ATI_RN_Proctored_Comprehensive_Form_A-1 With 100% Complete Questions and Answers

Document Content and Description Below

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 situational role change? 2 After a client views a video on an operative procedure, the best practice for the nurse is to 3 Which of the following nursing actions best promotes client safety when transcribing providers' orders? 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. Offer clear liquids. 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? 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? 8 A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching? ³ct by stopping and starting my 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 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? Request that the family bring potted plants instead. Teach the family that fresh plants of any type are prohibited. , bed. 12 Which of the following is the highest priority for the circulating nurse in maintaining a safe operating room environment? 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? 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? 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. could result in charges of false imprisonment for the nurse. is appropriate 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 18 Which of the following strategies best ensures that all nurses on staff have certain skills and knowledge? 19 Which of the following manifestations should a nurse expect to find in a client whose blood glucose is 650 mg/dL? 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. 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? 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? 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 27 A nurse recognizes which of the following older adult clients as being at the highest risk for a fall injury? 28 A hospital visitor is experiencing a tonic-clonic seizure while visiting a client. To prevent injury to the visitor, the nurse should 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<RXUSUHIHUHQFHIRUWDNLQJSLOOVVKRXOGEHGLVFXVVHGZLWK\RXUGRFWRU´ 30 A nurse is caring for a client who had a transurethral resection of the prostate and is receiving a continuous bladder irrigation. At the conclusion of the shift, the nurse collects the following data: Oral intake = 500 mL Bladder irrigant infused = 3,000 mL Foley catheter drainage = 4,000 mL :KLFKRIWKHIROORZLQJLVWKHFOLHQW¶VXULQDU\RXWSXW" 500 mL 1,000 mL 3,500 mL 4,000 mL 31 Which of the following findings should indicate to a nurse that a client has been effectively treated for Mycobacterium tuberculosis? 32 A client wants to review his medical chart, and he asks the nurse if he can see it. The nurse should tell the client that he has a legal right to review his medical chart. the primary care provider must give permission for the client to review his medical chart. he should speak to his primary care provider because the chart is written in medical terminology. his request to view his medical chart must be made in writing. 33 Which of the following is an appropriate nursing intervention to take when caring for a client in a crisis? 34 A nurse is caring for a client with thrombophlebitis. Which of the following interventions is appropriate for this client? 35 A nurse is caring for four clients who are hospitalized. In which of the following client situations should the nurse intervene by notifying the primary care provider? An older adult client awakens during the night to urinate. An adult client who had surgery 2 days ago awakens two to three times a night. A client reports insomnia and is observed napping during the day. A client snores loudly and reports headache when awakening. 36 While assessing a client in labor, the nurse observes the umbilical cord protruding from the client's vagina. After calling for assistance and requesting that the primary care provider be notified, the nurse should immediately prepare the client for an emergency cesarean birth. SUHSDUHWKHFOLHQWIRUDQDPQLRLQIXVLRQRIODFWDWHG5LQJHU¶VVROXWLRQ position the client on her side and insert a sterile gloved hand into the vagina to take pressure off the cord. PHDVXUHWKHFOLHQW¶VYLWDOVLJQVDQGIHWDOKHDUWUDWHDQGLQFUHDVe the IV flow rate. 37 A nurse is planning discharge teaching for the parents of a child with cystic fibrosis. Which of the following is most important for the nurse to emphasize? 38 A nurse is caring for four clients, each of whom has an assistive device. Which of the following clients needs further instruction? A client who locks both of his elbows when using his crutches to ambulate to the bathroom A client who rinses his prosthetic eye in warm normal saline A client who removes her hearing aid before spraying her hair with hairspray A client who takes a step, moves her walker forward, and then takes another step 39 When performing a mental status examination, a nurse should recognize that which of the following client findings indicates impaired cognition? 40 A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take next? 1RWLI\WKHFOLHQW¶VSULPDU\FDUHSURYLGHU Administer oxygen at 10 L/min via nasal cannula. Reevaluate the client for an ET cuff leak. Deliver breaths manually with a resuscitation bag. 41 A client is receiving epoetin alfa (Epogen) for treatment of anemia secondary to bone cancer. Which of the following client findings indicates the hematopoietic growth factor treatment has been effective? 