ATI Comprehensive Predictor Study Guide Part 1 (1938 Questions with 100% Correct Answers). Test bank

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ATI Comprehensive Predictor Study Guide Part 1 (1938 Questions with 100% Correct Answers) What can be delegated to Assistive personnel (AP)? - ✔✔- ADLs - bathing - grooming - dressing - ambula... ting - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk with a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer - ✔✔C A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning - ✔✔B C D An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postop to use an incentive spirometerB. Collecting a clean catch urine specimen from a client who was admitted on the previous shift C. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump - ✔✔D A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances - ✔✔B C E A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client? A. Charge nurse B. RN C. LVN D. AP - ✔✔B What is the study of conduct and character? - ✔✔Ethics What are the values and beliefs that guide behavior and decision making? - ✔✔Morals What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest - ✔✔Autonomy What are positive actions to help others - ✔✔BeneficienceWhat is an agreement to keep promises - ✔✔Fidelity What is fairness in care delivery and use of resources - ✔✔Justice What is avoidance of harm or injury - ✔✔Non-maleficence A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience - ✔✔A A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficience - ✔✔D A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ✔✔CA nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence - ✔✔D Which of the following situations can be identified as an ethical dilemma? A. A nurse on a med surge unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form - ✔✔C Most managers can be categorized as - ✔✔authoritative, democratic, and laissez faire makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings - ✔✔Authoritative includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessary - ✔✔Democratic makes very few decisions and does little planningmotivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation - ✔✔Laissez faire The nurse should consider the hierarchy of human needs when prioritizing interventions, which are? - ✔✔- Physiological needs first (oxygen, shelter, food) - Safety & security needs (physical safety) - Love and belonging - Self esteem - Self actualization The ABC framework identifies, in order, the three basic needs for sustaining life - ✔✔Airway Breathing Circulation Nurses must follow what code of standards in delegating and assigning tasks - ✔✔ANA codes of standards What values would a nurse possess to be a client advocate? - ✔✔- caring - autonomy - respect - empowerment What do the nurse need to keep in mind about the client when being their advocate? - ✔✔Client's religion & culture When should planning discharge process begin? a. at time of admissionb. 2 days after client is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge order - ✔✔A What is an interdisciplinary team? - ✔✔A group of health care professionals from different disciplines Fill in the blank: 1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. - ✔✔1 & 2 = collaboration What is the nurse's contribution to an interdisciplinary team? - ✔✔- knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems. A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils. - ✔✔2 A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure.3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 cc per hour. - ✔✔4 The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 1. increased pulse rate. 2. decreased temperature. 3. fine tremors. 4. increased radioactive iodine uptake level. - ✔✔2 A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head. - ✔✔3 Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position her on her abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist her with heat application and ROM exercises. - ✔✔4 The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient1. with his neck in a midline position and the head of the bed elevated 30°. 2. side-lying with his head extended and the bed flat. 3. in high Fowler's position with his head maintained in a neutral position. 4. in semi-Fowler's position with his head turned to the side. - ✔✔1 The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to 1. use a new sterile catheter each time he performs a catheterization. 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. 3. perform the catheterization procedure every 8 hours. 4. limit his fluid intake to reduce the number of times a catheterization is needed. - ✔✔2 A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication five minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture. - ✔✔4 A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment. - ✔✔1A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. reestablishes a trusting relationship with his/her other parent. 3. verbalizes that s/he is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse. - ✔✔3 An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks." - ✔✔2 After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes - ✔✔2 A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates.4. Magnesium. - ✔✔1 An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. 2. remain at the client's side to provide reassurance. 3. tell the client the name of the medication and its effects. 4. monitor the anticholinergic effects of the medication. - ✔✔1 The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization. - ✔✔1 The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety. - ✔✔3A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter. - ✔✔3 The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of 1. red meat and shellfish. 2. cottage cheese and ice cream. 3. fruit juices and milk. 4. fresh fruits and uncooked vegetables. - ✔✔1 A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure. - ✔✔3 A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real."2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication." - ✔✔3 The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is 1. before breakfast. 2. with dinner. 3. with food. 4. at hs. - ✔✔4 . If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 1. increasing respiratory difficulty seen with exertion. 2. cough productive of a large amount of thick, yellow mucus. 3. peripheral edema and anorexia. 4. twitching of extremities. - ✔✔3 The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of470 mg/dL. - ✔✔2 The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? 1. The client advances the cane 18 inches in front of her foot with each step. 2. The client holds the cane in her left hand. 3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the cane with her elbow flexed 60°. - ✔✔2 A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side. - ✔✔1 The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply - ✔✔1 A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?1. "I keep having recurring nightmares." 2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live." - ✔✔4 A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness. - ✔✔4 . The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations. - ✔✔1 An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-residue diet. 2. lie on her unoperated side. 3. exercise her arms and legs. 4. cough and deep breathe. - ✔✔4Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding. - ✔✔4 An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position. - ✔✔1 Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep. - ✔✔1 The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes. 2. It is necessary for the client to wear a mask at all times to prevent transmission ofthe disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for a duration of 6-9 months. - ✔✔4 The nurse's INITIAL priority when managing a physically assaultive client is to 1. restrict the client to the room. 2. place the client under one-to-one supervision. 3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area of other clients to prevent harm. - ✔✔3 A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be 1. confused with cold, clammy skin and a pulse of 110. 2. lethargic with hot, dry skin and rapid, deep respirations. 3. alert and cooperative with a BP of 130/80 and respirations of 12. 4. short of breath, with distended neck veins and a bounding pulse of 96. - ✔✔1 The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station.3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions. - ✔✔1 When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan. - ✔✔3 The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client. - ✔✔2 A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids. - ✔✔4A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0mg/dL. 4. The patient's hemoglobin is 8.5g/dL. - ✔✔3 A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says she feels pressure against her diaphragm when the baby moves. - ✔✔1 After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube. - ✔✔2 After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to theemergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli. - ✔✔2 The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room. - ✔✔4 A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via facemask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside. - ✔✔3 What type of infectious diseases are required to be reported to the health department? - ✔✔- severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA)What is the process of taking a telephone order from a provider? - ✔✔Patient name, drug, dose, route, frequency read back for accuracy A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene - ✔✔A B E A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting - ✔✔D A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care providerd) prepare to insert a new IV catheter - ✔✔A A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room - ✔✔A A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside - ✔✔A Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand - ✔✔B A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care - ✔✔C A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20 - ✔✔A A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly" - ✔✔C A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride - ✔✔CA nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step - ✔✔C Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardia - ✔✔A A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound - ✔✔C A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet - ✔✔DA nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? a) assess for bladder distention after 6 hr b) encourage the client to use a bed pan in the supine position c) restrict the clients intake of oral fluids d) pour warm water over the clients perineum - ✔✔D When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure. - ✔✔3 Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications. - ✔✔2 Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function. - ✔✔3A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation. - ✔✔2 During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. - ✔✔2 3 4 The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal. - ✔✔3 The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement.2. Headache. 3. Slowing of reflexes. 4. Fatigue. - ✔✔1 When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers - ✔✔4 What are some ways to identify a patient before giving a medication? - ✔✔The Joint Commission requires 2 client identifiers be used when administering medications. - clients name - assigned identification number - telephone number - birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients What are some things to teach about home safety with elderly patients? - ✔✔- Removing items that could cause the client to trip, such as throw rugs and loose carpets - Placing electrical cords and extension cords that against a wall behind furniture - Making sure that steps and sidewalks are in good repair - Placing grab bars near the toilet and in the tub or shower and installing a stool riser - Using a non-skid mat in the tub or shower - Placing a shower chair in the shower - Ensuring that lighting is adequate both inside and outside of the home A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.)A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. - ✔✔B C E A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. ____ Passive smoking ____ Carbon monoxide poisoning ____ Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking. - ✔✔C A B When performing nasotracheal suctioning what technique should be used? - ✔✔Sterile asepsis bc the trachea is considered sterile and prevents infections A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skinD. Bradypnea - ✔✔A What do you do when a client has a seizure - ✔✔- lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement seclusion and restraints - ✔✔-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min What position is good to use for a patient who is at high risk for a pressure ulcer - ✔✔30 degree lateral position is recommended for clients at risk for pressure ulcers health promotion (injury prevention-suffocation): infant (birth-1 yr) - ✔✔-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothinghypotension is classified with a reading below normal; - ✔✔systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation What temperature should pork be cooked at - ✔✔160 degrees What is the safest way to thaw out frozen foods - ✔✔In the refrigerator What are the precautions for vancomycin resistant enterococcus - ✔✔Standard precautions including hand washing and gloving should be followed What does a newborns poop look like - ✔✔If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency What is appropriate for an adolescent in the hospital? - ✔✔Puzzles and books What is the proper nutrition during pregnancy - ✔✔- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida - green leafy vegetables and brown rice What should be avoided during pregnancy - ✔✔Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby What is the most appropriate method for contraception for an adolescent - ✔✔IUD or implant If a patient has anorexia nervosa and works out constantly - ✔✔Allow them to workout and continue their regimen What medications can be taken to help with smoking cessation - ✔✔Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix)What are the five stages of grief - ✔✔denial anger bargaining depression acceptance discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss - ✔✔anticipatory grief involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time - ✔✔dysfunctional grief Signs for meningococcemia - ✔✔Vomiting, febrile, petechial rash (unstable) Levothyroxine effects - ✔✔Used to restore client's metabolic rate * Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension Multiple Sclerosis Patient - ✔✔Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration * Hair Loss = emotional distress * Amenorrhea = emotional distressMalnourished COPD patients - ✔✔(1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair" - ✔✔Anger stage Which Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again" - ✔✔Bargaining Stage How should you respond when client wants to discontinue dialysis - ✔✔"What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeutic What should the nurse do when one member of a support group expresses anger repeatedly? - ✔✔Focus more on the group members who have a positive outlook (Speak to group member privately to uncover source of anger) What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given? - ✔✔Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis) Long term effects of NSAIDS (Ibuprofen) - ✔✔Gastric Ulcerations, perforations, hemorrhage, hypertension Alcohol Use Manifestations of Withdrawal - ✔✔Body burns 0.5 oz of alcohol per hour * Withdrawal appears within 4-12 hours * Irritability + Tremors + Anxiety* Nausea + Vomiting + HA * Diaphoresis * Sleep Disturbances * TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) When does Discharge planning begin? - ✔✔At Admission Case Management nursing involves: - ✔✔*Decreasing cost by improving client outcomes * Providing education to optimize health participation * Advocating for services + client's rights What is bipolar disorder? - ✔✔Bipolar disorder is a mood disorder with recurrent episodes of depression and mania. What comorbidities may be observed with a patient who is bipolar? - ✔✔Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. What therapy will be useful for patients with bipolar? - ✔✔Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior. What kind of medications are indicated for abstinence maintenance of alcohol? - ✔✔Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral) Teaching points for naltrexone (Vivitrol)? - ✔✔Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen.A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals. - ✔✔B A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake - ✔✔C A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant - ✔✔D Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle. - ✔✔A Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotensionb) Bradycardia c) Warm moist skin d) Polyuria - ✔✔A The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool - ✔✔B After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver - ✔✔C A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth c) Regular diet d) Clear liquids - ✔✔B Bladder retraining for the treatment of urge incontinence: - ✔✔• Use timed voidings to increase intervals between voidings/decrease voiding frequency. • Perform pelvic floor (Kegel) exercises. • Perform relaxation techniques.• Offer undergarments while the client is retraining. • Teach the client not to ignore the urge to void. • Provide positive reinforcement as client maintains continence. • Eliminate or decrease caffeine drinks. • Take diuretics in the morning. what are normal creatinine levels? what are normal BUN levels? - ✔✔0.8-1.4 mg/dL 8-25 mg/dL What are total serum protein values (normals) - ✔✔6-8 g/dL Describe pre-albumin - ✔✔this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks) what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a normal potassium serum level? - ✔✔17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia) what are good sources of folic acid? - ✔✔Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils. Sources of potassium - ✔✔beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananaswhat is important about the diet of someone taking ACE inhibitors? - ✔✔can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas) Taking Coumadin. Which foods should the client limit? - ✔✔Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs? - ✔✔37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL what foods should you avoid if you have diverticulitis? - ✔✔avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) When taking MAOI's, limit your consumption of - ✔✔thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar... At what age does bone loss begin with osteoporotis what are normal Calcium levels? - ✔✔at age 35 (women) 