ATI_RN_Proctored_Comprehensive_Form_A-1

1 A client newly diagnosed with type 2 diabetes mellitus has returned for a 6-week follow-up visit. The nurse should know that which of the following behaviors indicates that the client has adapted successfully to a si ...

1 A client newly diagnosed with type 2 diabetes mellitus has returned for a 6-week follow-up visit. The nurse should know that which of the following behaviors indicates that the client has adapted successfully to a situational role change? Plans three meals a day and avoids snacks Monitors blood glucose once a day Adjusts employment hours to a regular schedule Walks barefoot at home to prevent fungal infections 2 After a client views a video on an operative procedure, the best practice for the nurse is to evaluate and document what the client learned. give the client a handout outlining information relayed in the video. ask the client to sign the informed consent. have the client sign the teaching tool signifying completion of video viewing. 3 Which of the following nursing actions best promotes client safety when transcribing providers' orders? Verify the order sheet contains the correct client identification. Check with another nurse for clarification of a confusing order. Perform transcription in a quiet area. Process orders in the sequence in which they are written. 4 A nurse is caring for a client who has a nursing diagnosis of impaired swallowing following a cerebrovascular accident (stroke). Which of the following nursing interventions is appropriate for this client? Provide nasotracheal suctioning. 3ODFHLQ)RZOHU¶VSRVLWLRQ Offer clear liquids. Restrict fluid intake. 5 A nurse is caring for a client who gave birth 10 hr earlier. The client is in the takingin phase of psychosocial and maternal adaptation. Which of the following is the most appropriate nursing intervention at this time? Instruct the client about infant and self-care. Encourage the mother to send her infant to the well-infant nursery so that she can rest. Listen to the mother's verbalization of her pregnancy and birth experience. Provide opportunities for the mother to be independent in self-care. 6 A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client? Hypokalemia Muscular depression Hyperglycemia Laryngeal stridor 7 A nurse is assessing a client who has a nasogastric feeding tube in place. Which of the following actions should the nurse take to prevent aspiration? Check for gastric residual every hour and hold the feeding if greater than 50 mL. Flush and clamp the nasogastric tube between feedings. Keep the head of the client's bed elevated at least 30° at all times. $XVFXOWDWHDQGGRFXPHQWWKHFOLHQW¶VERZHOVRXQGVHYHU\KU. 8 A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching? ³,ZLOOGHWHUPLQHZKLFKPXVFOHVWRFRQWUDct by stopping and starting my VWUHDPRIXULQH´ ³,ZLOODOWHUQDWHO\FRQWUDFWDQGUHOD[P\JOXWHDOPXVFOHV´ ³,ZLOOWU\WRKROGP\XULQHIRUDOLWWOHZKLOHDIWHU,ILUVWIeel the urge to XULQDWH´ ³,ZLOOSHUIRUPWKHH[HUFLVHVRQFHHDFKGD\EHIRUHEHG´ 9 A nurse is caring for a client with a terminal illness. The nurse recognizes that the IDPLO\¶VSULRULW\Qeed for support will most likely occur when meeting with a social worker about financial concerns related to continuing care. learning about hospice care and how to access services. making decisions about measures to prolong life and provide comfort. meeting with a member of their spiritual community to discuss funeral arrangements. 10 A nurse is developing a discharge plan of care for an older adult client on a rehabilitation unit following a cerebrovascular accident. Which of the following has the highest priority when planning care to facilitate a timely discharge? Arranging for transportation Identifying supportive family members Encouraging participation in physical therapy Consulting nutritional support services 11 A client with HIV is admitted to the medical-surgical unit with a respiratory LQIHFWLRQ7KHFOLHQW¶VIDPLO\PHPEHUUHTXHVWVWKDWIUHVKIORZHUVEHSODFHGLQWKH room every day. Which of the following is the appropriate nursing action? $OORZWKHIORZHUVEHFDXVHWKH\ZLOONHHSWKHFOLHQW¶VVSLULWVXS Request that the family bring potted plants instead. Teach the family that fresh plants of any type are prohibited. ,QVWUXFWWKHIDPLO\WKDWDQ\IORZHUVPXVWEHSODFHGDZD\IURPWKHFOLHQW¶V bed. 12 Which of the following is the highest priority for the circulating nurse in maintaining a safe operating room environment? Sterilizing the instruments after the procedure Reviewing the preoperative assessment Washing hands using foot-operated faucets Reporting any breaks in the sterile technique 13 A client with a tracheostomy is being sent home to be cared for by the spouse. The nurse should include which of the following information in discharge teaching? How to change the nondisposable tracheostomy tube daily How to properly operate the portable suction machine How to change the tracheostomy dressing using clean technique How to tie the tracheostomy tube snugly in place with the knot over the back of the neck 14 During the first 24 hr following a soft-tissue injury to the right ankle, which of the following nursing interventions will help reduce the client's discomfort? Apply an ice pack to the ankle for 20 to 30 min at a time. Keep the ankle in a dependent position. Place a heating pad on the ankle. Soak the ankle in room temperature water with Epsom salts. 