ATI Predictor Questions & Answers Test,100% CORRECT

ATI Predictor Questions & Answers Test 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 newbor ...

ATI Predictor Questions & Answers Test 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? Tetany 62 A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding? Dry, raised facial rash 63 A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognized as the priority finding? Coughing frothy, pink secretions 64 A nurse in a provider’s office is caring or a client who has Parkinson’s disease and has been taking levodopa for the past 5 weeks. The client reports a new onset of muscle twitching. Which of the following statements by the nurse is appropriate? “This is a manifestation of drug toxicity and may require a dosage reduction.” 65 A nurse in the labor and delivery unit is receiving medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? Phenytoin for seizure disorder 66 A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? Educating the client how to cover nose and mouth with tissue when coughing 67 A nurse is planning care for a client who has neutropenia. Which of the following nursing interventions is appropriate to include in the care plan? Remove fresh flowers from the client’s room. 68 A nurse is planning to change the dressing on a school age child who has sustained multiple burns. Which of the following actions should the nurse plan to take? Apply the dressing in a proximal to distal pattern 69 An older adult client tells the nurse,” I thought immunizations were for kids.” The nurse informs the client that older adults should receive which of the following immunizations? Herpes zoster vaccine 70 a nurse is caring for a client who was involuntarily admitted to the psychiatric unit following a failed suicide attempt. The provider prescribes a medication that is part of an experimental treatment. Which of the following actions should the nurse take? Exclude the client from the study due to involuntary admission 71 A nurse analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? Elevated blood urea nitrogen 72 a community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first? Determine the client’s living situation 73 a nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? Jugular vein distention 74 A nurse is assessing a client who is preparing for surgery. The client tells the nurse, “If something happens to me from which I cannot recover don’t want to go on a ventilator.” Which of the following is an appropriate response by the nurse? “You’re concerned that something may go wrong?” 75 A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? “has you partner physically hurt you before?” 76 A nurse is caring for a client who reports pain. Which of the following laboratory findings indicates myocardial damage? Troponin I 1.8ng/mL 77 a nurse is caring for a client who is prescribed furosemide. The nurse understands this medication is used to treat which of the following client conditions? Rales in lower lobes of lungs 78 A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community of which of the following is to generate new ideas to address the public health concern? A brainstorming session with nurses 79 a nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter? A female client who is prone to development of blood clots in the urine 80 A nurse manager is presenting information to the nursing staff regarding the appropriate use of the client restraints. Which of the following should the nurse include? The nurse should pad the bony prominences/ The nurse should remove the restraints every 2hrs/ The provider’s prescription should include the type of restraints to use 81 A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to eh facility. Which of the following clients should the nurse recommend for discharge? A client who is 1-day postoperative laparoscopic cholecystectomy whose temperature is 37.7 C. 82 A nurse is admitting a client who has chronic gout. The nurse anticipates which of the following provider prescriptions? Allopurinol 83. A nurse is caring for a client who is 2 days postoperative following a lumber laminectomy and is reporting nausea. Which of the following actions should the nurse take first? Administer an antiemetic 84. A nurse in the recovery room is a client who has a new tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify these finding as resulting from which of the following? Tubing may be kinked 85. A nurse is planning for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the assistive personnel AP? Measure I&O for a client who is receiving peritoneal dialysis Transfer the client from bed to chair with mechanical lift provide postmortem care on a client who experienced cardiac arrest 86. An assistive personnel (AP) at a long-term care facility reports to the nurse that another AP has spent the entire morning on the phone and has not completed the morning assignment. Which of the following is an appropriate action by the nurse? Ask the AP what work remains to be completed on the assignment 87. A community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house. Which of the following is a priority intervention? Suggest smoking cessation strategies to family members 88. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included? Newborn swallowing sounds are audible while breastfeeding Newborns’ stools are yellow and seedy after 7 days of breastfeeding Maternal breasts become soft following feedings 89. A nurse is caring for a client who will be having a transfusion of platelets. The nurse recognizes that the outcome of will be which of the following? