ATI_ Predictor _Q_A _Test .doc .document 100% verified

2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source ...

2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source 3 an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60 5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first? Arrange a meeting with teenage mothers who are high school students in the community 6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first? Place an NPO sign on the door of a client scheduled surgery 7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate? Covering insertion site with a transparent dressing 8 A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? A client who has agonal respirations 9 A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? Series of four hepatitis vaccines is recommended to prevent viral hepatitis 10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity? The nurse explains the potential risks of treatment 11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the client’s wishes. The nurse committed which of the following? Battery 12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure? Bilateral lung crackles 13//// 14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients? A client who has difficulty swallowing 15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? A general anesthetic is administered prior to ECT treatments 16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome Tachypnea/irritability/tremors 17 A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? Hyperemesis 18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Which of the following actions is appropriate for nurse to take? Ask the charge nurse to assign an experienced nurse to act as a resource 19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time? Allow the sibling to wave at the client through the window or door 20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150 mL per hr. prior to starting the infusion, which of the following actions should the nurse take? Review the chest x-ray report 21 A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrealipase. Which of the following should the nurse include in the teaching? Take with meals 22 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose? Alanine aminotransferase (ALT) 23 A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)? A 24-year-old male who has a casted femur fracture 24 A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father’s do-not-resuscitate request. Which of the following is a therapeutic response by the nurse? “Tell me your feelings about your father’s prognosis” 25 A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex allergy. The nurse should discuss that a cross reaction may occur with which of the following foods? Bananas 26 A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is appropriate for the nurse to assignment client to? A room with a temperature of 20 degrees (68f) 27 A nurse has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? Monitoring the insertion site for infection 28 A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicate the treatment is effective? Flat anterior fontanel 29 A nurse is reviewing medical for four clients. Which of the following represents appropriate documentation? Carafate 1 g PO 1 hr ac 30 A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse, “does this mean that I must stop nursing my baby?” which of the following is an appropriate statement by the nurse? “No, you can continue to nurse from both your breasts.” 31 A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “why did you choose to talk to me out of this room full of kids?” which of the following responses by the nurse is therapeutic? “you’re curious why I am interested in you and not the other?” 32 A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room. Which of the following actions should the nurse take first? Accompany the client away from the common area 33 A client who is precepting a nursing student is brings the following client observation to the nurse’s attention. Which of the following client should the nurse assess first? A client who is 3 days postoperative colectomy with a large, loose melena stool 34 A nurse is planning teaching for a client who is at 10 weeks gestation and has a history of urinary tract infections (UTIs). Which of the following information should the nurse plan to include in the teaching about UTI prevention? Empty the bladder before and after intercourse 35 A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24 hr following injury, the nurse should instruct the client to do which of the following? Intermittently place ice on the ankle 36 After evaluating the morning laboratory results on several clients, the provider writes prescriptions for four clients assigned to the nurse’s care. Which of the following prescriptions is the nurse’s highest priority? Administer vitamin K 10 mg IM to a client on warfarin with and INR of 6 37 a nurse is caring for a client who has ruptured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds. Which of the following should the nurse take first? Turn off the heparin drip 38 A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Exaggerate lip movements 39 A nurse is reviewing morning values of several clients. Which of the following findings is the highest priority for the nurse to report to the provider? A client who is prescribed digoxin and furosemide and has a potassium level of 3.1 mEq/L 40 A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action? Check orthostatic blood pressure 1 hr after administration 41 A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis? Apply venous plexus foot pumps 42 A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? Taking a daily walk on the hospital grounds 43 A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? Hold the bottle of sterile solution with the palm over the label while pouring 44 A nurse is reviewing the history and physical on a client who has right ventricular heart failure. Which of the following is an associated finding? Elevated pulmonary artery pressure 45 A nurse is assessing a client who has schizophrenia. Which of the following findings indicates a risk for self-harm? Auditory hallucinations 46 A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? “I’ll use my cell phone on the ear opposite of my pacemaker.” 47 A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox Judaism. Which of the following meal suggestions by the newly licensed nurse indicates a need for further teaching? Carrot sticks and cottage cheese 48 A nurse is preparing to auscultate a client’s apical pulse at the point of maximal impulse (PMI). The nurse should place the diaphragm of the stethoscope at which of the following locations? Fifth intercostal space at the left midclavicular line 49 A charge nurse in the emergency department is reviewing the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibly of child abuse? A 9-month-old infant who is dressed inappropriately for the current weather conditions 50 A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? Remind the client to place the cane on the unaffected side 51 A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation? Calcium 52 A nurse in the postanesthesia care unit is caring for four postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients. A client who had a thyroidectomy 53 A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse initiate first? Demonstrate how to perform the procedure 54 A visiting nurse is writing a plan of care for a client who is homebound and has stage 2 Alzheimer’s disease. Which of the following should the nurse include in the plan of care? Educate family about loss of family recognition 55 A nurse suspects another nurse is chemically impaired during the shift. Which of the following is an appropriate action for the nurse to take? Report to the nurse manager 56 A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125 mL/hr. Which of the following actions should the nurse plan to take? Dilute the solution prior to infusion 57 A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? The infusion pump for administering continuous feeding is turned off. 58 A nurse is admitting an unidentified female infant who was brought to the emergency department. Based on the assessment findings, the nurse should estimate the infant’s age to be which of the following? 6 months 59 A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? Have the client tilt her head slightly so that the medication enters the nasolacrimal duct 60 A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? Improve joint functioning 61 A nurse is performing a nutritional assessment on a client who has a calcium deficiency. The nurse should identify that the client is at risk for which of the following