ATI RN Comprehensive Online Practice 2019 B with NGN

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

18g

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? "I'm sure your family does not want you to die." "Why would you believe such things?" "How does this make you feel?" "You should talk to your family about your feelings."

"How does this make you feel?" This response encourages the client to evaluate their feelings.

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make? "You will be standing with your feet 1 foot apart." "You will place and hold your hands on your hips." "I will be standing across the room from you to evaluate your sense of balance." "I will be checking you once with your eyes open and once with them closed."

"I will be checking you once with your eyes open and once with them closed." The nurse should inform the client that the Romberg test will be performed once with eyes open and once with eyes closed. A Romberg test is performed to assess balance and motor function.

A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? (Select all that apply.) "I will breastfeed my baby on a schedule of every 4 hours." "I will bathe my baby daily." "I will place my baby on her stomach for sleeping." "I will cover my baby's body when I wash her hair." "I will use the bulb syringe first in her mouth and then in her nose."

"I will cover my baby's body when I wash her hair" is correct. Newborns are highly susceptible to heat loss. The client should wrap the newborn in a towel when washing the hair to minimize heat loss "I will use the bulb syringe first in her mouth and then in her nose" is correct. The client should suction the newborn's mouth first to remove secretions that the newborn could aspirate when suctioning the nares.

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? "I will change your IV tubing once every 48 hours." "Abdominal distention is an expected effect of this therapy." "I will need to check your gastric residual before administering feedings." "I will need to measure your weight daily."

"I will need to measure your weight daily." The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain.

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? "I will not allow anyone to smoke near my baby." "I will place bumper pads in my baby's crib." "My baby's head should be placed on a pillow for sleeping." "My baby should sleep in a side-lying position."

"I will not allow anyone to smoke near my baby." This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SIDS.

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? "I would like to talk to you about the unit policies regarding break time." "If you continue to take a long lunch break, I will have to report this to the nurse manager." "Have you thought about how your extended lunch breaks affect the other members of our team?" "Did you inform the other members of your team about when you left and returned from break?"

"I would like to talk to you about the unit policies regarding break time." The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront.

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make? "I understand this is a difficult decision." "Tell me more about your understanding of the options." "You will make the right choice." "I will ask your provider to talk with you further."

"Tell me more about your understanding of the options." This response by the nurse is therapeutic because it is offering a general lead that facilitates communication between the nurse and the client and will help the nurse to explore the client's feelings about the treatment options.

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? "Perhaps you think the ECT is dangerous, but I've seen it have good results." "You have the right to change your mind about this procedure at any time." "Everyone gets a little nervous about this procedure as the time for it approaches." "Your doctor wouldn't have suggested ECT if they didn't think it would help you."

"You have the right to change your mind about this procedure at any time." The client can refuse consent at any time for a procedure. The nurse is demonstrating advocacy by respecting the client's wishes regarding care.

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions? A client who is at 33 weeks of gestation and has severe gestational hypertension A client who is at 16 weeks of gestation and has a hydatidiform mole A client who is at 28 weeks of gestation and is experiencing vaginal bleeding A client who is at 36 weeks of gestation and has a positive group B streptococcal culture

A client who is at 33 weeks of gestation and has severe gestational hypertension The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client's reach.

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A client forgets to buy their partner a birthday gift after a disagreement. A client who was abused as a child describes the abuse as if it happened to someone else. A client who is shorter than average is verbally assertive with coworkers. A client states that they did not get a job promotion because the boss did not like them.

A client who was abused as a child describes the abuse as if it happened to someone else. The nurse should identify that this client is using the defense mechanism of dissociation because they are separating painful events from the conscious mind and describing the events as if they happened to another person.

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? Agency for Healthcare Research and Quality National Institutes of Health Department of Agriculture World Health Organization

Agency for Healthcare Research and Quality MY ANSWER The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ) regarding health care services for migrant farmworkers. The goal of AHRQ is to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations.

