ATI - Comprehensive Practice 2019 A

ATI - Comprehensive Practice 2019 A a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of the left lower leg. which of the following interventions should the nurse include i ...

ATI - Comprehensive Practice 2019 A a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of the left lower leg. which of the following interventions should the nurse include in the plan of care? - ✔✔elevate the affected leg ambulation should be encouraged a nurse is teaching a group of guardians about child safety measures. which of the following statements by a guardian indicates an understanding of the teaching? - ✔✔I should have my child avoid sun exposure between 10 am and 2 pm a home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? - ✔✔I will walk for short distances throughout the day a nurse is providing dietary teaching to the parents of a 6 month old infant. which of the following instructions should the nurse include? - ✔✔Introduce new foods one at a time over 5 to 7 days a charge nurse is planning care for a client who has mechanical restraints in place. which of the following interventions should the nurse include in the plan? - ✔✔Provide a staff member to stay with the client continuously can be physically or using an audiovisual device need to document every 15-30 minutes, a new prescription should be in every 4 hrs for adults, every 3 hrs for 9-17 years and every hour for those younger a community health nurse is assisting with the development of a disaster management plan. the nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? - ✔✔performing a rapid needs assessment a nurse manager is assisting with the orientation of a newly licensed nurse. which of the following actions by the nurse requires the nurse manager to intervene? - ✔✔tells the hospital chaplain a clients diagnosis a nurse is caring for a client who is in labor at 39 weeks of gestation. during the second stage of labor, the nurse observes early deceleration on the monitor tracing. which of the following actions should the nurse take? - ✔✔continue observing the fetal heart rate these are an expected finding a nurse manager is planning to make changes to the current scheduling system on the unit. to facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? - ✔✔provide information about scheduling issues to the staff unfreezing stage - increase understanding of why change is needed a nurse is planning teaching about allowable foods for a client who has a history of uric acid based urinary calculi formation. which of the following foods should the nurse include in the teaching? - ✔✔oranges can eat citrus fruits no chicken, no organ meats like liver, no red wine (avoiding purine) a charge nurse is teaching a newly licensed nurse how to identify true labor. which of the following should the nurse include in the teaching? - ✔✔the cervix transitions to an anterior position contractions will be felt in the lower abdomen and back, intensity increases with ambulation, cervix shortens and thins a nurse on a medical surgical unit is caring for a client prior to a surgical procedure. which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? - ✔✔the client is able to accurately describe the upcoming procedure a charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. which of the following actions should the charge nurse take first to provide teaching about chest tubes? - ✔✔ask the nurse about their knowledge of the procedure a nurse is teaching a client who has a new prescription for estradiol. for which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? - ✔✔headaches - can be indicative of a thromboembolic stroke a nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand maul seizure. availabale is diazepam solution for injection 5mg/mL. how many mL should the nurse administer? 0 - ✔✔0.6 mL a nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. which of the following staff members should the nurse assign to collect the information? - ✔✔An assistive personnel (AP) who is assisting a client to return to bed a nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm^3. which of the following interventions should the nurse include in the plan? - ✔✔withhold administering the varicella vaccine to the child - it is a live vaccine and should not be given a nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. which of the following instructions should the nurse include? select all - ✔✔A speech pathologist will be performing a swallowing study for you you should rest before eating meal thicken your beverage before drinking a nurse is assessing a client who has schizophrenia and is taking chlorpromazine. which of the following findings is the priority for the nurse to report to the provider? - ✔✔temperature 39.4 (102.9) a client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? - ✔✔flumazenil a nurse is caring for an older adult client in the PACU following general anesthesia. which of the following findings should the nurse report to the provider? - ✔✔audible stridor a nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. which of the following techniques should the nurse use to maintain surgical aseptic technique? - ✔✔set the catheter tray on the overbed table at waist height a nurse is planning care for a client who has a deficit with cranial nerve II. which of the following actions should the nurse plan to take? - ✔✔clear objects from the clients walking area a nurse is providing discharge instructions to a client following a total hip arthroplasty. which of the following instructions should the nurse include? - ✔✔install a raised toilet seat at home a nurse is assessing a client who is receiving a blood transfusion. which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? - ✔✔low back pain other signs include hypotension, tachycardia a nurse is caring for a child who is experiencing a tonic clinic seizure. which of the following actions should the nurse take? - ✔✔place the child in a side lying position a nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. which of the following actions should the nurse take to prevent clogging of the tube? - ✔✔flush the client's gastrostomy tube with 30 mL of water before administering the medication a nurse is assessing a client who has macular degeneration. which of the following findings should the nurse expect? - ✔✔decreased central vision a nurse is assessing a client who has schizophrenia. the nurse should identify the following alteration in speech as which of the following? - ✔✔clang association - uses words based on their sound rather than their meaning (this one had a lot of b words) a nurse in a clinic receives a call form a guardian whose child has varicella. the guardian asks when the child can return to school. which of the following responses should the nurse make? - ✔✔when the crusts have formed on every lesion a nurse is providing discharge instructions to a client who has a new prescription for warfarin. which of the following client statements should the nurse identify as an indication that the client understands the teaching? - ✔✔I should report a change in the color of my stools - red, black, tarry, etc. a nurse is assessing a school age child who has cystic fibrosis. which of the following findings is the priority for the nurse to report to the provider? - ✔✔hemoptysis 275 mL/24 hr when caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? - ✔✔blowing bubbles with liquid soap to blow the hurt away an assistive personnel and a nurse are turning a client onto the right side. which of the following actions by the AP requires the nurse to intervene? - ✔✔Places a pillow under the client's right arm the AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder a nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. which of the following actions should the nurse take? - ✔✔document the client's refusal of the medication a nurse is caring for four clients., which of the following clients should the nurse assign to an assistive personnel to assist with meals - ✔✔a client who has Alzheimer's disease and is demonstrating aphasia a mental health nurse is conducting the first of several meetings with a client whose partner recently died. the nurse should perform which of the following actions to establish trust during the orientation phase of the nurse client relationship - ✔✔establish the termination date of therapy a nurse is caring for a client who is at 28 weeks of gestation. the client asks the nurse to explain what causes her to have constipation. which of the following responses should the nurse make? - ✔✔the enlarged uterus compresses the intestines and causes constipation a nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0540 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis - ✔✔investigate environmental factors that might be contributing to client injury during these hours a nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. which of the following actions should the nurse take first? - ✔✔measure the clients vital signs (every 15 minutes until stable) a charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. which of the following information should the nurse plan to include? - ✔✔the family can have the child in an open casket without fearing that the organ donation might disfigure the child's body a nurse is teaching about total parenteral nutrition TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? - ✔✔you will receive fingersticks for blood glucose testing a nurse is caring for a client who h