8.6-10 mg/dL A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of - ✔✔calcium gluconate (because hypocalcemia causes Chvostek's sign) What are the S/S of lithium toxicity? (depakote for bipolar disorder) - ✔✔fine hand tremors, mild GI upset, slurred speech and muscle weaknessa nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid - ✔✔Aspirin a nurse responsible for a client receiving a antihypertensive medication is to - ✔✔teach the client to change position slowly to avoid dizziness or fainting a client should receive a dose of flumazenil ( romazicon) to treat symptoms of - ✔✔benzodiazepine overdose a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching - ✔✔I will tell my doctor before I stop taking the medication a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include - ✔✔1. change position slowly to minimize dizziness 2. chewing sugarless gum to prevent dry mouth a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ? - ✔✔what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the provider of client headache and ibuprofen us a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication - ✔✔thrombocytes, amylase count and liver function test alcohol withdrawal heroin withdrawal nicotine withdrawalalcohol abstinence opioid over dose - ✔✔chlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram ( antabuse) naloxone (narcan) a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client - ✔✔orthostatic hypotension a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client - ✔✔the nurse should monitor the client respiratory depression a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider - ✔✔serum potassium 5.2 a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk - ✔✔Toxic level of digoxin a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching - ✔✔i should decrease the amount of calcium in my diet while taking the medication A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity? - ✔✔* Verapamil (Calan) Adverse effect of Verapamil - ✔✔Avoid grapefruit juiceInteraction of diuretics and ACE inhibitors - ✔✔excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia What can prevent MI, stroke, or death in high-risk patients - ✔✔Ramipril What to monitor for when taking enoxaparin (lovenox) - ✔✔Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported What are the therapeutic effects of protamine - ✔✔Antidote to severe heparin overdose + Reversal of heparin administered during procedures How to prevent adverse effects of oxycodone - ✔✔can cause respiratory depression. What is the nursing intervention and/or client education ? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol). opioid agonists can cause Constipation What is the nursing intervention and/or client education ? - ✔✔Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation. Adverse effects of ferrous sulfate - ✔✔constipation;upset stomach; black or dark-colored stools; or. temporary staining of the teeth. Baclofen (Lioresal) therapeutic outcome: - ✔✔Decrease the frequency and severity of muscle spasms (MS). What is the difference between respiratory acidosis and respiratory alkalosis? - ✔✔Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45. Bowel elimination how to get a specimen collection - ✔✔Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine. Identifying manifestations of transient ischemic attacks - ✔✔symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke. Musculoskeletal congenital disorders - ✔✔Monitor skin for breakdown areas and prevent pressure sores. The nurse caring for a child in Buck's skin traction will keep the: - ✔✔Child pulled up in bed Where should the cath bag be placed when urinary catheterization - ✔✔Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux. What are the signs and symptoms of fluid volume deficit - ✔✔loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. What is the nursing action for dehiscence - ✔✔Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's .A nurse in a LTC facility notices a client who has Alzheimer's disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take? - ✔✔ANS: Escort the client to a quiet area on the nursing unit. - A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination? - ✔✔ANS: Use intermittent urinary catheterization for the client at regular intervals. - A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch. A nurse is assisting with an education program about car restraint safety for a group of parents. Which statement by the parent indicates an understanding of the instructions? - ✔✔ANS: "My 12YO child should place the shoulder-lap seatbelt low across his hips." - When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which instructions should the nurse include in the teaching? - ✔✔ANS: Drink high-protein and high-calorie nutritional supplements. - The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism and wasting of the client's muscle mass. When removing PPE after direct care for a client who requires airborne & contact precautions, which PPE is removed first? - ✔✔ANS: Gloves - The greatest risk is contamination from pathogens that might be present on the PPE; therefore, the priority action for the AP is to remove the gloves, which are considered the most contaminated. A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP? - ✔✔ANS: Generalized Petechiae- Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around the neck. However, petechiae all over the newborn's body can indicate infection or decreased platelet count and should be reported to the provider. A nurse is contributing to a teaching plan for a group of male adolescents about the A/E of anabolic steroid use. Which manifestations should the nurse include? - ✔✔ANS: Reduced height potential - Use of anabolic steroids in adolescence can lead to premature epiphyseal closure, thus reducing full height potential. A/E includes: Liver disorders, hyperlipidemia, breast enlargement, acne, and edema. A nurse is reinforcing teaching with an older adult client who has severe L-sided HF. Which statement should the nurse make? - ✔✔ANS: Rest for 15 minutes between activities. - The nurse should instruct to increase his activity gradually & to rest for a period of 15 min if he becomes tired. Clients who have HF should balance activity c rest to reduce cardiac workload. A nurse in a LTC facility is documenting the care of an older adult client. Which information should be included in weekly nursing care summary? - ✔✔ANS: Hydration Status - Older adult client are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client's hydration status & include this information in the weekly nursing care summary. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which information? - ✔✔ANS: Motor Response - The nurse should collect data about the client's motor response & assign the response a score of 1-6, according to the Glasgow Coma Scale. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which instruction should the nurse include? - ✔✔ANS: Apply the stocking in the morning. - The nurse should instruct the client to apply the elastic stocking in the morning and remove them at the end of the day before bedtime. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterization in 2 days. Which questions is the priority for the nurse to ask? - ✔✔ANS: "Do you know if you're allergic to iodine?"- The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. A nurse is planning to administer nystatin oral suspension to a client who has oral candidiasis. Which instructions should the nurse give? - ✔✔ANS: "Hold the medication in your mouth for several minutes prior to swallowing" - The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact of the medication with the organism. The client should then swallow or spit out the medication. A nurse is preparing to care for the assigned clients on her upcoming shift. Which time management strategies should the nurse plan to use? - ✔✔ANS: Prepare a priority list of client needs for the shift. - The nurse should prepare a client priority-to-do list, which could include administering time-critical medications. This will allow the nurse to determine which clients should receive care first. After witnessing the consent, what action should the nurse take next? - ✔✔ANS: Ask client what he understands about the procedure. Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee arthroplasty? - ✔✔ANS: Reapply antiembolitic stockings to the client ff a shower. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which statement made by the client indicates understanding of the teaching? - ✔✔ANS: "I will wear a soft scarf around my neck when I am outside" - Wash it with plain water without soap. NO heat source therapy. Only use electric razor if necessary, for shaving. A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who sis port-op. Which factor should the nurse consider when using this pain scale? - ✔✔ANS: Level Of Activity - The nurse should consider the infants level of activity when using FLACC pain scale. The FLACC is determined by five categories of behavior: Facial Expression, Leg Movement, Activity, and Consolability. A nurse is collecting data from a 5YO child at a well-child visit. Parent reports that the child is having frequent nightmares. Which statements by the parents indicates to the nurse that the child Is experiencing sleep terrors rather than nightmares? - ✔✔ANS: "My child goes back to sleep right away."