Nursing Concept Advanced Test ATI

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A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently & says she wants to die. Which of the following responses by the nurse is appropriate?

"Let's discuss some strategies you can use when this happens again."

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching?

Cue client by providing cards that portray common needs. -Using picture cards that portray common needs provides cues for the client and enhances communication

A nurse is caring for a client who has an UTI & is prescribed ciprofloxacin (Cipro). The client exhibits urticaria & angioedema following administration of the medication. Which of the following is the first action the nurse should take?

Determine respiratory rate (Think of ABC)

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication?

Excessive vomiting -Metabolic alkalosis is a potential complication of excessive vomiting bc of the loss of acid from the body.

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates further teaching?

It is the responsibility of the provider to obtain express consent.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?

Lethargy -It occurs when pressure is placed on the reticular activating system within the brainstem. Lethargy is the 1st sign of increased ICP.

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions?

Supine with head of the bed 30 degrees -Prevents hemorrhage by reducing blood flow to the brain

A nurse has assigned 4 tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first?

Take ABG specimen to the lab -ABG specimen are kept in ice so it should be transported immediately.


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