Nursing > ATI > ATI Comprehensive form B Solved 100% (All)
A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors main... tain a distance of 1.8m (6 feet) from the client C. Restrict fresh flowers from the clients room D. Assign the client to a private room with negative air pressure - ANSWER D A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? A. Limit your fat intake for 72 hours before the test B. You will need to fast the night before the test C. We will collect a urine sample the day after testing D. A blood sample will be collected every 15 minutes during the test - ANSWER B A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? A. A 6month old infant who has croup and an O2 saturation of 92% on room air B. A 15 year old adolescent who is 2 hour postop following an open reduction and internal fixation of the left ankle and is requesting pain medication C. A 3 year old toddler who has gastroenteritis, moderate dehydration, and had 2 loose bowel movements over the past 24 hours D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain. - ANSWER D A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? A. Diarrhea B. Urinary retention C. Purulent discharge D. Abdominal bloating - ANSWER D A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? A. Check the clients temperature B. Prepare to administer acetylcysteine to the client C. Place the client in the Trendelenburg position D. Check the client's oxygen saturation level - ANSWER D Restlessness and lightheadedness are indications of hypoxia. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A. An older adult client who reports constipation of 4 days B. A preschooler who has a skin rash C. An adolescent who has a closed fracture D. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? - ANSWER D A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? A. Adjust the crutches for comfort as needed B. Use a three-point gait. C. Wear leather soled shoes D. Advance the affected leg first when walking upstairs - ANSWER B A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand - ANSWER A A nurse is planning to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP? A. Perform gastrostomy feedings through a clients established gastrostomy tube B. Administer glycerin suppository to a client who is constipated C. Provide instructions about client care to a family member over the telephone D. Teach a client how to measure their own blood pressure - ANSWER A A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? A. Dry the newborn immediately after birth B. Maintain an ambient room temp of 24 celcius C. Use a protective cover on the scale when weighing the infant D. Place the newborns bassinet away from outside windows - ANSWER C Conduction is the process of losing heat through physical contact with another object or body. For example, if you were to sit on a metal chair, the heat from your body would transfer to the cold metal chair. Convection is the process of losing heat through the movement of air or water molecules across the skin A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client's heparin? A. aPTT B. PT C. INR D. WBC count - ANSWER A A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist - ANSWER B A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will administer aspirin to my child to treat pain or fever" B. "I will record an average of three readings from my child's peak expiratory flow meter" C. "I will place carpet in my child's bedroom to control allergens" D. "I will make sure my child receives a yearly influenza immunization." - ANSWER D -- Children who have asthma should be immunized and protected from infections. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? A. Obtain capillary blood glucose level every 2 hours B. Check the neurovascular status of the client's lower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour. D. Maintain the affected ankle elevated and immobilized - ANSWER C A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision - ANSWER D The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. Other adverse effects include constipation, urinary retention, and dry mouth. A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? A. "Perhaps you think the ECT is dangerous, but I've seen it have good results" B. "You have the right to change your mind about this procedure at any time." C. "Everyone gets a little nervous about this procedure as the time for it approaches" D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you" - ANSWER B A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lbs. What is the amount in grams the nurse should administer? - ANSWER 18g A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? A. Select a 1 inch needle B. Use a 45 degree angle when inserting the needle C. Use the ventrogluteal site D. Pinch the skin up during injection - ANSWER C A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching A. Check the functioning of oxygen equipment once each week B. Wear clothing made with cotton fabrics while oxygen is in use C. Apply petroleum-based lubricant to the nares as needed D. Store full oxygen tanks on their side - ANSWER B A nurse is providing teaching to the guardians of a newborn about measures to prevent SIDS. Which of the following guardian statements indicates an understanding of the teaching? A. "I will not allow anyone to smoke near my baby." B. "I will place bumper pads in my baby's crib" C. "My baby's head should be placed on a pillow for sleeping" D. "My baby should sleep in a side-lying position" - ANSWER A -- This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarettes smoke and the occurrence of SIDS. A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer? A. Nalbuphine B. Terbutaline C. Oxytocin D. Magnesium sulfate - ANSWER C A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? A. Contact the facility