42 While visiting a family health clinic, a 19-year-old client requests information regarding the correct use of condoms. Which of the following statements made by the nurse is correct? ³(QVXUHWKDWWKHFRQGRPILWVVQXJO\RYHUWKHWLSRIWKHSHQLV´ ³&RQGRPVDUHHTXDOO\HIIHFWLYHIRUELUWKFRQWUROZLWKRUZLWKRXWWKHXVHRI YDJLQDOVSHUPLFLGHV´ "When using implanted contraceptive methods, condoms should also be used to protect against STDs." ³8VHRIDSHWUROHXP-EDVHGOXEULFDQWZLWKDFRQGRPLQFUHDVHVWKHFRQGRP¶V HIIHFWLYHQHVV´ 43 A nurse is caring for a client with an upper gastrointestinal bleed. When performing a saline lavage through a nasogastric tube, the nurse should use which of the following techniques to prevent gastric aspiration? Insert a small-bore nasogastric tube. Ensure proper nasogastric tube placement by auscultating for air. Place the client in a side-lying position. Instill a minimum volume of 300 mL of NS. 44 One of the clients assigned to a nurse has become medically unstable. Due to the time the nurse must now spend with this client, provision of care to other assigned clients will be difficult. Which of the following tasks could be delegated to assistive personnel (AP)? 45 A nurse is providing palliative care to a client and his family. Which of the following statements by the family indicates an understanding of palliative care? ³,¶PUHOLHYHGWKDWP\IDWKHUZLOOGLHDWKRPH´ ³7KHQXUVHZLOOKHOSFRQWUROP\IDWKHU¶VSDLQ´ ³0\IDWKHU¶VOLIHFDQQRZEHSURORQJHG´ ³,ZLOOGLVFRQWLQXHP\IDWKHU¶VFKLURSUDFWLFWUHDWPHQWV´ 46 When providing safe care to a client being placed in restraints, which of the following nursing interventions is appropriate? Insert two fingers between the client and the restraint after it is secured to ensure that the fit is loose enough. Attach the restraints to an immobile part of the bed frame. Secure the restraints by tying a knot to prevent the client from sliding the straps and getting free. Release the physical restraint a minimum of every 4 hr. 47 Staff nurses on a medical unit implement a new program to improve cost HIIHFWLYHQHVV3ULRUWRH[LWLQJFOLHQWV¶URRPVWKHQXUVHVDUHWRDVN³,VWKHUHDQ\WKLQJ I can get you before I leavH"´:KLFKRIWKHIROORZLQJVXJJHVWVWKDWWKHQHZSURJUDP is effective at reducing costs? 48 A nurse is caring for a child with a new onset of seizures who is about to undergo an electroencephalogram (EEG). Which of the following should be included in teaching the child and parents about the procedure? 49 A nurse is caring for four clients who are scheduled for surgery today. Which of the following indicates that a client needs further intervention before surgery? 50 A nurse is caring for a client with a peripherally inserted central catheter (PICC). Prior to initiating an infusion through the PICC line, the nurse should take which of the following actions? Flush the line with heparin. Insert a noncoring Huber needle. Position the client in a left side-lying position. Confirm placement via chest x-ray. 51 $FOLHQWLVWDNLQJDQRSLRLGIRUSDLQSRVWRSHUDWLYHO\+HWHOOVWKHQXUVH³,KDYHQ¶W KDGDERZHOPRYHPHQWIRUGD\VDQG,QRUPDOO\JRHYHU\GD\´:KLFKRIWKH IROORZLQJLVWKHQXUVH¶VPRVWDSSURSULDte response? ³$VLGHHIIHFWRI\RXUSDLQPHGLFDWLRQLVFRQVWLSDWLRQ,ZLOOFRQWDFWWKH GRFWRUIRUDOD[DWLYHSUHVFULSWLRQ´ ³,ZLOOKDYHWKHGRFWRUVZLWFK\RXWRDGLIIHrent pain medication that will SUHYHQWDQ\IXUWKHUFRQVWLSDWLRQ´ ³2QFH\RXEHJLQWRHDWVROLGIRRG\RXZLOOEHDEOHWRKDYHDERZHO PRYHPHQW´ ³7KDWLVQRUPDO<RXUQRUPDO bowel pattern will resume when you go KRPH´ 52 A nurse is performing initial rounds and assesses four clients. Which of the following occurrences should be documented and reported to the charge nurse immediately? $FOLHQW¶VRXWSXWZDVP/PRUHWKDQKHURUDOLQWDNHIRUWKHSDVWKU A nurse shaved the chest of a client scheduled for cardiac surgery today. A client with diabetes mellitus has a blood glucose level of 150 mg/dL. A family member requests to spend the night in a client's room. 53 A nurse is directing the care of multiple clients. In determining how to best utilize the skills of a team that includes RNs, licensed practical nurses, and assistive personnel, which of the following is the most important information source? 54 A nurse is caring for a client who has a urinary tract infection and has been receiving a broad-spectrum cephalosporin. Which of the following serum laboratory results indicates medication effectiveness? 55 A nurse is caring for an infant receiving oxygen via an oxygen hood. Which of the following client findings indicates that the client may be experiencing oxygen toxicity? Hypoventilation Elevated blood pressure Substernal retractions Hyperthermia 56 A nurse is providing discharge instructions to the parents of a newborn. Which of the following instructions regarding newborn safety is most important for the parents to understand? Arrange for a child care provider who is trained in infant cardiopulmonary resuscitation. Install a baby monitor in the newborn's nursery and in the parents' bedroom. 7DNHWKHQHZERUQ¶VWHPSHUDWXUHXQGHUWKHDUPLIVLJQVRILOOQHVVDUHHYLGHQW Secure the newborn in a rear-facing approved infant car seat when riding in a motor vehicle. 57 A nurse is caring for a client on his first day after having knee surgery. Morning assessment reveals a pain level of 8/10 and a blood pressure of 180/90 mm Hg. Which of the following nursing actions should the nurse take first? Administer antihypertensive medication. Administer pain medication. Reassess the blood pressure. 