficient tissue perfusion. A pH level of 7.25 is below the expected reference range.
A nurse is teaching a group of assistive personnel about preventing pressure ulcers. Which of the following images should the nurse include in the teaching?
picture of client lying in bed with pillows under his feet -Pillows or blankets should be placed under the client's legs or ankles to prevent the heel from rubbing on the bed linens causing a friction rub that can lead to a pressure ulcer The nurse should teach the assistive personnel to place a pillow or blankets under the client's legs or ankles to prevent the heel from rubbing on the bed linens and causing a friction rub that can lead to a pressure ulcer. The head of the bed should be positioned at less than 30° to prevent shearing pressure. The nurse should teach the assistive personnel to not place a donut-shaped pillow in a wheelchair or chair because the pillow can compress and damage capillaries and increase tissue breakdown, which can lead to pressure ulcers.