15 A nurse is caring for a client with a mental health disorder. The client is agitated, and the nurse is concerned that the client may become aggressive. Fearful for his own safety, the nurse escorts the client to a room and locks her inside against her will. This action could initiate an involuntary commitment for the client. LVDSSURSULDWHJLYHQWKHQXUVH¶VSHUFHSWLRQRIDSHUVRQDOWKUHDW could result in charges of false imprisonment for the nurse. is appropriate prRYLGHGWKDWDSURYLGHU¶VRUGHULVVXEVHTXHQWO\REWDLQHG 16 When instructing a client with an L1-2 spinal cord injury regarding self-care adaptations, which of the following is an appropriate recommendation? Self-catheterization is an option when you feel the sensation of a full bladder. Arrange for a home health aide to bathe you twice a week. Adaptive devices are available to help you put on your shoes. Home delivery of meals is an option you may want to consider. 17 A 1-year-old child is prescribed ibuprofen after having a febrile seizure. The nurse should teach the parents that the best way to administer the medication is a chewable tablet. an elixir. an enteric coated tablet. a suppository. 18 Which of the following strategies best ensures that all nurses on staff have certain skills and knowledge? Providing nurse mentors Offering self-study modules Holding quarterly in-services Completing annual competence assessments 19 Which of the following manifestations should a nurse expect to find in a client whose blood glucose is 650 mg/dL? Slow, shallow respirations Headache Fruity breath odor Cool, clammy skin 20 A nurse is caring for a client diagnosed with depression who has been prescribed a tricyclic antidepressant. The nurse should recognize that which of the following client statements indicates an adverse effect that should be reported to the primary care provider? ³0\PRXWKLVFRQVWDQWO\GU\VLQFHVWDUWLQJWKHPHGLFDWLRQ´ ³,KDYHEHHQGURZV\LQWKHPRUQLQJV´ ³,KDYHQ WEHHQDEOHWRXULQDWHIRUVHYHUDOKRXUV´ ³0\H\HVKDYHEHHQVHQVLWLYHWRVXQOLJKWODWHO\´ 21 A client is scheduled for laparoscopic surgery at 1400. At 1100, the surgeon visits WKHFOLHQW¶VURRPDQGH[LWVDIWHUPLQZLWKDVLJQHGLQIRUPHGFRQVHQWIRUP7KH FOLHQWUHSRUWVWRWKHQXUVHWKDWKHGLGQRWXQGHUVWDQGWKHVXUJHRQ¶VH[SODQDWLRQ Which of the following actions should the nurse take? &DOOWKHVXUJHRQDQGUHTXHVWWKDWVKHUHWXUQWRWKHFOLHQW¶VURRPWRSURYLGH clarification. Tell the client that he will obtain more information before the surgery. Explain the procedure to the client and complete documentation. Call the operating room and delay the surgery. 22 Upon admittance to the hospital, a client states she does not have a written advance directive. After completing the admission assessment, the nurse explains that the client should complete an advance directive because it GHFUHDVHVOLDELOLW\IRUWKHFOLHQW¶VIDPLO\KRVSLWDOHPSOR\HHVDQGWKH hospital. guides primary care providers in planning care for individuals in accordance with their wishes. avoids the uncomfortable discussion of end-of-life care with the family and hospital staff. ILQDOL]HVWKHFOLHQW¶VGHFLVLRQVUHJDUGLQJOLIH-saving measures. 23 A nurse is providing care to a client with a head injury and suspected diabetes insipidus. Which of the following laboratory values should the nurse expect with a diagnosis of diabetes insipidus? Urine osmolality of 300 mOsm/L Urine specific gravity of 1.001 Serum sodium level of 132 mEq/L Serum potassium level of 3.1 mEq/L 24 A nurse is caring for a client who is postoperative for a thyroidectomy. The client is reporting paresthesias and muscle spasms. The nurse should anticipate a prescription for which of the following medications? Potassium chloride (K-Dur) Calcium chloride (Calciject) Lorazepam (Ativan) Cyclobenzaprine (Flexeril) 25 A nurse is caring for a child who has just been admitted to the acute care medical unit. Which of the following laboratory findings should the nurse recognize as indicative of rheumatic fever? Decreased Hgb and platelet count Decreased myoglobin and antinuclear antibody titer Elevated sedimentation rate and C-reactive protein Elevated creatine kinase and troponin 26 A nurse who is a first responder to a biological or chemical attack recognizes that decontamination should preferably be done at the closest hospital. outdoors. near the scene of exposure. in a shower. 27 A nurse recognizes which of the following older adult clients as being at the highest risk for a fall injury? A client who is postoperative and receiving sedation $FOLHQWZLWK$O]KHLPHU¶VGLVHDVHEHLQJFDUHGIRUDWKRPH A client in a nursing home with organic brain syndrome A client with aphasia following a cerebrovascular accident 28 A hospital visitor is experiencing a tonic-clonic seizure while visiting a client. To prevent injury to the visitor, the nurse should assist the visitor to an empty bed. clear furniture from around the visitor. move the visitor away from the client. insert a padded tongue blade. 29 A client has just been diagnosed with gestational diabetes and is prescribed insulin injections. She tellVWKHQXUVHWKDWVKHGRHVQ¶WZDQWWRJLYHKHUVHOIVKRWVDQGDVNV ZK\VKHFDQ¶WWDNHDSLOOLQVWHDG:KLFKRIWKHIROORZLQJQXUVLQJUHVSRQVHVLV appropriate? ³3LOOVXVHGWRWUHDWGLDEHWHVKDYHEHHQNQRZQWRSRVVLEly cause birth GHIHFWV´ ³$SSURSULDWHSUHJQDQF\ZHLJKWJDLQLVLQKLELWHGE\XVHRIWKHSLOOV´ ³3LOOVXVHGWRWUHDWGLDEHWHVDUHPRUHOLNHO\WRFDXVHK\SRJO\FHPLD´ ³ [Show More]