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? Creatinine 1.1 mg/dL Albumin 2.8 g/dL Triglycerides 100 mg/dL Alkaline phosphatase 118 units/L

Albumin 2.8 g/dL The nurse should recognize that an albumin level of less than 3.5 g/dL indicates malnutrition and a need for additional nutritional supplementation. The expected reference range for albumin is 3.5 to 5 g/dL.

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? Amount of vaginal bleeding Amount of urinary output Pain level Fundal height

Amount of vaginal bleeding The first action the nurse should take using the nursing process is to assess the amount of vaginal bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the nurse's priority.

A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order Fluoxetine 20 mg PO daily Initiate suicide precautions Low-sodium diet Potassium 40 mEq PO daily

Anticipated Initiate suicide precautions Potassium 40 mEq PO daily Contraindicated Fluoxetine 20 mg PO daily Low-sodium diet When generating solutions for a client who has bipolar disorder, the nurse should anticipate prescription for potassium and suicide precautions. The client has hypokalemia which is treated with a potassium supplement. The client has a recent suicide attempt and is exhibiting manifestations of depression. Therefore, the nurse should anticipate that the client with be placed on suicide precautions, which include continuous monitoring. The nurse should identify that a low-sodium diet and fluoxetine are contraindicated for this client. A low-sodium diet increases their risk for a lithium toxicity. The client has a history of severe allergic reaction to SSRIs, so fluoxetine should not be administered.

The nurse is continuing to care for the adolescent. Which of the following prescriptions should the nurse anticipate from the provider? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent. Potential Prescription Prepare the adolescent for surgery. Remove the splint. Apply ice to the affected extremity. Elevate the right leg above heart level.

Anticipated Prepare the adolescent for surgery. Remove the splint. Contraindicated Apply ice to the affected extremity. Elevate the right leg above heart level. When generating solutions for an adolescent who has compartment syndrome, the nurse should anticipate that the adolescent will need a fasciotomy. A fasciotomy is needed to decrease atrial spasms and increase perfusion within the muscle compartments. The nurse should recognize that elevating the right leg above heart level, and applying ice to the affected extremity are all contraindicated for an adolescent who has compartment syndrome. Elevating the right leg above heart level and applying ice to the affected extremity will further compromise blood flow.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Evaluate dietary intake for a client who has anorexia. Measure the vital signs of a client who just returned from the PACU. Arrange the lunch tray for a client who has a hip fracture. Assess I&O for a client who is receiving dialysis.

Arrange the lunch tray for a client who has a hip fracture. Assisting a client with meals is within the range of function of the AP.

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take? Withhold pain medications for 24 hr after the old patch is removed. Ask another nurse to witness the disposal of the new patch. Seal the patches in a plastic bag and place in the client's trash basket. Stick the two patches to each other and place them in the sharps bin.

Ask another nurse to witness the disposal of the new patch. The nurse should have another nurse witness the waste of the fentanyl patch. The nurse should then waste the medication in a secure receptacle, according to agency policy, when disposing of any unused portion of a controlled substance.

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? Evaluate the changes the partner requests. Review the client's plan of care. Analyze other reports of poor care to look for trends. Ask the partner to list specific concerns.

Ask the partner to list specific concerns. The first action the nurse should take using the nursing process is to assess the situation by asking the partner to list specific concerns.

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? Insert air in the tube and listen for gurgling sounds in the epigastric area. Aspirate contents from the tube and verify the pH level. Review the medical record for previous x-ray verification of placement. Auscultate the lungs for adventitious breath sounds.A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? "Perhaps you think the ECT is dangerous, but I've seen it have good results." "You have the right to change your mind about this procedure at any time." "Everyone gets a little nervous about this procedure as the time for it approaches." "Your

Aspirate contents from the tube and verify the pH level. MY ANSWER The nurse should verify that the pH level of the client's gastric aspirate is less than 5 to determine proper placement of a client's NG feeding tube prior to administering a bolus feeding.

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take? Assess the apical pulse while the newborn is crying. Palpate the radial pulse for 30 seconds. Listen to the apical pulse while palpating the radial pulse. Auscultate the apical pulse at least 1 min.

