ATI sorpresa

A nurse reports an incident of suspected child abuse.

"As a nurse, I am required by law to report suspected child abuse." ~ CORRECT My Answer A nurse is required by law to report suspected child abuse. Therefore, this is a truthful, non-accusatory response.

A client becomes very dejected and states '' no one really care what happens to me . Life isn't worth living anymore . '' Which of the following responses should the nurse make ?

"I care about you, and I am concerned that you feel so sad." ~ CORRECT My Answer This is an open-ended therapeutic statement that focuses on the client's feelings, shows empathy, and allows for further exploration of the client's belief that life is not worth living in order to keep the client safe from suicidal thoughts. Page 25 of 34 A nurse reports an incident of suspected child abuse.

A nurse is teaching assistive personnel (AP), about using personal protective equipment while caring for a client. Which of the following statement should the nurse identify as an indication that the AP understands the instructions?

"I will wear gloves and a gown when bathing a client who has open skin lesions." ~ CORRECT My Answer The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.

A nurse is reviewing information about the HIPPA with a newly licensed nurse. Which fo the following states by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."| ~ CORRECT My Answer This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and as closure or his or her own personal health information.

A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

A 10-year-old child who has sickle cell anemia who reports severe chest pain CORRECT When using the urgent vs. nonurgent approach to client care, the nurse should determine that the 10-year-old child who has sickle cell anemia and reports severe chest pain should be assessed first. This finding is a medical emergency because it is a manifestation of acute chest syndrome.

A nurse is caring for a client who has been prescribed bedrest. The plan of care indicates that the client should perfume isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax. ~ CORRECT My Answer Isometric exercises involves static (no movement)contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this cient？

KYPHOSIS a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral tractures.

nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

MEDIAN VEIN IN THE FOREARM The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurses ear when setting up the client's meal tray?

Mask ~ CORRECT My Answer The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket. Which begins to smolder, which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity. CORRECT The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

a nurse is caring for a older adult who has alert and orienteered at admission but now sees increasingly restless and intermittently confused > which of the following actions should the nurse take address the client's safety needs?

Move the client to a room closer to the nurses' station. ~ CORRECT My Answer This will make it easier for the staff to observe the client, should the client behave in an unsafe manner

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Shakiness and diaphoresis CORRECT When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.

A nurse is caring for a client who is dying. The client says "my mother died in the hospital, but I did not get there before she died". Which of the following statement should the nurse make?

"I wonder if you are fearful of dying alone." CORRECT The nurse is verbalizing the client's implied concerns and seeks to validate if this is the client's concern.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the the following room assignments should the nurse make for the client?

A room with air exhaust directly to the outdoor environment ~ CORRECT My Answer A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae ~ CORRECT My Answer To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is providing teaching for a cient who has binge-eating aisorder and is morbidly obese. The chient has been prescribed orlistat. Which or the following statements indicates to the nurse that the client understands the teaching?

I will stop taking orlistat and call my doctor if my urine gets darker in color CORRECT My Answer Orlisat can cause severe liver damage; therefore, the client should be taught manifestations of liver damage, including dark-colored urine, light-colored stools, aundice, anorexia, vomlung, and Tatigue. "I will feel less hungry during meals while I am taking orlistat.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has a nasogastric (NG) tube to suction| ~ CORRECT My Answer Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions.

ATELECTASIS Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes In position, therective coughing, and underlying lung aisease are risk factors for the development of atelectas!s.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Albumin CORRECT A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands. ~ CORRECT My Answer The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the prose of the test is to check the stool for which of the following substances?

Blood

A nurse is proving oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care. ~ CORRECT My Answer Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiative?

Droplet| ～ CORRECT My Answer The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airbonres precaution and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safety to the radiology department for ca hest x-ray?

Have the client wear a mask CORRECT My Answer When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is admitting a client who has experienced a weight loss of 11kg ( 25lb) in the past 3 months. The client weighed 40kg ( 88lb) and believes she is fat . Which of the following aspects of care should be the nurse consider the priority for this client ?

Identify the client's nutritional status. CORRECT According to the nursing process, the nurse should perform an assessment first to gather enough data regarding nutritional status and other findings in order to plan, implement, and evaluate care. The assessment identifies client nutrition needs as well as complications the client might be experiencing related to the eating disorder.

A nurse is caring for a client who is undergoing a lumbar puncture . Which of the following is the priority action for the nurse take to maintain privacy for the client ?

Pull the curtains around the client's bed CORRECT Pulling the curtains bed assures privacy to the client

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different site. ~ CORRECT My Answer It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A nurse is working with assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

Removing the abdominal dressing CORRECT The nurse cannot delegate assessment, diagnosis, planning, or evaluation because these are steps of the nursing suca taurant ern tan tune aroung and ton a desig the yone should agest using. sterile technique to complete a dressing change.

A newly licensed nurse is applying prescribed wrist restraint on a client. Which of the following actions should the nurse take?

Respiratory rate ~ CORRECT My Answer Airway, breathing, and circulation are the priority focus of the nurse at this time. Meperidine can cause respiratory depression and the client's respiratory rate should be monitored prior to administering this medication.

A nurse in a long term care facility is planning care for several clients . Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Scheduling a diagnostic study for a client

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie. CORRECT The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen?

Send specimen container immediately to the lab.

A nurse is administering nasal decongestant drops to client. Which of the following actions should the nurse take?

Tell the client to blow her nose gently before the instillation.

When planning delegations tasks to AP a nurse considers the five rights of delegations . Which of the following should the nurse consider when using one of the five rights of delegation ?

The AP has the knowledge and skill to perform tasks CORRECT The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

The client developed a tolerance to the medication. ~ CORRECT My Answer The nurse should document that the client has developed a tolerance to the medication. Morphine is a narcotic | analgesic used for the treatment of severe pain. Tolerance is an adverse effect of narcotic analgesics in which a larger dose is needed to produce the same response.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC count ~ CORRECT My Answer An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the nathomans rancinn an infartion A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? Lower the height of the solution container. ~ CORRECT My Answer If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping nas passed.

A nurse accidentally sticks her hand with a syringe needle after administering and IM injection to a client . Which of the following actions should the nurse take first ?

Wash the area of the puncture thoroughly with soap and water CORRECT The greatest risk to this client is injury from any bloodborne pathogens on the needle; therefore, the first action the nurse should take is to provide immediate first aid by scrubbing the area thoroughly with soap and water.