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ATI RN Comprehensive Online Practice B - Questions and answers

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ATI RN Comprehensive Online Practice B RN Comprehensive Online Practice 2016 B 1. Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? Ask another nu... rse to witness the disposal of the new patch. 2. Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8 Withhold the heparin infusion 3. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina Floating dark spots 4. infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider Irritability when being held. signifies increased ICP 5. Assessing a newborn heart rate follow actions the nurse should take Auscultate the apical pulse and count beats for at least 1 min. 6. Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool Insert a lubricated gloved finger and advance along the rectal wall. 7. Dietary teaching for a new prescription of phenelzine Broccoli, Yogurt, Cream Cheese 8. Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse document in the client's medical record? Time the medication was given 9. Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain. Can indicate peritonitis from a ruptured appendix. 10. Community health nurse providing teaching on home safety for older adults Have grab bars installed around your bathtub and toilet. 11. School age child with scald burns on both hands and wrists suspected abuse Contact child protective services. 12. Client who has acute blood loss following trauma refuses potentially life saving blood transfusion Explore the client's reasons fro refusing the treatment 13. Discussing common prenatal discomfort 20 weeks gestational I will wear a supportive bra overnight 14. Discharge instructions to client to received home oxygen therapy Wear clothing made with cotton fabrics while oxygen is in use. 15. Preparing an educational session about advocacy to a group of nurses Advocacy is a leadership role that helps others to self actualize 16. Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and decreased urinary output Irrigate the catheter with 0.9% sodium chloride irrigation 17. Child with sickle cell anemia and is having a vaso-occlusive crisis Infuse IV fluids 18. Client teaching about the basal body temp method for birth control Your body temperature might decrease slightly just prior to ovulation 19. Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent Proceed with provision of medical care 20. Client who has fluid volume overload. Which tasks can nurse delegate to UAP Measure the client's daily weight 21. Checking for Chvostek's sign The nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia. 22. Reviewing urinalysis report of client with acute glomerulonephritis expected findings Protein 23. Newly admitted child. Which of the following actions should the nurse include in the plan Administer high dose antibiotic therapy 24. Client with cancer deciding between two treatment plans tell me more about your understanding of the options. 25. Caring for a client receiving hemodalysis with AV fistula Auscultate the affected extremity for a bruit 26. Oncology unit nurse is administering doxorubicin to breast cancer patient Inspect the client's mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding 27. Hospice nurse consulting about receiving home services We can expect the hospice nurse to provide support for us after our mother's death 28. Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure about this now I'm afraid it's too risky You have the right to refuse to have the ECT even after you have agreed to it 29. Discharge instructions about newborn care to a client 2 days postpartum I will cover my baby's body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose. 30. Assigning task roles for group of clients in community mental health clinic. Which should be assigned to group functioning the orienter Noting the progress of the group toward assigned goals 31. Nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster A client who has cellulitis and is receiving oral antibiotics every 8 hours. 32. Developing a client education program about osteoporosis for older adult clients Sedentary lifestyle 33. Charge is providing educational session about infection control for a group of staff on isolation precautions A client who requires airborne precautions should be placed in a negative pressure airflow room 34. Preparing to assist with a thoracentesis for a client who has pleurisy Instruct the client to avoid deep breathing during the procedure 35. Caring for a school age child taking valporic acid. Diagnostic tests Serum liver enzyme levels 36. Inpatient mental health unit is monitoring a visit between client with aggressive behavior and the client's partner The client is pacing around the chair in which his partner is sitting. 37. Home health nurse evaluating a school age child with cystic fibrosis initiates a request for high frequency chest compression vest My child has only a small amount of mucus after percussion therapy 38. Planning care for a client with left sided weakness following a stroke Support the client's left arm on a pillow while sitting caring for a client who has schizophrenia who recently started risperidone - Implement fall precautions for the client 39. Caring for a child with a fever and fluid filled vesicles on trunk and extremities. Identify priority Initiate transmission based precautions 40. Assessing client for compartment syndrome expected findings Edema 41. Just received change of shift report on 4 clients. Which should the nurse assess first A client who is postop with abdominal distention and no bowel sounds 42. Assessing a client after administering epinephrine for anaphylactic reactions. Identify adverse effect of this med Report of Chest pain 43. Provide teaching to client 24 wks gestation scheduled for glucose tolerance test You will need to fast the night before the test. 44. Assessing older adult client with pneumonia acute confusion 45. Teaching for client about right to confidentiality You can provide a list of family members who can receive information about the diagnosis. 