Auscultate the apical pulse at least 1 min. The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn's heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? Borderline Antisocial Histrionic Paranoid

Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation.

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) Broccoli Yogurt Pepperoni pizza Cream cheese Bologna sandwich

Broccoli is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli does not contain tyramine. Yogurt is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Yogurt contains little or no tyramine. Cream cheese is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Cream cheese contains little or no tyramine.

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C is correct. The nurse should assess the infant's abdomen for distention and visible peristalsis, which are manifestations of HD.

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? Constipation Urinary urgency Cervical laceration Retained placenta

Cervical laceration The nurse should assess the client for complications associated with a vacuum-assisted birth such as perineal, vaginal, or cervical lacerations.

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process. Assessment Findings Weight WBC Bowel pattern Temperature Heart rate Albumin level Abdominal pain location

Crohn's Disease Temperature Weight Bowel pattern WBC Albumin level Abdominal pain location Ulcerative Colitis Temperature Weight WBC Albumin level Peritonitis Temperature WBC Heart rate Temperature is consistent with Crohn's disease, ulcerative colitis, and peritonitis. The client's temperature is elevated. This can occur with all three of the above disease processes due to inflammation and infection. Weight is consistent with Crohn's disease and ulcerative colitis. The client has lost weight since their initial appointment 2 months ago. Unintended weight loss can occur with Crohn's disease and ulcerative colitis due to malabsorption in the gastrointestinal tract. Bowel pattern is consistent with Crohn's disease. The client reports frequent soft, loose stools without the presence of blood. This is most consistent with Crohn's disease. Clients who has ulcerative colitis often have liquid, bloody stools. WBC is consistent with Crohn's disease, ulcerative colitis, and peritonitis. The client's WBC is elevated, which can occur with all three of the above disease processes because of inflammation and infection. Heart rate is consistent peritonitis. The client's heart rate is elevated, which may occur with peritonitis due to inflammation, infection, and dehydration. Albumin level is consistent with Crohn's disease and ulcerative colitis. The client has a decreased albumin level. Unintended weight loss can occur with Crohn's disease and ulcerative colitis due to malabsorption in the gastrointestinal tract. Abdominal pain location is consistent with Crohn's disease. The client reports abdominal pain in the right lower quadrant, which occurs with Crohn's disease. Clients experiencing peritonitis often experience generalized abdominal pain that can radiate to the shoulder and back.

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Calories Protein Potassium Fiber

Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation.

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? Decreased blood pressure Decreased hallucinations Decreased cholesterol Decreased esophageal reflux

Decreased hallucinations The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia.

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? Delegate non-nursing tasks to ancillary staff. Stock client rooms with extra supplies. Assign dedicated equipment to each client's room. Change continuous IV infusion tubing every 24 hr.

Delegate non-nursing tasks to ancillary staff. Delegating non-nursing tasks to ancillary staff is an effective method of providing high-quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? Difficulty performing ADLs Inability to swallow clear liquids Elevated blood glucose levels Unsteady gait when ambulating

Difficulty performing ADLs The nurse should initiate a referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, and eating.

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication? Diarrhea Dry mouth Photophobia Bruising

Dry mouth Clonidine is an indirect-acting antiadrenergic agent used for hypertension, severe pain, and attention deficit disorder. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of clonidine.

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload? Oliguria Bradycardia Dyspnea Poor skin turgor

Dyspnea The nurse should recognize that dyspnea indicates the client could be experiencing fluid overload. Fluid overload can lead to the backup of fluid in the pulmonary system resulting in shortness of breath.

A nurse is caring for an adolescent. Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply. Apply warm packs to right extremity for the first 24 hr. Elevate affected limb at chest level. Perform neurovascular assessments every hour. Assist the adolescent with ambulation from bed to chair. Remove indwelling urinary catheter when no longer indicated.