- The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmare has difficulty returning to sleep because of continued fear. A nurse is assisting with the care of a school-age child immediately ff surgery. The child weighs 21.8 kg (48 lb) & has a chest tube applied to suction. Which finding should the nurse report to PCP? - ✔✔ANS: 250 mL of sanguineous drainage over the last 3 hr - More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutive hr ff surgery. It indicates active hemorrhaging. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which instructions should the nurse include? - ✔✔ANS: Apply capsaicin cream 4x/day - Apply it topically to provide warmth & relieve joint pain. A nurse is reinforcing teaching about managing manifestation of anxiety with a client who has generalized anxiety disorder. Which information should the nurse include? - ✔✔ANS: Say the word "STOP" when upsetting thoughts occur. A nurse in a LTC facility is collecting data form a client who has been receiving betaxolol to treat glaucoma. Which findings is an A/E if this medication? - ✔✔ANS: Bradycardia - Betaxolol is a beta blocker that can produce systemic effects, including bradycardia A nurse in an outpatient surgery center is reinforcing discharge teaching with a client ff a lithotripsy for uric acid stones. Which instructions should the nurse plan to include? - ✔✔ANS: Strain the urine to collect stone fragments. A nurse in a provider's office is reinforcing teaching with a client who is to follow a 2,000 mg sodiumrestricted diet. Which client food selections indicates understanding of the teaching? - ✔✔ANS: Canned Peaches. A nurse is preparing to perform a bladder scan for a client. Which action should the nurse take? - ✔✔ANS: Tell the client she should not experience any discomfort.A nurse is contributing to the plan of care for a client who has a prescription for ROM exercises of the shoulder. Which exercise should the nurse recommend promoting shoulder hyperextension? - ✔✔ANS: Move her arm behind her body with her elbow straight. A nurse is collecting data from an older adult client who has a gastric ulcer. Which finding should the nurse identify as a complication to report to the provider? - ✔✔ANS: Hematemesis A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which statement by the newly licensed nurse indicates understanding of this method of pain control? - ✔✔ANS: "I should report leaking at the insertion site to the anesthesiologist" A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation immediately ff a transurethral resection of the prostate (TURP). Which of the ff interventions should the nurse include? - ✔✔ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color. A nurse is caring for a client who is scheduled for a mastectomy the ff day. The client is tearful & tells the nurse that she is not ready to have this procedure done at this time. What response should the nurse give? - ✔✔ANS: "Would you like for me to talk to the surgeon with you?" A nurse is collecting data from a school-age child who has hypoglycemia. What is the manifestation to expect? - ✔✔ANS: Sweating A nurse is assisting with a community education program for parents of preschoolers about recommended activities to promote physical development. Which of the ff statement should the nurse make? - ✔✔ANS: "You should provide unorganized play activities for your child each day." A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which findings indicates the client is experiencing a therapeutic response to this medication? - ✔✔ANS: Report of a decrease in the number of stools. - Pancrelipase is administered as a replacement therapy for a deficiency in pancreatic enzymes, which results in steatorrhea, or fatty stools. A nurse is caring for a client who is 12-hour post-op ff total knee arthroplasty. What action should the nurse take? - ✔✔ANS: Place an abduction wedge between the client's legs when he is in bed.A nurse is reinforcing teaching regarding puberty with a group of prepubescent female clients. Which information should the nurse include in the teaching? - ✔✔ANS: "You will gain weight before you start to get taller." NO ORAL CONTARCEPTIVES for: - ✔✔CAD A nurse is caring for a client who is at 34 weeks gestation and has mild preeclampsia. Which finding indicates a progression from mild to severe preeclampsia? - ✔✔ANS: Client reports of blurred vision. A nurse is reinforcing teaching with a client who has asthma & has a prescription of theophylline. What statement should the nurse make? - ✔✔ANS: Discontinue drinking caffeinated beverages A/E of metronidazole: - ✔✔Reddish-brown urine A home health nurse is collecting data from an older adult client who has generalized anxiety disorder. The client lives at home with her partner & sibling. Which responses by the client's partner is the priority for the nurse to address? - ✔✔ANS: "Her prescription isn't generic, so we can't afford it anymore." Patient having difficulty using eating utensils. - ✔✔Refer patient to OT Child who have ingested full bottle of acetaminophen, instructions? - ✔✔instruct parents to take the child to the ER A client requesting information from a nurse about creating a health care proxy. Which statement should the nurse make? - ✔✔ANS: "The person you appoint will make health care decisions for you if you cannot do so yourself." Venipuncture location? - ✔✔antecubital fossa The nurse should stop the infusion if the patient is: - ✔✔is having edema above the catheter insertion site.A nurse is contributing to the plan of care for a client who has pneumonia. Which entries should the nurse include in the plan? - ✔✔ANS: "Client prefers bathing in the evening." Strategies to teach parents about pediculosis capitis (Head lice) management: - ✔✔ANS: Store child clothing in a separate cubicle when at school. Boil brushed and combs in water for 10 min. Dry bed linens & clothing in a hot dryer for at least 20 min. Caring for a client who has GTube. What actions should the nurse take? - ✔✔ANS: Flush the tube with 50-60 mL of warm water if the tube becomes clogged Caring for client who is 4 hr post-op ff GI surgery & NG is placed for decompression. Which action should the nurse take? - ✔✔ANS: Keep the plugged tube above the level of the stomach when the client is ambulating. Reinforcing teaching with a client who is scheduled for an exercise electrocardiography (ECG) stress test. What instruction to give? - ✔✔ANS: Recommend the client wear comfortable shoes during the test. - Informed consent must be signed, Instruct client to eat 2-3 hr before test and then remain NPO to prevent GI upset during test. A client who is Orthodox Judaism with terminal illness. - ✔✔The nurse should assure the client family member will stay with his body after death. The triage nurse can discharge which pt? - ✔✔A client who has pneumonia and is currently receiving oral antibiotic may be discharged to have more rooms for new admission patient. Avoid Ibuprofen when taking: - ✔✔"PRIL" medications. A nurse observes a client in labor. What interventions should the nurse recommend? - ✔✔ANS: Squatting using a birth ball, Counter pressure to the sacral area, & leaning forward while kneeling.Sitting and leaning forward using both hands for support is an expected finding for a: - ✔✔7-month old infant. Type 1 DM, patient indicates understanding of patient teaching when he/she states that? - ✔✔"I will dispose of my needles in a plastic laundry detergent container". - It is puncture-proof! If a client is having difficulty sleeping, offer? - ✔✔a whole grain cracker red meat is high in? - ✔✔iron peanut butter is good for? - ✔✔protein External rotation is a clinical manifestation to expect to a client with: - ✔✔hip fx An action the nurse should take prior to performing an immunization to a preschooler? - ✔✔"Let's give the medication to your doll first" Stool to expect 24 hrs after birth of an infant: - ✔✔Dark green and viscous Atorvastatin A/E: - ✔✔muscle pain Suggest walking outside with a staff member to a patient with: - ✔✔bipolar disorder & in a manic phase. An infection with gonorrhea may result to: - ✔✔infertility Physical neglect indication when collecting a from a toddler is when: - ✔✔"the toddler is inadequately dressed for the weather"OD on digoxin: - ✔✔check vs Anorexia Nervosa care plan? - ✔✔record i/o Documenting client care in the medical record, entries to include would be: - ✔✔"Client remains NPO until X-Ray procedure is complete To initiate Babinski reflex? - ✔✔Stroke the sole of the infant's foot upward & toward the great toe Report an ECG result with: - ✔✔PR interval 0.24 seconds. When patient report of nuchal rigidity, H/A, along with fever & chills. The nurse should anticipate the MD to order what diagnostic tests? - ✔✔ANS: Cerebrospinal fluid analysis - The client findings are consistent with bacterial meningitis. A lumbar puncture should be performed to obtain cerebrospinal fluid to confirm the diagnosis. Post-Op Lumbar puncture: - ✔✔Instruct patient to increase fluid intake. The client must take montelukast: - ✔✔once daily at bedtime when taking phenytoin as a measure to assist with the possible A/E: - ✔✔perform daily gum massage Morphine A/E: - ✔✔resp less than 12 complication of mechanical ventilation? - ✔✔pH of 7.5 Urine specific gravity with DI: - ✔✔below 1.0024hr hr postpartum, boggy uterus with heavy lochia. Which of the following actions should the nurse take? - ✔✔-Massage the uterus to expel clots - Rationale: ABC approach, priority is to massage uterus to expel clots and increase uterine firmness, resulting in decreased bleeding Deficit in Cranial nerve 2: results in visual impairment and lead to falls, a nurse should: - ✔✔clear objects from the walking area A nurse is interviewing a client who has just lost her home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? - ✔✔-Determine the client's