chaplain to visit with the client B. Explain the process of leaving the facility against medical advice C. Make a referral for social services D. Encourage the client to continue with inpatient care - ANSWER C A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first? A. Obtain a prescription for the client to receive an enzyme product B. Aspirate the client's tube C. Flush the client's tube with 30 mL of water D. Change the position of the client - ANSWER D A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions? A. Administer a bowel preparation the night before the procedure B. Place the client on bed rest for 24 hours after the procedure C. Perform pulmonary function tests following the procedure D. Instruct the client to avoid coughing during the procedure - ANSWER D A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? A. "Droplet precautions should be initiated for client who tests positive for measles" B. "A client who requires airborne precautions should be placed in a negative pressure airflow room" C. "Airborne precautions should be initiated for a client who has Clostridium Difficile" D. "A client who is immunocompromised should be placed in a negative pressure airflow room" - ANSWER B A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) A.Broccoli B. Yogurt C. Pepperoni pizza D. Cream cheese E. Bologna sandwich - ANSWER A, B, D A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect? A. Paradoxical chest movement B. Subcutaneous emphysema C. Acute confusion D. Distended neck veins - ANSWER C A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A. Maintain a flexible daily schedule for the client B. Use a reward system to modify the child's behavior C. Provide a variety of family members to care for the child D. Administer alprazolam as needed to reduce the child's anxiety - ANSWER B A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? - ANSWER 12.5 gtt/min (or 13 if rounding to nearest whole number) A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems with passing stool. This is present at birth (congenital) as a result of missing nerve cells in the muscle of the baby's colon A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers D. A client states that they did not get a job promotion because the boss did not like them - ANSWER B A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. irritability B. increased urination C. vomiting D. facial flushing - ANSWER A A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? A. A client who transfers their anger about their job onto their family and then apologizes B. A client who misses provider appointments because they say they are too busy C. A client who channels their energy into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place for him at dinner each night - ANSWER C The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby. A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. A hospice nurse will come to the house each time our mother needs pain medication C. Now that my mother is receiving hospice services, we will not be able to get respite care D. Hospice care focuses on arranging treatment that will prolong our mother's life - ANSWER A Hospice care includes bereavement services after a family member's death. A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta - ANSWER C A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? A. Weight gain B. Decrease in anteroposterior diameter of the chest C. HCO3- 24 mEq/L D. pH 7.31 - ANSWER D COPD causes hypoventilation, which leads to retained CO2. High amounts of CO2 lead to acidosis (pH below 7.35) A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (select all that apply) A. "You will give the medication every 4 hours" B. "Shake the medication bottle feel before each dose is given." C. "Store the medication in the refrigerator." D. "Report diarrhea to the provider immediately." E. "Discard the unused portion of medication after 21 days" - ANSWER B, C, D A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? A. Instruct the client to void B. Position the client on their left side C. Insert an IV catheter D. Prepare the client for moderate (conscious) sedation - ANSWER A A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A. Initiate contract precautions for the client upon admission B. Restrict visitors from entering the client's room during hospitalization C. Wear a surgical mask while providing care for the client D. Have the client wear a surgical mask while being transported outside the room - ANSWER D A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take? A. Teach the client to massage the affected extremity B. Instruct the client to elevate the affected extremity when sitting C. Assess pulses proximal to the affected area D. Apply a cold compress to the affected extremity - ANSWER B A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? A. Drainage system located above the clients chest wall B. Continuous bubbling in the water seal chamber C. Occlusive dressing on the insertion site D. Drainage of 125 mL/hr - ANSWER C All chest tube dressings should be an occlusive, air tight dressing to prevent air leaks. In order to keep the dressing occlusive and to avoid an air leak, tape all the connections from the insertion site of the patient to the chest drainage unit. If the water seal is continuously bubbling, you should suspect an air leak. Think of the lungs as wrapped in plastic. An air leak occurs when there is a hole in the plastic wrap allowing air to escape from the lung tissue into to the pleural cavity. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here is so controlling" C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting - ANSWER D Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Evaluate dietary intake for a client who has anorexia [Show More]
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