58 A nurse should give priority to which of the following interventions when initiating IV antimicrobial therapy? 59 A child is 6 hr post abdominal surgery. One hour ago, the nurse administered morphine sulfate for pain. Which of the following behaviors is the best indicator that the pain medication has been effective? 60 A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, the nurse should assist the client into the lithotomy position. place a wedge under one of the client's hips. insert a pillow under the client's knees. position the client in reverse Trendelenburg. 61 :KLFKRIWKHIROORZLQJLQWHUYHQWLRQVVKRXOGWKHQXUVHLQFOXGHLQWKHFOLHQW¶VSODQRI care to prevent development of phlebitis from a peripheral IV? Change the IV site every 72 hr. Elevate the extremity while infusing IV fluids. 62 $FOLHQW¶VRUGHUVLQFOXGH'5W 1,000 mL over 8 hr. The tubing drip rate is 10 gtt/mL. The nurse should adjust the flow rate to which of the following infusion rates? 63 A client is to receive 300 mg phenytoin (Dilantin) by mouth twice daily. The medication is available in a 125 mg/5 mL solution. How many milliliters should the nurse administer for each dose? 64 A client with gestational hypertension is experiencing toxic effects from magnesium sulfate therapy. The nurse should anticipate administering which of the following medications to counteract the adverse effects? 65 A newborn whose mother had gestational diabetes is hypoglycemic at birth. Which of the following actions should the nurse take? Feed the newborn as soon as possible. Encourage non-nutritive sucking. Place the newborn under a radiant warmer. Check urine for ketones. 66 A nurse in an outpatient clinic is reviewing the results of four clients who have had screening procedures. Which of the following results indicates a need for client follow-up? 67 A nurse is teaching a client with GERD about omeprazole (Prilosec). Which of the following indicates a need for further teaching? 68 Which of the following statements made by a client indicates that the client has developed trust with the nurse? 69 After giving 5 mg of morphine to a client from a 10 mg vial, the nurse should do which of the following with the remaining morphine? 70 A nurse is caring for a client with bone cancer who is taking morphine sulfate to control generalized pain. The primary care provider also prescribes amitriptyline (Elavil). The nurse recognizes that the rationale for the addition of amitriptyline is to decrease agitation. increase bowel motility. improve mood. resolve inflammation. 71 A 2-month-old infant has received immunizations at a well-child appointment. The nurse should instruct the parent to report which of the following within the first 48 hr? 72 An older adult client who resides in a long-term care facility reports insomnia and excessive daytime sleepiness. To promote rest for the client, the nurse should plan to perform which of the following interventions? Contact the primary care provider for a sedative-hypnotic prescription. $VVHVVWKHFOLHQW¶VXVXDOEHGWLPHURXWLQH Offer the client a warm cup of tea before bedtime. 73 A client's advance directive states that he does not want dialysis when his health condition worsens. The client is currently competent and agrees to dialysis. The nurse should 74 :KLFKRIWKHIROORZLQJEHVWLQGLFDWHVWRDQXUVHWKDWDWHUPLQDOO\LOOFOLHQW¶VVSLULWXDO needs are being met? 75 A nurse should recognize that which of the following older adults is at the highest risk for social isolation? A client who is hearing impaired and lives with his adult children A client who is unable to drive and lives in an assisted-living facility A client who is oxygen dependent and lives alone in an apartment community A client who is confused and has an in-home caregiver 76 When performing a 12-lead ECG for a client, the nurse should take which of the following actions? 3ODFHWKHFOLHQWLQ)RZOHU¶VSRVLWLRQZLWKDUPVUHVWLQJFRPIRUWDEO\DWKLV sides. Inform the client that he might feel some tingling sensations during the test. $SSO\HOHFWURGHVWRIODWVXUIDFHVDERYHWKHFOLHQW¶VZULVWVDQGDQNOHV Instruct the client to hold his breath to the count of 10 at the start of the test. 77 A nurse is discharging a client who has a colostomy. The client states that she would like to use her moisturizing soap to clean around the stoma. Which of the following responses by the nurse is most appropriate? ³,WLVDFFHSWDEOHWRXVHWKLVVRDSLILWPDNHV\RXFRPIRUWDEOH´ ³<RXPD\ZDQWWRWU\RWKHUVRDSVWRGHWHUPLQHZKDWLVEHVWWRFOHDQDURXQG WKHVWRPD´ ³/XEULFDQWVLQPRLVWXUL]LQJVRDSVPD\LQWHrfere with adhesion of the DSSOLDQFH´ ³8VHRIPRLVWXUL]LQJVRDSVPD\FRQWULEXWHWRVNLQLQIHFWLRQV´ 78 A nurse is providing dietary instruction to a client diagnosed with acute cholecystitis. The nurse recommends which of the following as the most appropriate food choice for lunch? 79 A nurse is caring for a client admitted with a spinal cord injury. After the nurse immobilizes the spine, which of the following is the next priority? Assess respiratory pattern and effort. Prevent the formation of pressure ulcers. Monitor sensorimotor function in the extremities. Promote bowel and bladder function. 80 Following a gastric resection, a client experiences a cramping sensation, increased pulse rate, dizziness, and nausea after eating a meal. To help reduce these symptoms, the nurse instructs the client to consume plenty of high-fiber foods at each meal. add carbohydrates and dairy products to the diet. restrict liquids during, at least 1 hr prior to, and after meals. eat three large meals daily with no snacking in between. 