Elevate affected limb at chest level. Perform neurovascular assessments every hour. Remove indwelling urinary catheter when no longer indicated. When analyzing cues for a post-operative adolescent, actions the nurse should take include elevating the affected limb at chest level, performing neurovascular assessments every hour, and removing the indwelling urinary catheter when it is no longer indicated. The nurse should elevate the affected limb at chest level to reduce edema. Neurovascular assessments should be performed every hour for the first 24 hr post-surgery for immediate recognition of neurovascular compromise. For clients who have an indwelling urinary catheter, evidence-based practice indicates the catheter should be removed as soon as possible or within 24 hr if no longer indicated.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? Instruct the client about the importance of regular medical appointments. Encourage the client to participate in daily exercise. Explain proper foot care techniques to the client. Ensure that the client understands the medication regimen.

Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs. risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly.

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? Document the client's refusal in the medical record. Honor the client's decision to refuse the blood transfusion. Explore the client's reasons for refusing the treatment. Discuss the client's refusal with the provider.

Explore the client's reasons for refusing the treatment. The first action the nurse should take when using the nursing process is assessment. The nurse should gather more data regarding the client's decision to refuse the blood transfusion.

The nurse is assessing the adolescent 4 hr following fasciotomy. Click to highlight the findings below that indicate the adolescent's condition is improving. Adolescent is drowsy and reports nausea. Respirations shallow. Lungs clear. Unproductive cough present. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with hypoactive bowel sounds in all four quadrants. Right lower extremity fasciotomy, dressing clean, dry, and intact. Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10.

Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10. When evaluating outcomes, the nurse should identify that the adolescent's extremity pulse, capillary refill, skin temperature, no reports of numbness or tingling, and a decrease in pain are all findings that indicate the fasciotomy was effective. A fasciotomy is a surgical procedure that creates an incision in the muscle fascia to relieve pressure within the compartment. The relief of the pressure restores perfusion to the area and reduces pain.

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? Facilitate an interdisciplinary conference at the new facility for the family. Refer the client and family to a social worker for assistance and a follow-up meeting. Reassure the client's family that the same provider will provide care at the new facility. Tell the family that the rehabilitation facility has an excellent client care record.

Facilitate an interdisciplinary conference at the new facility for the family. Initiating an interdisciplinary conference will address the family's concerns about providing optimal care for the client.

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)? February 1 February 8 February 15 February 22

February 15 Using Nägele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th.

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? Form a committee of staff members to investigate current staffing issues. Provide support to staff members who are resistant to staffing changes. Schedule a staff meeting to present the different options to staff members. Give the staff members advance written notice of staffing changes.

Form a committee of staff members to investigate current staffing issues. The first action the nurse should take when using the nursing process is to assess the current staffing issue. The first stage of change is the "unfreezing stage," in which information is gathered about the problem. Therefore, the first action the nurse manager should take is to form a committee to investigate the problem.

A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take? Hold the insulin pen device perpendicular to the client's skin to inject the medication. Shake the insulin pen device prior to injecting the medication. Withdraw the insulin from the pen device into an insulin syringe. Hold the pen device in place for 3 seconds after injecting the insulin.

Hold the insulin pen device perpendicular to the client's skin to inject the medication. The nurse should hold the insulin pen perpendicular to the client's skin to inject the medication, which ensures the insulin enters the subcutaneous tissue.

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? Implement fall precautions for the client. Monitor the client's thyroid function. Place the client on a fluid restriction. Discontinue the medication if hallucinations occur.

Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client.

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? Encourage the client to take a cool sponge bath each morning. Administer opioid analgesia. Increase the client's dietary iron intake. Restrict the client's intake of foods high in purines.

Increase the client's dietary iron intake. Clients who have rheumatoid arthritis require foods high in protein, vitamins, and iron to promote tissue repair. The nurse should encourage the client to increase their intake of dietary iron. NSAIDS, rather than opioid analgesic medications, are used to relieve the pain and inflammation associated with rheumatoid arthritis.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? Irritability Increased urination Vomiting Facial flushing

Irritability The nurse should instruct the client to monitor for irritability, which can indicate decreased blood glucose levels.