46. Caring for a client reporting nausea and vomiting the past 2 days Urine specific gravity 1.052 47. Caring for a client postop after receiving moderate conscious sedation suddenly becomes restless and reports feeling lightheaded Check the client's oxygen saturation level 48. Assessing client who is 11 wks gestation and reports drinking ginger tea. signs of it's effectiveness The client reports a decrease in episodes of nausea 49. Teaching a client who newly diagnosed with DM. Instructions on manifestations of hypoglycemia Irritability 50. caring for a client with DVT Instruct the client to elevate the affected extremity when sitting 51. Providing info to a client immediately before Romberg test I will be checking you once with your eyes open and once with them closed 52. Providing teaching to parents of child with autism spectrum disorder Use a reward system to modify the child's behavior 53. Teaching a client undergoing ECT about adverse effects Short term memory loss 54. Caring for a client with active TB about disease transmission Have the client wear a surgical mask while being transported outside the room. 55. Assess 1 wk old for palmer grasp reflex By touching the palms of the infant's hands near the base of the digits causing the flexion of the fingers 56. Conducting a mental status examination on newly admitted client. Priority assesment Ideals of self harm 57. Caring for a client with a prescription of chlorpromazine indications of effectiveness Decreased hallucinations 58. Assessing a client whose partner recently died. States I don't know what to do without my partner. Life is not worth living You seem to be having a difficulty time right now 59. Developing discharge plan for school age child with thrombocytopenia. What should the child avoid Blowing the nose it increases the risk for bleeding or hemorrhaging. 60. Reviewing lab report for client in end stage kidney disease who received hemodialysis 24 hr ago. Findings to report to provider sodium 148 mEq/ 61. Caring for a client with a magnesium level of 2.5 mEq/l Initiate continuous cardiac monitoring 62. Outpatient mental health clinic clients which of the following clients is effectively using sublimation as a defense mechanism A client who channels her energy into a new hobby following the loss of her job 63. Caring for a group of clients which one should the nurse see first An older adult client who is anxious and attempting to pull out his IV line 64. Preparing to teach about dietary management to a client with Crohn's disease with a enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in his diet Fiber 65. Caring for a client who is in resuscitation phase of burn injury Hyponatremia 66. Teaching self-administration of insulin to a client with short acting and intermediate acting insulin Pinches the skin prior to injecting the insulin 67. Teaching a client 26 wks gestation about a glucose tolerance test. avoid caffeine 68. Caring for a client who has hyperthyroidism Tremors 69. Caring for a newborn with herpes simplex virus which precautions should be initiated Contact 70. Postpartum nurse is caring for 4 clients which one should be on seizure precautions. A client who is as 33 wks of gestation and has severe gestational hypertension 71. Assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Assess for adverse effects Have you had any stomach pain or bloody stools 72. Caring for older adult who is experiencing chronic anorexia and receiving tube feedings. Lab values that indicate additional nutrients are needed Albumin 2.8 g/dL 73. Teaching to school age child with asthma using albuterol dose inhaler instructions Take the medication 15 min before playing sports 74. Assessing a client with decreased visual acuity due to cataracts. Identify physiological changes Increased opacity of the lens 75. Mental health clinic caring for clients. Which of the following clients is using dissociation as a defense mechanism? A client who was abused as a child describes the abuse as if it happened to someone else 76. Assessing a 2 wk old newborn with a birth weight of 3.64 kg being breastfed. Indicators of effective breastfeeding The newborn has 6 to 8 wet diapers per day 77. Preparing to administer a blood transfusion to a client . Ensure proper client identification Verify the client and blood product information with another licensed nurse 78. Reviewing client's right with the nurses on the unit. Informed consent promotes which of the following ethical principles Autonomy 79. Teaching about lithium to client who has bipolar disorder Notify your provider if your experience increased thirst 80. Change of shift report informs of newly admitted client with disoriented and combative during the night. Actions the day shift nurse should take Move the client to a room near the nurses' station. 