81 A nurse is performing a nonstress test on a client who is pregnant at 41-weeks gestation. The nurse notes that the client is having contractions every 2 to 3 min. Which of the following actions should the nurse take first? 82 A nurse is caring for an older adult client who has chronic renal failure and is prescribed acetaminophen for fever. The nurse can expect that the dosage will be 83 A nurse is caring for a client immediately following surgery under general DQHVWKHVLD7KHFOLHQW¶VSDLQLVEHLQJPDQDJHGE\PRUSKLQHYLDDSDWLHQW-controlled analgesia pump. The nurse should give priority to assessing the client for which of the following adverse medication interactions? Urinary output < 30 mL/hr 84 A nurse is preparing an adolescent client for allergy skin testing. The nurse should expect the adolescent to select which of the following instructional approaches? 85 A nurse is caring for a client with herpes zoster. Which of the following statements indicates that the client needs more teaching? ³, A client is transferred from the PACU to a private room on the surgical unit. During 86 $SULPDU\FDUHSURYLGHULVDERXWWRGLVFRQWLQXHDFOLHQW¶VFKHVWWXEHZLWKRXWJLYLQJ WKHFOLHQW¶VSUHSURFHGXUHSDLQPHGLFDWLRQWLPHWREHHIIHFWLYH:KLFKRIWKH following actions should the nurse take at this time? 87 A 4-year-old child is being seen in the emergency department after being involved in a motor vehicle crash. The child has a fractured humerus and will be placed in a synthetic cast prior to discharge. Which of the following is an appropriate intervention to include in parent teaching? 88 Parents of an infant ask for information regarding immunization schedules. The nurse should suggest that the parents obtain the most current immunization schedule from which of the following sources? 89 A nurse is caring for a client who has permanent drooping on the left side of the face following a cerebrovascular accident (stroke). The client refuses to see any family members. Which of the following interventions will best help the client adapt to this body image change? Initiate a family conference to address the issue. Establish short-term goals that will enable the client to look in a mirror. Educate the client about short- and long-term effects of stroke. Offer contact information for stroke recovery support groups. 90 A nurse is taking the blood pressure of a client who has come to the clinic for a blood pressure check due to suspected hypertension. Which of the following techniques is appropriate? Take the blood pressure in both arms and use the arm with the lower reading for subsequent measurements. 3RVLWLRQWKHFOLHQW¶V arm above the level of the heart while obtaining the reading. Deflate the cuff quickly after reaching 30 mm Hg above the palpated systolic pressure. Calculate the average of two readings obtained on the same arm at least 2 min apart. 91 $QXUVHLVFDULQJIRUDFOLHQWIROORZLQJDWRWDOKLSDUWKURSODVW\7KHFOLHQW¶VOHJVDUH too large for antiembolic stockings/devices. Which of the following interventions should the nurse expect to implement? 92 A nurse should recognize that which of the following clients is at greatest risk for developing acute poststreptococcal glomerulonephritis? A 2-month-old girl with pyloric stenosis An 18-year-old girl in the second trimester of pregnancy A 7-year-old boy recovering from impetigo 93 A nurse is caring for a client with an epidural catheter for opioid administration for pain control. When the nurse is changing the dressing, which of the following is the highest priority? 94 Which of the following client findings indicates a need for complementary therapy? A client with posttraumatic stress disorder is experiencing nightmares. A client has first-degree burns over 10% of his body. A client with schizophrenia is experiencing hallucinations. A client with diabetes mellitus is noncompliant with his diet. 95 Which of the following findings best indicates that outcomes have been met for a client who has been physically abused by her spouse? mental health clinic. The client reports attending group counseling for abuse victims at the mental health clinic. The client reports that she has a safety plan in place and will implement it when necessary. his wife again. 96 An RN has delegated a Foley catheter insertion to a licensed practical nurse (LPN) for a client who has been unable to void for 10 hr. Which of the following outcomes will require further intervention by the RN? The LPN reports 60 mL of clear, straw-colored urine output. The LPN reports the need for lidocaine gel. The LPN reports that the specific gravity of the urine output is 1.030. The LPN receives help from an assistive personnel to perform the procedure. 97 A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about the disorder. To prevent a sickle cell crisis, the nurse emphasizes the importance of 98 A client who is receiving phenytoin (Dilantin) for seizure disorder has been prescribed isoniazid (INH) and rifampin (Rifadin). Which of the following should the nurse conclude if the client develops ataxia and incoordination? 99 A nurse is caring for a client who has undergone a modified radical mastectomy. The client has two Jackson-Pratt drains. The nurse should J report drainage greater than 25 mL in the first 24 hr. position the affected extremity below the level of the drain. empty and compress the reservoir. 