ATI Comprehensive Guide 2023 A+

9. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions ...

9. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? A. Rupture the amniotic sac B. Medicate the client for pain C. Prepare the client for a cesarean section D. Perform a vaginal exam Ans- Prepare the client for a cesarean section 177. A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? A. Client fell out of bed because an assistive personnel left the rails of the bed down B. Client's roommate thinks the client is confused and fell when getting out of bed C. Client appears to have slipped in water but reports no injuries D. Client found lying on the floor near the bedside table Ans- Client found lying on the floor near the bedside table 178. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod Ans- A 10-year-old client who has pneumonia and is receiving respiratory treatments 179. A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? A. Hepatotoxicity B. Ototoxicity C. Hypercalcemia D. Hypertension Ans- Ototoxicity 180. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit Ans- Thready pulse 1. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? A. Inform the client of available community resources B. Assist the client in finding child care options C. Agree upon short-term goals for the client D. Ask the client about their understanding of the diagnosis Ans- Inform the client of available community resources 2. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? A. Clear fluid drainage from the nares B. Report of pain around the eyes C. Dried blood in the mouth D. Mandibular asymmetry Ans- Clear fluid drainage from the nares 3. A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? A. Profuse milky white discharge B. Frequency and dysuria C. Low-grade fever D. Hematuria Ans- Profuse milky white discharge 4. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? A. This technique prevents injury to the sciatic nerve B. This technique decreases the risk of subcutaneous infiltration C. This technique allows a larger amount of medication to be injected D. This technique increases the absorption rate of the drug Ans- This technique decreases the risk of subcutaneous infiltration 10. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? A. Instill erythromycin ophthalmic ointment in the newborn's eyes B. Weigh the newborn C. Place identification bracelets on the newborn D. Dry the newborn Ans- Dry the newborn 11. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis B. Hepatitis B is transmitted by contaminated food C. Chronic hepatitis can lead to renal cell cancer D. Clients who have a history of viral hepatitis are unable to donate blood Ans- Clients who have a history of viral hepatitis are unable to donate blood 12. A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care? A. Work with the client to create a flexible daily schedule B. Gradually decrease the time allowed for ritualistic behavior C. Offer solutions to assist in problem solving D. Teach the client to meditate about obsessive thoughts Ans- Work with the client to create a flexible daily schedule 13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? A. Healthy weight B. Malnutrition C. Overweight D. Obesity Ans- Malnutrition 14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? A. Perform another internal exam B. Notify the client's provider C. Check the FHR D. Obtain a pH test of the fluid Ans- Check the FHR 15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? A. Encourage the client to gain 2.3 kg per week B. Weigh the client once per week throughout hospitalization C. Monitor the client for 1 hr after meals D. Allow the client to choose meal times Ans- I think its D 16. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is A. Asymmetric, with variegated coloring B. Scaly and red C. Brown, with a wart-like texture D. Firm and rubbery Ans- Asymmetric, with variegated colorin