81. Caring for an 18-month old toddler who has a blood lead level of 3mcb/dL. Which of the following actions should the nurse take Recommend re-screening in 1 year 82. Assessing a client who has bipolar. Which of the following alterations in speech is the client using Flight of Ideas 83. Working in ED triaging 4 clients. Which of the following clients should the nurse recommend for treatment first? A middle aged adult client who has unstable vital signs 84. Admission assessment on a client who had a recent positive pregnancy test. First day of her last menstrual period was May 8 . Nagel's rule EDB February 15 85. Assessing a client who received 2 units of packed RBCs 48 hr ago. Findings that indicate the therapy is effective? Hemoglobin 14.9 g/dL 86. Caring for a client who recently signed informed consent to donate a kidney to her sibling in ERF. States "I don't want my brother to die, but what if I need this kidney one day?" You afraid that you other kidney will fail at some point after the organ donation 87. A nurse is preparing to administer an IM injection to a client who is obese Use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels. 88. Providing education to the parent of school age child with asthma. Indicates understanding? I will make sure my child receives a yearly influenza vaccination 89. Admitting a client who has pneumonia. Should initiate which type of isolation precautions? Droplet 90. Assessing a client who has COPD pH 7.31. Respiratory acidosis is an expected finding for a client who has COPD 91. Providing teaching for teaching for a client who has a fracture of the right fibula with a short leg cast in place. Client is non weight bearing for 6 weeks. Use a three-point gait 92. Caring for a child who has hypotonic dehydration and is receiving an oral re-hydration solution. Lab results indicates treatment effective Serum sodium 136 mEq/L 93. Assessing a client who has pulmonary edema. Finding to expect Pink, frothy sputum-due to fluid leaking across the pulmonary capillaries and into the lung tissue. 94. Received change of shift report on 4 clients. Which one should the nurse intervene to prevent food and medication interaction? A client who is receiving a MAOI and is requesting a cheeseburger for dinner. -Contains tyramine can cause hypertension 95. Assessing a client following vaginal delivery and notes heavy lochia and a boggy fundus. Which med should be administered Oxytocin 96. Caring for a client with a new diagnosis of terminal cancer. Client states he would like to go home to be with family and loved ones. Make a referral for social services 97. Caring for a client who is taking valproic acid for seizure control. Adverse effect to monitor and report Jaundice-clients are at risk for liver damage. 98. Manager planning to use a democratic leadership style. Which of the actions demonstrates democratic leadership style? Seeks input from the other nurses 99. Assessing a client with history of seeking counseling for relationship problems. Shows the nurse multiple superficial self-inflicted lacerations on her forearms. This behavior should be identified as a characteristic of which personality disorder Borderline-emotionally unstable, have troubled interpersonal relationships and often engage in harmful behaviors such as cutting, substance use and suicidal thoughts. 100. Nurse preceptor is evaluating the performance of newly licensed nurse. which action should the preceptor intervene on Starts a task by determining what supplies are needed. Should gather prior to beginning task for effective time management. 101. Providing teaching about advance directives to a middle adult client. Which response indicates understanding? I can designate my partner as my health care surrogate 102. Teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following is an example of reportable incident and an indication for completing a report A nurse administered a medication via the wrong route. 103. Caring for a newborn immediately after delivery. Which interventions should be implemented to prevent heat loss by conduction? Use a protective cover on the scale when weighting the infant. 104. Caring for a client in stage 4 of labor who is receiving oxytocin via continuous IV. Priority assessment Amount of vaginal bleeding 105. Preparing to transfer a client from ICU to the medical floor. Client was recently weaned from mechanical ventilation follow a pneumonectomy. Information to include in change of shift report The time of the client's last dose of pain medication. So the receiving nurse can anticipate what time to give the next dose. 106. Charge nurse notices one of the nurses on the shift frequently violates unit policies by taking an extended amount of time on break. Statement that addresses the conflict I would like to talk to you about the nit policies regarding break time. 107. Providing discharge teaching about disease management for a client who has a new diagnosis of DM. Priority activities Ensure the client understand the medication regimen. Because this position limits the flow of the instilled solution out of the stomach and prevents aspiration. 108. Caring for a client who has gastrointestinal bleeding and an NG tube in place. Action that should be taken while performing gastric lavage. Ask the client to lie on the left side 109. Planning to delegate client care tasks to an assistive personnel. Which task can be delegated? Perform gastrectomy feeding through a client's established gastrostomy tube. 110. Providing teaching to client with peripheral arterial disease. Indications of understanding Applies lubricating lotion to her feet to prevent cracked skin. Store the medication in the refrigerator. 