100 A client who has a second-degree burn tells the nurse that the dressing changes are very painful. Which of the following nursing interventions is appropriate? Allow the client to determine when dressing changes will occur. 8VHK\GURWKHUDS\RQWKHFOLHQW¶VZRXQGVWRUHPRYHROGGUHVVLQJV Teach the client relaxation techniques to be used during dressing changes. Assure the client that dressing changes will become less painful as the wound heals. 101 A nurse is preparing an older adult client for discharge. As the nurse is going over the discharge instruction 102 When providing nursing care and support for a client with a gambling dependency, which of the following is the most appropriate intervention? defense mechanisms, such as denial. Encourage the client to review his past incidents of gambling and the negative feelings he experienced during those times. Help the client to gain awareness that he is responsible for his gambling dependency and needs to develop better impulse-control. Establish client goals and have the client explain what actions he will take to prevent and manage gambling relapses. 103 A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure wrists. Which of the following actions should the nurse take to address suspicions of 104 A nurse is receiving a change-of-shift report on four clients. Which of the following clients is at the greatest risk for developing an infection? A client who takes prednisone every morning A client who completed chemotherapy last year A client whose morning blood glucose was 130 mg/dL A client with an increased platelet count 105 A nurse delegates the task of ambulating a client to an assistive personnel (AP). At the end of the shift, the nurse discovers that the client has not been ambulated. This situation could have best been avoided if the nurse had checked with the AP mid-shift to make sure that the client had been 106 A nurse is planning health promotion education for adolescents. Which of the following interventions is appropriate? Give a presentation on the immediate potential consequences of substance use. Encourage group discussions during sex education classes. Distribute detailed visual handouts regarding the impact of smoking on lifelong health. Invite parents to attend health education programs with their adolescents. 107 A nurse is discussing circumcision with a new mother. Which of the following actions should the nurse take to ensure informed consent? 108 A client is diagnosed with an acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin in the emergency department. Which of the following findings indicates that the client is experiencing a satisfactory response to these interventions? 109 A nurse is caring for a client with hyponatremia and heart failure. The assessment reveals moist lung sounds, bounding pulse, increased blood pressure, and pitting SHULSKHUDOHGHPD:KLFKRIWKHIROORZLQJVKRXOGEHWKHQXUVH¶VSULRULW\ intervention? Administer diuretics. /LPLWWKHFOLHQW¶VIOXLGLQWDNH Infuse an IV solution of 0.9% NS. Insert a Foley catheter. 110 A nurse is assessing a client who has been taking an estrogen-progestin oral contraceptive. Which of the following side effects should the nurse recognize as being related to an excess of estrogen? Breast tenderness 111 A nurse is teaching a client stress management techniques. Which of the following client statements indicates effective learning? ³(YHQWKRXJK,KDYHEHHQGHHSEUHDWKLQJ,¶PVWLOOWLUHGDORW´ ³,ZULWHLQP\MRXUQDOWRH[SUHVVP\IHHOLQJVHYHQWKRXJKP\JUDPPDULV EDG´ ³,DPXVLQJJXLGHGLPDJHU\EXW,QHHGKHOSOHDUQLQJWRIRFXV´ ³,KDYHEHHQPHGLWDWLQJEXWP\PLQGZDQGHUVWRRIUHTXHQWO\´ 112 A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? 113 A nurse is providing teaching to a family of an infant with decreased cardiac output due to congenital heart disease. Which of the following strategies regarding care for this infant should be included in the teaching? Maintain the infant in the supine position when sleeping or not being held. Perform infant care activities frequently and intermittently throughout the day. Bathe the infant and change the bed linens daily to reduce the risk of infection. Observe for signs of hunger, such as sucking on fists, in order to feed the infant before crying occurs. 114 A nurse is providing discharge teaching to a client following a total hip replacement. Which of the following statements made by the client indicates an understanding of the discharge teaching? "I cannot wait to get home and soak in my bathtub." "It might be hard for me to stay in bed for 3 or 4 days." ,ZRQ¶WFURVVP\OHJVZKHQ,VLWLQDFKDLU ,VKRXOGVOHHSRQP\JRRGVLGHIRUWKHQH[WZHHNV´ 115 A nurse is providing client teaching regarding sumatriptan (Imitrex). Which of the following client statements indicates that the client understands the expected effects and appropriate uses of this medication? ³,VKRXOGXVHWKLVPHGLFDWLRQGDLO\WRSUHYHQWUHRFFXUUHQFHRIP\ PLJUDLQHV´ ³,ZLOOWDNHWKLVPHGLFDWLRQDWWKHRQVHWRIDPLJUDLQH´ ³7KLVPHGLFDWLRQZRUNVE\GLODWLQJWKHEORRGYHVVHOVRIP\KHDG´ "If I need a second dose, I will have to wait at least 12 hr." 116 A nurse is instructing an adolescent recently diagnosed with type 1 diabetes mellitus about self-blood glucose monitoring (SBGM). Which of the following is the most important reason the adolescent should perform SBGM? 117 A nurse is assigned to care for a client who is managing his own continuous ambulatory peritoneal dialysis treatment at home. The nurse is unfamiliar with the FOLHQW¶VSODQRIFDUH7KHQXUVHVKRXOG 118 Which of the following assessment findings indicates a complication following an angiogram with a femoral approach? 