NSG 4060 Comprehensive ATI Practice B

A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? Hemoglobin 14.9 g/dL The nurse should ide ...

A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? Hemoglobin 14.9 g/dL The nurse should identify that packed RBCs a re-administered to clients who have a decreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females, indicating the therapy has been effective. A nurse working in an emergency department is triaging four clients. Which of the following clients, should the nurse recommend for treatment first? A middle adult client who has unstable vital signs. Using the stable vs unstable approach to client care, the nurse should recommend priority treatment for the client who has unstable vital signs because this client requires immediate treatment to reduce the risk of further injury or possible death. A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to the CNA? Measure the client’s daily weight It is within the CNA range of function to measure a client’s daily weight, so the nurse should delegate this task to them. A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse should administer? 18 g A nurse is conduction a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint? In the correct image, the adolescent is abduction the hip joint by moving the leg away from the midline of the body. A nurse is caring for a client who has hyperthyroidism. Which of the following findings should What does the nurse expect? Tremors Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia. A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following findings should the nurse expect? Nuchal rigidity This is a manifestation of bacterial meningitis. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take? Auscultate the apical pulse at least 1 min. The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds. 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? Instruct the client to avoid coughing during the procedure. It is important for the nurse to remind the client to avoid coughing and to lie still during a thoracentesis to avoid puncturing the pleura. A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings is a potential indication of child sexual abuse? The child exhibits discomfort while walking. The nurse should identify this finding as a potential indication of child sexual abuse. A nurse is preparing to teach about dietary management to a client who has Crohn’s disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Fiber The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and inflammation. A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following total knee arthroplasty. Which of the following actions should the nurse take? Turn off the CPM machine during mealtime. This promotes client comfort and dietary intake. 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 the client? Radial vein of the inner arm. This site will have adequate subcutaneous tissue.