perception of the personal impact of the crisis - First thing in the nursing process is assessment so assess client's feelings and understanding of the natural disaster and its personal impact An assistive personnel (AP) and a nurse are turning a client on to her right side. Which of the following actions by the AP requires the nurse to intervene? - ✔✔place pillows under the pt right arm A nurse in a community center is providing an educational session to a group of women about ovarian cancer. For which of the following manifestations should the nurse instruct the women to contact their providers? - ✔✔-Abd bloating - The nurse should include the presence of abdominal bloating as an early indication of ovarian cancer as well as other manifestations which include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. Hypokalemia s/s - ✔✔signs and symptoms: muscle weakness and decreased deep tendon reflexes Hypocalcemia s/s - ✔✔numbness and tingling of the extremities and around the mouth car safety, d/c teaching: - ✔✔-secure the retainer clip at the level of your baby's armpits - The nurse should instruct the client to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs.Nurse in ED is admitting a client who has cardiac tamponade, which assessment finding should the nurse expect? - ✔✔-pulsus paradoxus - The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension. Allowable foods for a client who has a hx of uric-acid based urinary calculi formation. Which of the following foods should the nurse recommend that the client include in his diet? - ✔✔- citrus fruits such as oranges - Avoid animal-based proteins and alcohol A nurse is caring for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse take to provide comfort to this client? - ✔✔- Allow for frequent rest periods throughout the day -To maintain muscle strength, joint function and ROM - Warm shower instead of warm TUB baths First trimester with an acupressure on wrist, indicates that this therapy is having desired effects? - ✔✔- Ihave not vomited for the past two weeks - Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body the client can use to alleviate nausea and vomiting. Risk of development of a pressure ulcer? - ✔✔recent weight loss 4hr post op following a total vaginal hysterectomy, actions to take first? - ✔✔- measure client's VS - The first action the nurse should take when using the nursing process is to assess the client. The nurse should measure the client's vital signs to assess for respiratory depression and hypotension resulting from anesthesia. A nurse in an emergency department is reviewing the prescriptions of an older adult client who has type 1 DM. reports of severe ankle pain after falling from a stepstool at home. Which order should the nurse verify with the provider? - ✔✔- apply a cold pack to the edematous area on the client's ankle for 30mins every other hour- The nurse should verify a prescription for a cold pack because type 1 diabetes mellitus is a contraindication for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Discharge teaching for a client who has colorectal cancer and is post op following a new colostomy? - ✔✔- arrange for a referral to social services (correct) -initiate a consult with an enterostomal therapist (correct) -provide the pt with info about the american cancer society (correct) -postpone the pt discharge (incorrect) -give the pt info about local support groups (correct) Alprazolam (Xanax) - ✔✔-Initiate fall precautions - Can cause orthostatic hypotension, dizziness, drowsiness and fainting upon arising celiac dx diet teaching - ✔✔- gluten free diet - avoid wheat, barley, rye, malt (malt milk or vinegar). An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client? 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position. - ✔✔1. in semi-Fowler's position. A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing.3. Grand mal seizures. 4. Decreased level of consciousness. - ✔✔4. Decreased level of consciousness. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says she feels pressure against her diaphragm when the baby moves. - ✔✔1. The client's urine test is positive for glucose and acetone. A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment - ✔✔1. Potassium chloride for IV administration. A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication." - ✔✔3. "You are experiencing a side effect of Haldol." A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse?1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter - ✔✔3. The dialysate outflow is cloudy. An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks.": - ✔✔2. "Wear sunscreen and a hat when outdoors." Avoid what with verapamil? - ✔✔grapefruit juice Adverse effects of ferrous sulfate: - ✔✔constipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube. - ✔✔2. Aspirate the gastric contents with a syringe.After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes - ✔✔2. Alteration in skin integrity related to decrease in tissue oxygenation. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.: - ✔✔2. There is clear fluid draining from the client's right ear. ventriculoperitoneal shunt post op for infant with hydrocephalus report what to provider - ✔✔irritability when being held early detection of men's prostate cancer - ✔✔annual measurement of prostate specific antigen (PSA) should be performed for men over 50 method to evaluate nurse's time management skills - ✔✔maintain regular notes about the nurse's time management skillsafter receiving report assess who first? - ✔✔post op client with abdominal distention and no bowel sounds because of paralytic ileus nurses documents dressing change that was not performed what should charge nurse do first? - ✔✔gather more info about staff nurse's actions ASSESSSSS assessing newborn immediate intervention - ✔✔grunting, tachypnea, nasal flaring proper steps of crutches while climbing stairs - ✔✔1) stand in tripod position 2) place body weight on crutches 3) place unaffected e.g. on stair 4) move affected leg and crutches up to the stair antisocial personality disorder - ✔✔lack of remorse thrombocytopenia instruct nurse to avoid what - ✔✔nose blowing estradiol monitor and report what to provider - ✔✔headaches, hypertension client with depression which if most important finding to report to an interdisciplinary conference - ✔✔the client's appetite has diminished over the last week 12 yr old bacterial meningitis which finding indicates client is experiencing increased intracranial pressure (ICP) - ✔✔Memory Loss nurse assisting with thoracentesis for a client who has pleurisy nurse should plan to do what - ✔✔instruct the client to avoid deep breathing during procedureappropriate action for client who will need physical therapy - ✔✔involve client in selection of pt provider nursing action for a client who is receiving continuous passive motion (CPM) following a total knee arthroplasty - ✔✔turn off the CPM mating during meal time urine output 15 ml/hr what additional assessment data is indicative of fluid volume deficit - ✔✔orthostatic hypotension! inc bun, tachy, nurse difficulty staffing weekend shifts. which actions should nurse manager take first to successfully implement staffing changes - ✔✔form a staff task force to investigate current staffing issues mental client becoming increasingly loud and belligerent nurse action - ✔✔use calm and clear statements to set limits teaching for peripheral artery disease - ✔✔apply lubricating lotion to the feet to pre even cracting of the skin. don't elevate feet above heart esophagogastroduodenoscopy (EGD) findings to report - ✔✔cool, clammy skin digoxin toxicity - ✔✔nausea!!! diarrhea failure to thrive - ✔✔develop a structured routine epinephrine adverse effects - ✔✔report of chest pain! client to see first? - ✔✔older client who is confused and attempting to pull on IVvalproic acid (Depakote) which side effects should nurse monitor and report? - ✔✔Jaundice!! pulmonary edema crohns disease decrease what in diet? - ✔✔fiber 18 hr post op client following cesarean birth, highest priority finding - ✔✔unilateral tenderness of the left lower extremity fractured ankle ice applied every 20 min report what finding to provider? - ✔✔cyanosis of nail beds appropriate action for early decelerations - ✔✔continue observing the fetal heart rate active labor receiving oxytocin. fur shows variability with accelerations. nursing action? - ✔✔document and continue to monitor community mental health clinic which group is appropriate for nurse to lead? - ✔✔medication education group risk for osteoporosis - ✔✔sedentary lifestyle 15 min immediate postpartum period requires immediate action by nurse? - ✔✔bobby uterus who should receive rhogam - ✔✔an o- woman following spontaneous abortion first trimester routine prenatal exam when checking if fetal heart can be detected nurse should - ✔✔place scope midline just above the symphysis pubis and apply firm pressure appropriate action for intravenous pyelogram for next day - ✔✔administer laxative, npo, econurage fluidsA nurse in a provider's office is reviewing a female client's medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week) a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 - ✔✔Vitamin B12 A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? Hyponatremia Hyperkalemia- LESS Hypercalcemia hypoglycemia - ✔✔Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? - ✔✔"Rise slowly when getting out of bed" A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) A client who is scheduled for colonoscopy and taking sodium phosphate A client who received a Mantoux test 48 hours ago and has induration