119 Which of the following clients is appropriate for the nurse to refer to speech therapy for a swallow evaluation? An adolescent with anorexia who is cachectic A middle-age adult with gastroesophageal reflux disease A premature infant with a poor suck reflex and failure to thrive An older adult who has difficulty taking in fluids 120 Which of the following is an activity a nurse should engage in to assist in disaster preparedness? 121 A nurse is caring for a client who has right-sided weakness after a recent cerebrovascular accident (stroke). The nurse should 122 Following a cerebrovascular accident (stroke), a client experiences right hemiparesis and expressive aphasia. Which of the following best promotes communication among health care team members? 6ZDOORZLQJSUHFDXWLRQVDUHSRVWHGDERYHWKHKHDGRIWKHFOLHQW¶VEHG Changes LQWKHFOLHQW¶VWUHDWPHQWSODQDUHQRWHGLQWKHPHGLFDOUHFRUG Interdisciplinary team meetings are held on a regular basis. 7KHFOLHQW¶VSURJUHVVLVUHFRUGHGLQWKHQXUVLng notes. 123 Which of the following clients should a nurse evacuate first when a fire occurs? 124 Which of the following nursing interventions should a nurse implement when using music therapy to assist a client in controlling his pain? Provide classical music selections because of their soothing, calming qualities. Set the volume level low so the client will need to concentrate on the music. Plan for sessions that last about 30 min to maximize the therapeutic value. Encourage the client to perform range-of-motion exercises while listening. 125 A client is diagnosed with a pulmonary embolism. Which of the following client findings is consistent with effective treatment? 126 A nurse is developing a plan of care for an older adult client with hearing loss. Which of the following interventions should be included in the plan? 127 A nurse is providing teaching to clients in an outpatient mental health setting. Which of the following client statements indicates understanding of the teaching? A client taking lithium states she will use aspirin when she experiences a headache. A client taking methylphenidate (Ritalin) states he will take his medication at bedtime for greater effectiveness. A client taking disulfiram (Antabuse) states he will only drink alcohol in moderation. A client taking sertraline (Zoloft) states she knows she will not feel the full benefits for 2 to 3 months. 128 A nurse is caring for a client who is undergoing external radiation treatment for cancer. Which of the following should be included in the client teaching? Wash the irradiated area with antiseptic soap daily. Use an ointment on the area to prevent drying. 129 A client is admitted with second-degree burns over 30% of her body. She is SUHVFULEHGP/KURIODFWDWHG5LQJHU¶VVROXWLRQ,9:KLFKRIWKHIollowing infusion rates will assure that the client will receive 1/2 of the total volume within the first 8 hr? 85 mL/hr 170 mL/hr 255 mL/hr 340 mL/hr 130 A charge nurse is attempting to resolve a conflict between two nurses who both insist that the charge nurse favors the other when making daily assignments. Which of the following is the most effective conflict-resolution strategy that the charge nurse can use? Prove that this is not true by showing them the assignment sheet. Collaborate with the two nurses when making assignments. 5HLQIRUFHWRWKHQXUVHVWKDWLWLVWKHFKDUJHQXUVH¶VUROHWRPDNH assignments. Arrange for the nurses to have as few shifts together as possible. 131 A nurse is caring for a client with pneumonia who has just been diagnosed with +,97KHQXUVHOHDUQVWKDWWKHFOLHQW¶VSDUWQHUVHOGRPYLVLWVVLQFHWKHGLDJQRVLV Which of the following strategies is appropriate for the nurse to implement? 132 $QXUVHLVFDULQJIRUDFOLHQWZLWK&URKQ¶V disease. Which of the following breakfast menu items is appropriate for this client? 133 A nurse is caring for an older adult client in a long-term care facility. Recent laboratory values show increased hemoglobin, hematocrit, and urine osmolarity. These findings suggest 134 A client is admitted to the emergency department following a motor vehicle crash. Which of the following findings is consistent with hypovolemic shock? Change in level of consciousness Decreased respiratory rate Increased urine output Hyperactive deep tendon reflexes 135 A labor nurse is caring for a woman in active labor who does not speak English. The client grimaces with each contraction but remains silent. The nurse should first 136 When performing triage during a community disaster, a nurse should understand that the highest priority clients in a disaster situation are those who have lifethreatening injuries and 137 A nurse is caring for a client with heart failure who is receiving D5NS at a rate of 125 mL/hr. The client reports shortness of breath. Which of the following actions should the nurse take first? 138 When reviewing the ABGs of a client who has uncompensated respiratory alkalosis, the nurse should expect to see which of the following results? 139 A nurse is performing a dressing change on a client with an open wound. Which of the following actions should the nurse take to dispose of the soiled dressing? Place the dressing in the trash in the bathroom and alert housekeeping. Take the dressing to the soiled utility room and place it in an impenetrable container. Put the dressing in a biohazard bag and tie the bag securely. $UUDQJHIRUDVHSDUDWHWUDVKFRQWDLQHULQWKHFOLHQW¶VURRPGHVLJQDWHGIRU soiled dressings. 