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? Initiate continuous cardiac monitoring. Administer 40 mEq/L potassium chloride PO with orange juice. Provide a diet rich in legumes, nuts, and green vegetables. Monitor the client for tetany.

Initiate continuous cardiac monitoring. The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? Encourage oral fluids. Apply topical calamine lotion. Administer acetaminophen as an antipyretic. Initiate transmission-based precautions.

Initiate transmission-based precautions. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to initiate transmission-based precautions for the child. The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? Place the client in the lithotomy position. Elicit a vagal response by performing gentle rectal stimulation. Administer oral bisacodyl 30 min prior to the procedure. Insert a lubricated gloved finger and advance along the rectal wall.

Insert a lubricated gloved finger and advance along the rectal wall. The nurse should insert a lubricated gloved finger and advance it along the rectal wall when digitally evacuating stool.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? Instruct the client to void. Position the client on their left side. Insert an IV catheter. Prepare the client for moderate (conscious) sedation.

Instruct the client to void. The nurse should instruct the client to void prior to the procedure, because an empty bladder decreases the risk of a bladder puncture and minimizes the client's discomfort during the procedure.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? Contact the facility chaplain to visit with the client. Explain the process of leaving the facility against medical advice. Make a referral for social services. Encourage the client to continue with inpatient care.

Make a referral for social services. As a client advocate, the nurse should support the client's decisions and obtain a referral for social services to ensure that the client's needs at home are met. Social services can set up home care or hospice care services for the client if needed.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? Organizing the work environment Delegating assigned tasks appropriately Making a list of activities to complete Rewarding yourself for accomplishing goals

Making a list of activities to complete According to evidence-based practice, planning is the most important step in managing time effectively. Therefore, the nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Palpate the degree of edema. Regulate IV pump fluid rate. Measure the client's daily weight. Assess the client's vital signs.

Measure the client's daily weight. It is within the AP's range of function to measure a client's daily weight, so the nurse should delegate this task to the AP.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Assess the client's IV site every 8 hr. Check the client's WBC count every 48 hr. Monitor the client's mouth every 8 hr. Change the client's IV tubing every 48 hr.

Monitor the client's mouth every 8 hr. The nurse should monitor the client's mouth at least every 8 hr for manifestations of an infection, such as sores or lesions.

During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take? Keep the client's television on with the volume low. Insert an indwelling urinary catheter to minimize interaction with the client. Consult the provider regarding administering a mild sedative on a schedule. Move the client to a room near the nurses' station.

Move the client to a room near the nurses' station. The day shift nurse should move the client to a room near the nurses' station to enhance the staff's ability to keep the client under frequent observation.

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? Heart rate 136/min Nasal flaring Transient strabismus Overlapping of sutures

Nasal flaring The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting.

A nurse is caring for a client who is postoperative following an appendectomy. Which of the following 4 client findings should the nurse report to the provider? Nausea Lungs sounds Bowel sounds Incision characteristics Heart rate Vomiting Pain level Oxygen saturation

Nausea Heart rate Pain level Oxygen saturation When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider.

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? Measuring the group's work against the assigned objectives Noting the progress of the group toward assigned goals Sharing experiences as an authority figure Offering new and fresh ideas on an issue

Noting the progress of the group toward assigned goals Noting the progress of the group toward assigned goals is the task of the orienteer.

A nurse is caring for an adolescent. Select the 4 findings that require follow-up. Pedal pulse Pain Blood pressure Capillary refill Skin temperature Heart rate

Pedal pulse Pain Capillary refill Skin temperature When recognizing cues, the nurse should identify the assessment findings that require follow-up in an adolescent who has an injury to the right leg include capillary refill, pedal pulse, skin temperature, and pain. The adolescent rates their pain as 10 on a scale of 0 to 10, which requires follow-up by the nurse. A capillary refill of 4 seconds is not within the expected reference range of less than 2 seconds. A pedal pulse of +1 is diminished and not within the expected reference range. Skin temperature of the right extremity is cool to the touch, which is an unexpected finding. These findings are indicative of decreased perfusion to the extremity and require follow-up by the nurse.