A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) - ✔✔A client who received a Mantoux test 48 hours ago and has induration A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? "Have your child drink a small glass of water after swallowing the medication." "Repeat the dose if your child vomits within 1 hour after taking the medication.""You can add the medication to a half-cup of your child's favorite juice." "Limit your child's potassium intake while she is taking this medication." - ✔✔"Have your child drink a small glass of water after swallowing the medication. Pg 117 in ATI Nursing Care of children. "Give water following administration to prevent tooth decay if the child has teeth." A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? a. Potassium level 4.2 mEq/L b. Apical pulse 58/min c. Digoxin level 1 mg/mL d. Constipation for 2 days - ✔✔c. Digoxin level 1 mg/mL A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client's seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy - ✔✔c. The client is showing evidence of phenytoin toxicity Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive impairment (http://emedicine.medscape.com/article/816447-clinical#b4 also states that this is an indication of phenytoin toxicity); According to my Davis Drug Guide book, progressive s/s of phenytoin toxicity include ataxia, nystagmus, confusion, nausea, slurred speech & dizziness. A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (SATA) a. "I can substitute one medication for another if I run out because that all fight infection." b. "I will wash my hands each time I cough."c. "I will wear a mask when I am in a public area." d. "I am glad I don't have to have any more sputum specimens." e. "I don't need to worry where I go once I start taking my medications." - ✔✔b. "I will wash my hands each time I cough." c. "I will wear a mask when I am in a public area." A nurse is caring for a client who has a prescription for warfarin. When reviewing the client's current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) Aspirin Magnesium sulfate Gingko biloba. Cetirizine E. Ibuprofen. - ✔✔Aspirin Gingko biloba. E. Ibuprofen. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next. - ✔✔Administer flumazenil to the client. A nurse is caring for a client who has depression and reports taking ST. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? a. Serotonin syndrome b. Tardive dyskinesia c. Pseudo parkinsonism. d. Acute dystonia. - ✔✔Serotonin syndromeA nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? Hyporeflexia Tachypnea (bradypnea, less than 12/min) Pruritus (sign of allergic reaction) Polyuria (oliguria, less than 30 ml/hr) - ✔✔Hyporeflexia Rationale: OB PDF pg.61, decreased or absent DTRs. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? P . 235 pharm ch 30 a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV - ✔✔d. Administer calcium gluconate IV Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? Measure the client's urine output every hour. Restrict the client's total fluid intake to 250ml/hr. Monitor the FHR via Doppler every 30 min Give the client protamine if sign of magnesium sulfate toxicity occur. - ✔✔Measure the client's urine output every hour. - monitor for toxicity. Rationale: OB ati book. Page 66.Monitor for magnesium sulfate toxicity, and discontinue for any of the following adverse e ects: loss of deep tendon re exes, urinary output less than 30 mL/hr, respiratory depression (less than 12/min), pulmonary edema, and chest pain. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing?Morphine Digoxin Prednisone Omeprazole - ✔✔Prednisone A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? a. "I will decrease my fluid intake while taking this medication." b. "I will expect to have black, tarry stools." c. "I will take my medication with meals." d. "I will monitor for weight loss while on this medication." - ✔✔c. "I will take my medication with meals." A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications a. Methylprednisolone b. Ondansetron c. Guaifenesin d. Amoxicillin - ✔✔a. Methylprednisolone A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? p . 88 ch 13 maternity Continue the monitor the fetal heart rate Stop the oxytocin infusion Perform a vaginal examination Initiate an amnioinfusion - ✔✔Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMEDA nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin? a. Diabetes mellitus b. Shoulder presentation c. Post-term with oligohydramnios d. Chorioamnionitis - ✔✔c. Post-term with oligohydramnios A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. "You will need to continue to take the multi-medication regimen for 4 months." b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." c. "You will need to remain hospitalized for treatment." d. "You will need to wear a mask at all times." - ✔✔b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. "Your urine can turn a dark orange." b. "Watch for a change in the sclera of your eyes." c. "Watch for any changes in vision." d. "Take Vitamin B6 daily." - ✔✔c. "Watch for any changes in vision." A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (SATA) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum - ✔✔a. Persistent coughc. Fatigue d. Night sweats A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? a. Obtain the specimen immediately upon the client waking up. b. Wait 1 day to collect the specimen if the client cannot provide sputum. c. Ask the client to provide 15 to 20 ml of sputum in the container. d. Wear sterile gloves to collect specimen from the client. - ✔✔a. Obtain the specimen immediately upon the client waking up. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? Give the dose over 60 minAdminister the medication undiluted Obtain trough level 30 min after the medication infusion Inject 1% lidocaine prior to each dose Rationale: page 597. PHARM ati book. - ✔✔Give the dose over 60 min to avoid infusion reactions such as Red Man syndrome: rashes, flushing, tachycardia, and hypotension - administer slowly over 60 min Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication? Respiratory rate 22/min Hgb 8.7 g/dL 2+ pitting edema of the ankles Creatinine 2.3 mg/dL - ✔✔Creatinine 2.3 mg/dL (pharm pg. 365: nephrotoxicity) A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? Arterial blood gasSerum potassium Liver function test Serum creatinine - ✔✔Liver function test Rationale: MH RM 10.0 Ch.23 p.124; Hepatotoxicity ATI Pharmacology - complication hepatotoxicity → assess baseline liver function & monitor liver function regularly Client diagnosed of acute MI and is being treated with a thrombolytic, aspirin, and IV heparin. Which of the following findings should indicate the nurse that the client is experiencing a satisfactory response to these interventions? Q wave is noted on the cardiac monitor tracing S3 heart sounds are present The client's aPTT is two times the control The client's stool is guaiac positive - ✔✔The client's aPTT is two times the control A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? Document administration of the medication upon removal from the medication dispensing system Withhold the medication if the client does not appear to be in pain. Count the current number of unit doses available in the medication dispensing system Withhold the medication if the client has a fever - ✔✔Count the current number of unit doses available in the medication dispensing system A nurse is caring for a school age child who is postoperative and received morphine IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority? Bradypnea Sedation Euphoria Constipation - ✔✔BradypneaA nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? a. "Morphine 3 mg SQ every 4 hr. PRN for pain." b. "Morphine 3 mg subcutaneous (Unable to read)." c. "Morphine 3.0 mg sub q every 4 hr. PRN for pain." d. "Morphine 3 mg SQ q4 hr. PRN for pain." - ✔✔b. "Morphine 3 mg subcutaneous (Unable to read)." A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? a. "I am allergic to morphine." b. "I take antacids several times a day." c. "I had a blood clot in my leg several years ago." d. "It hurts to take a deep breath." - ✔✔b. "I take antacids several times a day." A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? a. Productive cough b. Urinary retention c. Rhinitis d. Fever - ✔✔b. Urinary retention A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? - ✔✔Ensure that the newborn wears a diaper. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? P . 146 ch 19 CONFIRMED a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count - ✔✔c. Serum potassium- diuretic that retains potassium= hyperkalemic riskRationale ATI PDF p: 146 Pharm Complications: hyperkalemia A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client's lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? Place a cardiac monitor on the client Stop the IV infusion of insulin Administer oral potassium to the client- potassium is already high Initiate a 24 hr urine collection - ✔✔Place a cardiac monitor on the client Rationale: potassium level is too high so yeah place a cardiac monitor on the client b/c hyperkalemia can lead to dysrhythmias. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? a. Withhold the next dose. b. Increase the dosage. c. Discontinue the medication. d. Administer the medication. - ✔✔Administer the medication Teaching for a client undergoing radiation therapy and has stomatitis. Which of the responses by the client indicates an understanding of the teaching? "I should limit my intake of dairy products to prevent nausea." "I should use a soft-bristle toothbrush to clean my teeth after meals." "I should moisten my lips with lemon-glycerin swabs." "I should gargle with an alcohol-based mouthwash to kill germs." - ✔✔"I should use a soft-bristle toothbrush to clean my teeth after meals." A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority? a. Excoriation of the skin on the neck and chestb. Dysphagia c. Client reports a pain level of 6 on scale from 0-10 d. Xerostomia - ✔✔b. Dysphagia A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? Instruct the client to empty her bladder prior to the procedure. Position the client over an overbed table prior to the procedure. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. Initiate NPO status 4 hr prior to the procedure. - ✔✔Instruct the client to empty her bladder prior to the procedure. Rationale: MS RM 10.0 Ch.47 p.299; Preprocedure nursing actions: Have the client void, or insert an indwelling urinary catheter. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? Compare the client's current weight with preprocedure weight. Check the client's serum albumin levels (Check possible albumin for possible complication not for effectiveness) Examine for leakage at thes site of the procedure Confirm that the client is able to urinate (To check for complication not effectiveness) - ✔✔Compare the client's current weight with preprocedure weight. Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and remove ascites fluid in the abdominal wall. A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? a. Decreased hematocrit b. Increased blood pressurec. Tachycardia d. Hypothermia - ✔✔c. Tachycardia A nurse is providing discharge teaching to a client who has CKD and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? Consume foods high in potassium Eat 1 g/kg of protein per day Drink at least 3 L of fluid daily Take magnesium hydroxide for indigestion - ✔✔Eat 1 g/kg of protein per day (medsurg pg. 382: "at least 2 L water daily; control protein; restrict sodium, potassium, phosphorous, and magnesium") A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? - ✔✔Check the vascular access site for bleeding after dialysis. Child with sickle cell anemia. The nurse should emphasize the importance of which of the following factors to prevent sickle cell crisis? A low-protein diet Adequate hydration Calorie restriction Increased iron intake - ✔✔Adequate hydration A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? Initiate IV fluid replacement Start a 24-hr urine collectionGive aspirin to reduce pain Encourage ambulation - ✔✔Initiate IV fluid replacement- BLOOD IS TOO VISCOUS =P . 125 ch 21 obstruction = tissue hypoxia. CONFIRMEDA nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? a. Substernal retractions b. Hematuria c. Temperature 37.9°C (100.2°F) d. Sneezing - ✔✔a. Substernal retractions A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? a. Periorbital edema b. Decreased frequency of urination c. Enuresis d. Diarrhea - ✔✔Enuresis A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? - ✔✔"Drink 2 liters of warm water per day". A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility Ask a student nurse who speaks the same language to translate Have the child translate Allow the clients partner to translate - ✔✔Request a female translator interpreter through the facility A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take? Monitor the client's urinary output Check the client VSEvaluate the client's pain level Palpate the client's fundus - ✔✔Palpate the client's fundus A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (SATA) Foul perineal odor Fundus displaced to the right Lochia serosa Fundus 4 cm (1.6 in) below the umbilicus Postpartum chill - ✔✔Lochia serosa Fundus 4 cm (1.6 in) below the umbilicus A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? Align a trochanter wedge between the clients legs Place a towel roll under the clients neck Apply an orthotic to the clients foot Position a pillow under the client's knees - ✔✔Apply an orthotic to the clients foot Rationale: Casting or splinting techniques are used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint from prolonged immobilization. It is also popular for treating contractures resulting from an increase in muscle tone from nerve injury. After an initial holding cast is applied for seven to 10 days, a series of positional casts are applied at weekly intervals. Before the application of each new cast, the joint is moved as much as can be tolerated by the patient, and measured by a goniometer. When as much motion as possible is obtained after stretching, another final cast is applied to maintain the newly acquired motion. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? a. Place an ice pack over the cast. b. Palpate the pulse distal to the cast. c. Teach the client to keep the cast clean and dryd. Position the casted extremity on a pillow. - ✔✔b. Palpate the pulse distal to the cast. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closedsuction drain. Which of the following actions should the nurse take? Reset the vacuum by compressing the container Secure the drain to the bedding Position the affected extremity below the level of the client's heart Maintain the client in a supine position for the first 24 hr. - ✔✔Reset the vacuum by compressing the container The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? "If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease." b. "There is no need to have genetic counseling if I know that I have a family history of mental illness." c. "My family has genetic risk for breast cancer, so I am considering a total mastectomy." d. "Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments." - ✔✔My family has genetic risk for breast cancer, so I am considering a total mastectomy" A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → ESI Level 2 required immediate pain control per Triage, hypotension with signs of hypoperfusion. - ✔✔a. Below the knee amputation → ESI Level 1- Patients with signs and symptoms of compartment syndrome are at high risk for extremity loss and should be assigned ESI level 2. Other patients with high-risk orthopedic injuries include any extremity injury with compromised neurovascular function, partial or complete amputations, or trauma mechanisms identified as having a high risk of injury such as serious acceleration, deceleration, pedestrian struck by a car, and gunshot or stab wound victims. Patients with possible fractures of the pelvis, femur, or hip and other extremity dislocations should be carefully evaluated and vital signsconsidered. These fractures can be associated with significant blood loss. Again, hemodynamically unstable patients who need immediate life-saving intervention such as high-level amputations meet ESI level-1 criteria. High level amputations meet ESI level 1. -Patients with inhalation injuries from closed space smoke inhalation or chemical exposure should be considered high-risk for potential airway compromise. If the patient presents with significant airway distress and requires immediate intervention, they meet level-1 criteria. Patients with third-degree burns should also be considered high-risk and be assigned ESI level 2. It is possible that they will require transfer to a burn center for definitive care. A nurse hears an AP telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? Malpractice Battery Assault Negligence - ✔✔Assault A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? - ✔✔"I take a calcium and vitamin D supplement daily Toddler who has cystic fibrosis. Which of the following instructions should the nurse include? "Perform chest percussion and postural drainage at least twice daily." "Administer pancreatic enzymes on an empty stomach." "Restrict intake of foods that contain gluten." "Use a nebulizer to administer a bronchodilator following airway clearance therapy." - ✔✔"Perform chest percussion and postural drainage at least twice daily." A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? Perform the procedure twice a day Hold hand to perform percussions on the child Administer a bronchodilator after the procedurePerform the procedure prior to meals - ✔✔ A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? P . 106 CH 19 PEDs Take pancrelipase Complete oral hygiene Eat a meal Use an albuterol inhaler - ✔✔Use an albuterol inhaler AA nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? a. Positioning both hands on the grips with his elbows slightly flexed b. Supporting his body weight while leaning on the axillary crutch pads c. Stepping with his affected leg first when going up stairs d. Moving both crutches with the stronger leg forward - ✔✔Positioning both hands on the grips with his elbows slightly flexed Rationale: . CRUTCH INSTRUCTIONS ● Do not alter crutches after fitting. ● Follow the prescribed crutch gait. ● Support body weight at the hand grips with elbows flexed at 30°. ● Position the crutches on the unaffected side when sitting or rising from a chair. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? Submerge the adolescent feet in ice water Cover the adolescent with a thermal blanket → if hypothermia. Administer oral acetaminophen Initiate seizure precautions - ✔✔Initiate seizure precautionsRationale: Hyperthermia occurs when a person's body temperature rises and remains above the normal; 98.6°F Most frequently, this occurs during the heat of summer and among the elderly. However, it may also be triggered by other medical conditions or certain medications. Rapid cooling may be the single most important action to prevent death or permanent disability. To mitigate organ damage, the goal should be to reduce rectal temperature to below 40°C within 30 minutes of beginning cooling therapy. The question does not indicate whether it is malignant hyperthermia which could have been caused by a medication. The question simply asks that the person has hyperthermia. A nurse is caring for a client who is febrile. To reduce fever, the nurse applies a cooling blanket. Which of the findings indicates the client is having an adverse reaction to the cooling? Tachycardia Flushing Shivering Restlessness - ✔✔Shivering A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? p . 287 ch 43 Check the mouth for smooth and smoky breath Calculate the fluid replacement based on vital signs and urinary output Determine the location and depth of burns Administer antibiotics to prevent sepsis. - ✔✔Check the mouth for smooth and smoky breath - airway obstruction via foreign body A client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse nutritional requirements? a. (Unable to read) (Chose this one) b. Keep a calorie count for food and beverages. c. Schedule meals at 6 hr. intervals d. Provide low-protein high carbohydrate diet - ✔✔a. (Unable to read) (Chose this one) Circumcised newborn. Which of the following instructions should the nurse include in the teaching? "Wrap sterile gauze around the penis if bleeding occurs.""Use soap to cleanse the site." "Apply petroleum jelly to the glans with diaper changes." (OB pg. 178) "Remove yellow exudate around the penis." - ✔✔"Apply petroleum jelly to the glans with diaper changes." (OB pg. 178) a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will change my baby's diaper at least every 4 hours b. I will apply an ice pack to my baby's penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change - ✔✔a. I will change my baby's diaper at least every 4 hours Teach the parents to keep the area clean. Change the newborn's diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client's plan of care? (SATA) a. Speak to the client at a slower rate. b. Assist the client to use flash cards with pictures. c. Speak to the client in a loud voice. d. Complete sentences that the client cannot finish. e. Give instructions one step at a time. - ✔✔a. Speak to the client at a slower rate. b. Assist the client to use flash cards with pictures. e. Give instructions one step at a time. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Summon a security guardb. Explain the risks of leaving c. Complete an incident report d. Notify a social worker - ✔✔b. Explain the risks of leaving Rationale: fund ati pg 17 - When a client decides to leave the facility against medical advice (without a discharge prescription), the nurse notifies the provider and discusses with the client the risks to expect when leaving the facility prior to discharge. Management of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? Social worker Respiratory therapist Speech-language pathologist Occupational therapist - ✔✔Speech-language pathologist A charge nurse observes a coworker who has impaired coordination and is drowsy while performing routine tasks. Which of the following actions should the charge nurse take first? Obtain support from another nurse before filing a report Document observations about the nurse's behavior Reassign the nurse's client-care duties to another nurse Report the nurse's behavior to the nurse manager - ✔✔Report the nurse's behavior to the nurse manager A nurse is caring for a client who has UTI and has been taking cefaclor. Which of the following serum laboratory results indicates the medication is effective? Eosinophils 3.9% WBC 9,200/mm3 Bun 32 mg/dLCreatinine 2.3 mg/dL - ✔✔ A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? Offer high-calorie, high protein snacks to the client Recommend the family provide the client privacy during meals Weigh the client once each day Encourage the client to eat foods selected by the dietitian - ✔✔ A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? - ✔✔Confirm the client's perception of the event Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan? Refer to the hallucinations as if they are real Encourage the client to lie down in a quiet room Ask the client directly what he is hearing Avoid eye contact with the client - ✔✔Ask the client directly what he is hearing A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, "It's hard not to listen to the voices." Which of the following questions should the nurse ask the client? a. "Do you understand that the voices are not real?" b. "Why do you think the voices are talking to you?" c. "Have you tried going to a private place when this occurs?" d. "What helps you ignore what you are hearing?" - ✔✔"What helps you ignore what you are hearing?" A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? "I should clean my stoma with warm water"( can use low ph soap and water)" My stoma should be bright pink or red"(pink,red and moist) "I should change the stoma pouch every day" "I should cut my pouch opening ⅛ inch larger than my stoma"(allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. - ✔✔"I should change the stoma pouch every day" Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? a. your baby will be given 2 ounces of water to drink prior to the test b. this test will be repeated when your baby is 2 months old c. a nurse will draw blood from your baby's inner elbow d. this test should be performed after you baby is 24 hours old - ✔✔d. this test should be performed after you baby is 24 hours old ATI MATERNITY 281■ Newborn genetic screening is mandated in all states. A capillary heel stick should be done 24 hr following birth. For results to be accurate, the newborn must have received formula or breast milk for at least 24 hr. If the newborn is discharged before 24 hr of age, the test should be repeated in 1 to 2 weeks. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? Weight gain Dry mouth Sedation Shuffling gait - ✔✔Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to the provider. ATI PHARM 110 Rationale: e book pg 69 ch 10 A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?Avocados Whole grain bread Pepperoni pizza Smoked salmon - ✔✔Whole grain bread Rationale: MAOIs = antidepressants; avoid foods with high tyramine content (eg, aged cheeses, sour cream, red wines, beer, bologna, pepperoni, salami, summer sausage, pickled herring, liver, meat prepared with tenderizers, canned figs, raisins, bananas, avocados, soy sauce, fava beans, yeast extracts), drink alcohol, or consume large quantities of caffeine (coffee, tea, chocolate, or cola) A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian a. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat." b. A client who has gout and states, "I can continue to eat anchovies on my pizza." c. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium." d. A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with a full glass of water." - ✔✔b. A client who has gout and states, "I can continue to eat anchovies on my pizza." A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? Instruct the client to lift her chin when swallowing Sit at or below the client's eye level during feedings Talk with the client during her feeding Discourage the client from coughing during feedings - ✔✔Sit at or below the client's eye level during feedings a home health nurse is caring for an adult client who reports, "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take? a. encourage the client to increase fluid intake b. initiate a consultation with a speech→ language pathologist;c. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal - ✔✔b. initiate a consultation with a speech→ language pathologist; swallow eval R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? a. Place food on the left side of the client's mouth when he is ready to eat. b. Provide total care in performing the client's ADLs. c. Maintain the client on bed rest. d. Place the client's left arm on a pillow while he is sitting. - ✔✔d. Place the client's left arm on a pillow while he is sitting. A newly LPN working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? Using an electronic massaging system to remind clients when to take medications Educating clients about contraindications to specific immunizations Helping clients understand health screenings covered by their insurance plans Providing clients with info about the benefits of exercise - ✔✔Using an electronic massaging system to remind clients when to take medications Client who is 48 hr. postoperative following a total hip arthroplasty. Which of the following actions should the nurse include in the plan of care? Place the client on a full liquid diet Administer low-dose heparin Maintain the client on bed rest Use and incentive spirometer every 3hr - ✔✔Administer low-dose heparinA nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? Administer atropine to the client if tachycardia is present Maintain the indwelling urinary catheter until the client is ready for discharge Prepare for fluid volume replacement if the central venous pressure steadily increases Check the client's hemoglobin level if chest tube drainage is 300 mL in the first 1 hr - ✔✔Check the client's hemoglobin level if chest tube drainage is 300 mL in the first 1 hr (medsurg pg. 185: volume exceeding 150 mL/hr could be a sign of hemorrhage) A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hr (for asthma) c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr - ✔✔Administer analgesics on a scheduled basis for the first 24 hr [Show More]

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