140 A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse assess first? A client on telemetry with occasional premature ventricular contractions A client who had a morning blood glucose of 70 mg/dL and drank a glass of orange juice A client who was admitted for abdominal pain and has a nasogastric tube set to low suction A client receiving oxygen via a nonrebreather mask with an SaO2 of 88% 141 A charge nurse must instruct two staff nurses in the use of a new infusion pump. He knows from previous experience that these two nurses are kinesthetic learners. Which of the following teaching methods should the charge nurse use? Have the nurses watch a video provided by the pump's manufacturer. Ask the nurses to perform a return demonstration of pump setup and use. Have a nurse who is experienced with the pump give a verbal explanation. Ask the nurses to read the accompanying booklet provided by the pump's manufacturer. 142 A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment? 143 A nurse should recognize and document which of the following as an expected finding for a client with a central vascular access device? 144 A nurse is observing a new graduate, who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the graduate nurse indicates a need for the nurse to intervene? Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved Schedules a bag and tubing change for 24 hr after the start of the infusion 3ODQVIRUDFKHFNRIWKHFOLHQW¶VILQJHUVWLFNJOXFRVHOHYHOHYHU\KU 8VHVWKH731,9WXELQJWRDGPLQLVWHUWKHFOLHQW¶VQH[WGRVHRIDQWLELRWLFV 145 A nurse is teaching a client about surgical wound care at home. Which of the following statements by the client indicates an understanding of wound care? 146 Which of the following nursing actions is most likely to promote independent dressing in a client who has Stage 1 Alzheimer's disease? Give instructions to the client and then leave the room. Lay out the appropriate clothing for the client each day. Clearly explain to the client which articles of clothing are appropriate. Ask the client to choose what to wear. 147 Which of the following assessment findings indicates that a client is experiencing a complication from conscious sedation? 148 A client develops anxiety and tachypnea at the start of a blood transfusion. The nurse should take which of the following actions next? 149 $FOLHQWPHHWVZLWKWKHQXUVHIRUKHUILUVWSUHQDWDOYLVLW7KHFOLHQW¶VODVWPHQVWUXDO SHULRGEHJDQRQ$SULO8VLQJ1lJHOH¶VUXOHWKHQXUVHGHWHUPLQHVWKDWWKHFOLHQW¶V expected delivery date is January 5. January 12. January 19. January 26. 150 A nurse refuses to care for a client who frequently comes to the emergency department requesting pain medication. Which of the following actions should the charge nurse take? Insist the nurse take the assignment. Instruct the nurse to limit interactions with the client. 151 $KRPHKHDOWKQXUVHLVSHUIRUPLQJDQLQLWLDODVVHVVPHQWRIDFOLHQW¶VKRPH:KLFK of the following must be immediately removed by the nurse? 152 Which of the following client findings is an indication that a client with bipolar disorder is about to experience a relapse? 153 A client presents to the birthing unit reporting the onset of contractions. Which of the following client findings is consistent with false labor? 154 A nurse is caring for four clients who are using various assistive devices. Which of the following client findings suggests a need for further education regarding appropriate use of an assistive device? A client tells the nurse he uses tongs to pick up his newspaper and socks. A client replaces the rubber grips on two of the legs of his walker with old tennis balls. A client with mild weakness in her right leg is walking with her cane in her left hand. A client asks his wife to place his dentures under his pillow after cleaning them. 155 A nurse is caring for a client admitted to the emergency department following a motor vehicle crash. The Glasgow coma scale rating is 15. The nurse should recognize that the client 156 A client is brought to the emergency department with a full-thickness burn of the thorax. Which of the following is the most important nursing intervention? 157 A client has a repair of a retinal detachment. Which of the following interventions should the nurse anticipate implementing to prevent complications during the recovery period? Encourage the client to drink 3 L of fluid a day. 3RVLWLRQWKHFOLHQW¶VKHDGLQDGHSHQGHQWSRVLWLRQWRDLGGUDLQDJH Administer a stool softener to prevent straining during defecation. Offer prescribed pain medications around the clock. 158 A nurse is caring for an infant with gastroenteritis. Which of the following assessment findings should the nurse report to the primary care provider? 159 A client undergoing surgery is receiving succinylcholine and nitrous oxide. The FOLHQW¶VWHPSHUDWXUHDEUXSWO\ULVHVWRƒ&ƒ)DQGWKHFOLHQW¶VPXVFOHV become rigid. The nurse should initially take which of the following actions? Give an IV administration of the muscle relaxant dantrolene. Administer an antipyretic. Discontinue administration of the neuromuscular blocking agent. Infuse iced saline intravenously. 160 A client is diagnosed with HIV. Which of the following should the nurse plan to teach the client to help prevent the spread of HIV infection? 