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? Perform gastrostomy feedings through a client's established gastrostomy tube. Determine if the PRN pain medication administered 30 min ago has helped. Provide instructions about client care to a family member over the telephone. Teach a client how to measure their own blood pressure.

Perform gastrostomy feedings through a client's established gastrostomy tube. The nurse should delegate providing gastrostomy feedings through the client's established gastrostomy tube to an AP because this task is within the AP's range of function.

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? Contact the facility's ethics committee. Obtain consent from the client's employer. Limit care to comfort measures. Proceed with provision of medical care.

Proceed with provision of medical care. When a client is unable to give informed consent in an emergency, health care personnel can proceed with necessary life-saving care because the law considers this implied consent.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? Radial vein of the inner arm Great saphenous vein of the leg Dorsal plexus vein of the foot Basilic vein of the hand

Radial vein of the inner arm The nurse should select the radial vein of the inner arm when initiating IV access for an older adult client because this site will have adequate subcutaneous tissue.

A nurse is caring for a client who is pregnant. The nurse is providing discharge teaching to the client. For each discharge instruction, click to specify if each action is recommended or contraindicated for the client. Nursing action Drink warm ginger ale when nauseated. Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Increase intake of high-fat foods.

Recommended Drink warm ginger ale when nauseated. Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Contraindicated Increase intake of high-fat foods. When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication? Hypotension Report of tinnitus Report of chest pain Ecchymosis

Report of chest pain The nurse should identify that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina.

A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? Avoids initiating change Seeks input from the other nurses Makes decisions quickly Limits the amount of feedback to the staff

Seeks input from the other nurses A nurse manager who uses a democratic leadership style includes members of the team when making decisions and encourages staff members to participate in the decision-making process.

A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? Chest x-ray Serum liver enzyme levels ABGs Urine culture and sensitivity

Serum liver enzyme levels Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to prescribe laboratory tests to assess the child's liver function prior to and periodically during therapy.

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up. Speech Neuro status Weight Restlessness Auditory hallucinations

Speech Restlessness Auditory hallucinations When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow-up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Massage bony prominences on the client's left side. Support the client's left arm on a pillow while sitting. Position the bedside table on the client's left side. Place the client's cane on their left side while ambulating.

Support the client's left arm on a pillow while sitting. The nurse should the support the client's affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation.

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first? Instruct a staff member to maintain a log of emergency care provided. Apply cervical spine collars to children who have suspected neck trauma. Notify guardians of the emergency and injuries to their children. Survey the scene for potential hazards to staff and children.

Survey the scene for potential hazards to staff and children. The first action the nurse should take when using the nursing process is to assess the situation. By surveying the scene, the nurse can identify potential hazards to staff and children. These findings allow the nurse and staff to enter the scene and safely provide care to injured children and help decrease the risk for further injury.

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include? Clean the mouthpiece with warm water every 2 weeks. Wait 10 seconds between inhalations. Take a quick inhalation when pressing the dispenser. Take the medication 15 min before playing sports.

Take the medication 15 min before playing sports. The nurse should instruct the child to take the medication 5 to 20 min prior to exercise to promote bronchodilation. The medication's effects begin immediately, peak in 30 to 60 min, and can last for up to 5 hr.

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? Hypoxemia Tension pneumothorax Malignant hypertension Atelectasis

Tension pneumothorax The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP. The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins.

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? The LPN and AP lower the side rails before lifting the client up in bed. Prior to lifting the client, the LPN and AP raise the bed to waist level. The LPN and the AP grasp the client under his arms to lift him up in bed. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

The LPN and the AP grasp the client under his arms to lift him up in bed. The LPN and AP should not grasp the client under the arms when lifting, as this can result in shoulder dislocation or other injury to the client. Therefore, the RN should intervene and instruct the nurses to use a draw sheet or friction-reducing device to lift the client.