111. Providing discharge teaching for preschool age child with a new prescription for Amoxicillian/clavulanate suspension. Shake the medication bottle well before each dose is given. Report diarrhea to the provider immediately. Store medication in refrigerator 112. Caring for a client with COPD and becomes extremely short of breath. Interventions by the nurse requires completion of an incident report Increasing oxygen via nasal cannula to 6 L/min 113. Assessing correct placement of a client's NG feeding tube prior to administering a bolus feeding. Aspirate contents form the tube and verify the pH level 114. Preparing to transfer a client to a rehab facility who had a stroke Family is concerned about the level of care the client will receive? Facilitate an interdisciplinary conference at the new facility for the family 115. Caring for a client receiving a continuous heparin infusion. Lab test to review prior to adjusting the client's heparin? aPTT 116. Providing care for a client with a colostomy Place the skin barrier over the stoma and hold it for 30 seconds. 117. Preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM to an agitated client Inject air into both vials prior to withdrawing the medications. 118. Talking with a client with stage IV breast cancer. Which statement is a constructive use of a defense mechanism I told my doctor that I would like to start a support group for other women who are sick in my community 119. Preparing a sterile field for sterile dressing change. Maintain sterile objects within the line of vision 120. Preparing to teach a group of newly licensed nurses about effective time management. Include as priority Making a list of activities to complete 121. Reviewing ABG values of a client. Client has a pH of 7.20, PaCO2 of 60 mmHg, and HCO 3 of 25 mEq/l Respiratory acidosis 122. Client receiving IV fluids of 150 mL/h which indicates fluid overload dyspnea 123. Caring for 4 clients. Which task should be delegated to assistive personnel Arrange the lunch tray for a client who has a hip fracture. 124. Caring for a client who is 2 days postpartum. Which behaviors should indicate the client is bonding with newborn The client tells visitors how much the newborn looks like her sister. 125. Assessing a preschooler with facial laceration. Identify potential indication of sexual abuse The child exhibits discomfort while sitting. 126. Enters a client's room and sees smoke coming from a small fire in the trash can. Action to take first. Remove the client from the room 127. Rural community health nurse developing a plan to improve health care delivery for migrant farmworkers. Agency for Healthcare Research and quality 128. Assessing a newborn following vaginal birth. Findings to report to provider Nasal flaring 129. Manager in long term care having difficulty with staffing weekend shift is planning to implement changes to the scheduling procedure. Form a committee of staff members to investigate current staffing issues. 130. Assessing a client who has depressive disorder taking amitriptyline. Identify adverse effects. Blurred vision 131. School nurse is notified of an emergency which several children were injured following the collapse of playground equipment. Survey the scene for potential hazards to staff and children. 132. Manager preparing an educational session for staff about how to provide cost effective care Delegate non-nursing tasks to ancillary staff. 133. Creating plan of care for child with acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 Administer granulocyte colony-stimulating factor to the child 134. Providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. Use pictures to illustrate the procedure to the client 135. Caring for a client with a prescription for continuous passive motion machine following total knee arthroplasty Turn off the CPM machine during mealtime. 136. Caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. Adverse effects of PEEP Tension pneumothorax 137. Performing an abdominal assessment on a client Sequence of actions Inspect, auscultate, percuss then palpate. 138. Caring for a client with a new prescription of Clonidine. Adverse side effects Dry mouth 139. Reviewing lab results of a toddler with hemophilia A. Which aPTT values should the nurse expect? 45 seconds 140. Updating the plan of care for a client who is 48 hr post op following laryngectomy and unable to speak. Plan to take first Determine the client's reading skills 141. Caring for a client who asks about taking ginseng to improve her appetite. Identify that ginseng can decrease the effectiveness of which medication. Timolol 142. Preparing client for paracentesis. Action to take Instruct the client to void. 143. Rn observing a LPN and a AP move a client up in bed. When should the nurse intervene The LPN and the AP grasp the client under his arms to life him up in bed. 144. Assessing a client who has had a stroke. For which should the nurse initiate referral for occupational therapy Difficulty performing ADLs 145. Assessing a client taking propranolol. Indication of adverse reaction Coughing at night. 146. Conducting visual acuity testing using the Snellen letter chart for a school age child with eyeglasses You should keep both eyes open during the testing. 147. Caring for a multiparous client following a vacuum-assisted birth. Assess for which possible complication. Cervical laceration [Show More]

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