161 A nurse can help ensure that a client's privacy is protected during a pelvic examination by helping the client to undress and providing a drape for privacy. assisting the client into the lithotomy position, then closing the curtains around the examination table. providing a gown and drape, asking the client to undress from the waist down, and then leaving the room for a few minutes. leaving the client to undress and drape and asking her to open the door when she is ready. 162 A nurse is interviewing the husband of a woman who has been admitted in the manic phase of bipolar disorder. The husband states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is most therapeutic? "What do you think you're going to do about your situation?" ´ 163 Which of the following nursing interventions has the highest priority in promoting a therapeutic milieu for a group of clients? 164 A nurse removes an IV catheter from a client who developed phlebitis at a peripheral IV site. Which of the following is the most important piece of data that should be included in the documentation? Time of day Condition of the catheter How much fluid the client received Notification of the provider 165 A nurse is assessing a client's need for restraints. Which of the following is an acceptable reason for the use of physical restraints? 166 A nurse is caring for four clients who are receiving respiratory medications. The nurse should notify the primary care provider about which of the following client findings? A client taking oral albuterol (Proventil) reports shakiness with initial dose. A client taking inhaled budesonide (Pulmicort) develops hoarseness. A client receiving inhaled salmeterol (Serevent) reports a peak expiratory flow in the yellow zone. A client taking oral theophylline (Theolair) has a pulse oximetry reading of 94%. 167 A client who is a data programmer presents with reports of tingling and numbness of the index and middle fingers of the right hand. Which of the following should be included when teaching about activities to help prevent carpal tunnel syndrome? Maintain the computer monitor at a height that requires slight flexion of the neck. Sit with back erect, feet on floor, and shoulders slightly rounded. Set the chair at a height that allows the wrists to maintain a neutral position. Place elbows on the arm rests of the chair when using the keyboard. 168 A client is receiving internal radiation therapy for cervical cancer. Which of the following statements made by the client indicates understanding of the therapy? ³,IWKHUDGLDWLRQLPSODQWFRPHVRXW,ZLOOTXLFNO\UHLQVHUWLW´ 169 A nurse is caring for a client who is receiving IV potassium chloride for hypokalemia related to the use of potassium-wasting diuretics. The nurse evaluates hypokalemia treatment as successful if which of the following is noted? Urine output is increased. Blood glucose returns to normal. Pulse rate becomes regular. Blood pressure is decreased. 170 A nurse is caring for a client who has a medication order that is unfamiliar to the nurse. Which of the following actions should the nurse take first? 171 To ensure proper client identification when providing care, the best nursing action is to 172 A nurse is assessing a client for uterine atony. To assess for atony, the nurse should 173 A nurse reviews laboratory studies for a client with dyspnea. An elevation in which of the following values iQGLFDWHVWKDWWKHFOLHQW¶VG\VSQHDLVUHODWHGWRKHDUWIDLOXUH rather than myocardial infarction? 174 A community health nurse is discussing injury prevention with teachers in a day care. Which of the following developmental factors places toddlers at risk for injury? Oral fixation Lack of muscular coordination Underdeveloped depth perception Risk-taking behavior 175 Which of the following assessment findings should the nurse expect to find in a 2year-old child? 176 A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? 177 A client has received a transfusion of 250 mL of packed red blood cells. Which of the following findings indicates that the client is responding positively to the transfusion? 7KHFOLHQW¶VKHPRJORELQOHYHOLQFUHDVHVIROORZLQJWKHWUDQVIXVLRQ The client is afebrile during and following the transfusion. 7KHFOLHQW¶VOXQJVRXQGVUHPDLQFOHDUGXULQJDQGDIWHUWKHWUDQVIXVLRQ The FOLHQW¶VEORRGSUHVVXUHLQFUHDVHVWRPP+JIROORZLQJWKH transfusion. 178 The roommate of a university student who was recently hospitalized for bacterial meningitis asks if she is in danger of developing the infection. Which of the following is the appropriate response by the nurse? ³%DFWHULDOPHQLQJLWLVFDQEHSUHYHQWHGLIDQWLELRWLFVDUHWDNHQIROORZLQJ exposure to the infection." ³%DFWHUial meningitis is spread by contaminated food or water; therefore, infection is unlikely." ³%DFWHULDOPHQLQJLWLVUDUHO\RFFXUVLQ\RXQJDGXOWVXQOHVVWKHLPPXQH system is suppressed." ³%DFWHULDOPHQLQJLWLVFDQQRWEHWUDQVPLWWHGGLUHFWO\IURPRQHSHUVRQWR another." 179 A nurse is planning care for a client hospitalized with COPD who is experiencing persistent fatigue. Which of the following is an appropriate nursing action to address WKHFOLHQW¶VIDWLJXH" Arrange for rest periods between interventions. Administer a sedative at bedtime to promote adequate hours of sleep. Arrange for a long rest period every afternoon. Administer a bronchodilator at bedtime to prevent nocturnal dyspnea. [Show More]

Last updated: 2 years ago

Preview 1 out of 56 pages