The nurse is continuing to care for the adolescent. The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery? The adolescent has not voided in 4 hr. The adolescent's blood pressure is 131/89 mm Hg. The adolescent's parents have concerns regarding the surgery. The adolescent reports severe pain.

The adolescent's parents have concerns regarding the surgery. When taking actions for an adolescent who is scheduled for a fasciotomy, the nurse should notify the provider if the parents of the adolescent have questions or concerns regarding the procedure, which could indicate lack of understanding about the informed consent

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse? The child exhibits discomfort while walking. The child has thin extremities. The child has bruises on the upper back. The child is wearing a stained shirt.

The child exhibits discomfort while walking. The nurse should identify this finding as a potential indication of child sexual abuse.

The nurse is continuing to care for the adolescent. Complete the following sentence by using the lists of options. The client is at highest risk for developing Select... compartment syndrome pulmonary embolism infection as evidenced by the client's drop Select... temperature immobility paresthesia

The client is at highest risk for developing compartment syndrome as evidenced by the client's drop paresthesia. The nurse should determine that the priority hypothesis is the adolescent is developing compartment syndrome as evidenced by paresthesia in the right foot. When using the urgent vs. nonurgent approach to care, the nurse determines that the priority finding is paresthesia. This can indicate compartment syndrome, which requires immediate intervention. Therefore, this finding is the highest priority.

A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Box 1 as evidenced by Box 2. Box 1 postpartum hemorrhage infection hyperglycemia seizures hypoxemia Box 2 Oxygen saturation platelet count WBC blood pressure capillary blood glucose

The client is at risk for developing seizures as evidenced by blood pressure . When analyzing cues, the nurse should recognize the client is at risk for developing seizures as evidenced by the client's blood pressure. The client is reporting a new onset of headache, blurred vision, and nausea. Assessment of the client demonstrates significantly elevated blood pressure, hyperreflexia, and clonus. These findings indicate central nervous system irritability, which increases the risk for seizures, also known as eclampsia.

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Box 1 due to Box 2. Box 1 infection spinal shock hemorrhagic stroke respiratory depression injection site reaction Box 2 urinary catheter placement tardive dyskinesia hypervolemia autonomic dysreflexia dexamethasone intake

The client is at risk for developing spinal shock due to autonomic dysreflexia .

A nurse is caring for a client who has bulimia nervosa. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing and . Conditions hyponatremia hypoglycemia metabolic alkalosis cardiovascular abnormalities

The client is at risk for developing and . Conditions hyponatremia cardiovascular abnormalities The nurse should determine that the client is at the greatest risk of developing hyponatremia and cardiovascular abnormalities due to chronic vomiting. When a client is chronically vomiting, electrolyte imbalances can occur. Cardiovascular abnormalities, such as bradycardia, arrhythmias, and electrocardiograph changes, can occur.

A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED). Complete the following sentence by using the list of options. The client is at risk for developing Select... confusion tetany polyuria due to Select... calcium level hypertension sodium level

The client is at risk for developing confusion due to sodium level. Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should monitor the client's level of consciousness and place the client on fall and seizure precautions.

A nurse is caring for a client. Complete the following sentence by using the list of options. The client is exhibiting manifestations of Select... anorexia nervosa bulimia nervosa binge eating disorder and is at risk for Select... parotid swelling esophageal rupture arrhythmia

The client is exhibiting manifestations of anorexia nervosa and is at risk for arrhythmia. When analyzing cues, the nurse should identify the client is exhibiting manifestations of anorexia nervosa and is at risk for developing cardiac arrhythmia. Manifestations of anorexia nervosa include low BMI, weight loss, food restriction, lanugo, edema, cold extremities. Complications of anorexia nervosa can include arrhythmias, decreased bone density, muscle weakening, and heart failure.

A nurse is caring for a client who is in spinal cord injury (SCI) unit. Complete the following sentence by using the list of options. The nurse should first address the client's Select... blood pressure temperature oxygen saturation followed by the client's Select.... Select... bowel sounds urinary output deep tendon reflexes

The nurse should first address the client's oxygen saturation followed by the client's urinary output. The nurse should determine that the priority hypothesis is decreased oxygenation followed by decreased urine output. When using the airway, breathing, circulation framework, the priority finding the nurse should address is the oxygen saturation measurement of 92%. Impaired functioning of the intercostal muscles and nerves of the diaphragm increases the risk of atelectasis and pneumonia for the client who has a SCI as evidenced by oxygen saturation of 92%. The nurse should analyze the cues and determine that the next priority finding to address is the client's urine output. Urine output of 30 mL/hr or less for more than 2 hr requires assessment. When using the greatest risk framework, the nurse should identify that the urine output should be addressed next. The nurse should recognize the risk of autonomic dysreflexia from urinary retention and should observe the client's abdominal distention, assess for bladder distention, and check the urinary catheter tubing for obstruction.

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The nurse should first inspect the client's abdomen to assess skin integrity and symmetry. Next, the nurse should perform auscultation. Because palpation and percussion can alter bowel sounds, the nurse should auscultate prior to these steps. After auscultation, the nurse should percuss the client's abdomen for tympany, dullness, absence, or flatness of resonance. Lastly, the nurse should palpate the abdomen for tenderness, pain, or the presence of a mass

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? The last time the provider evaluated the client The client's most recent ventilator settings The time of the client's last dose of pain medication The frequency in which the client presses the call button

The time of the client's last dose of pain medication The nurse should recognize that an effective handoff report provides a baseline of the client's status for comparison and should include any recent changes or priority situations affecting the client's condition. Therefore, the time of the client's last dose of pain medication is important to include so the receiving nurse can anticipate what time to give the next dose.

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? Completion of the incident report Time the medication was given Reason for the medication error Notification of the pharmacist

Time the medication was given The nurse should document the time, the name of the medication, the dose, and the route in which the medication was given on the client's medication administration record immediately after it was administered. The nurse should also document the time that the incorrect medication was administered to the client in the incident report, as this is a fact directly related to the occurrence.

A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect? Dry, coarse hair Bradycardia Tremors Periorbital edema

Tremors Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia.

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take? Prepare to administer vitamin K1. Prepare to administer alteplase. Withhold the heparin infusion. Withhold the next dose of warfarin.

Withhold the heparin infusion. MY ANSWER The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld, until the aPTT returns to the therapeutic range.

A nurse is caring for a client who is postoperative following administration of general anesthesia.

Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? Maintain a flexible daily schedule for the child. Use a reward system to modify the child's behavior. Provide a variety of family members to care for the child. Administer alprazolam as needed to reduce the child's anxiety.

Use a reward system to modify the child's behavior. Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior.

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? Check the client's blood type and crossmatch it against the provider's orders. Ask the client to state their blood type prior to beginning blood administration. Compare information on the blood product to the informed consent form. Verify the client and blood product information with another licensed nurse.

Verify the client and blood product information with another licensed nurse. The nurse should compare the blood product label against the medical record and the client's identification number with another nurse to ensure the correct blood product is administered to the correct client.

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? Check the functioning of oxygen equipment once each week. Wear clothing made with cotton fabrics while oxygen is in use. Apply petroleum-based lubricant to the nares as needed. Store full oxygen tanks on their side.

Wear clothing made with cotton fabrics while oxygen is in use. The nurse should instruct the client to wear clothing made with cotton fabrics rather than synthetic or woolen fabric when the oxygen is in use. Woolen and synthetic fabrics can generate static electricity, which increases the risk for a fire.

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol? Weight loss Wheezing Blood pressure 146/92 mm Hg Heart rate 110/min

Wheezing MY ANSWER The nurse should recognize that wheezing can indicate the client is experiencing an adverse reaction to the medication.

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? aPTT PT INR WBC count

aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value.

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? Weight gain Decrease in anteroposterior diameter of the chest HCO3- 24 mEq/L pH 7.31

pH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35 to 7.45. A pH level less than 7.35 indicates acidosis. For a client who has COPD, a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45 mm Hg, indicating respiratory acidosis.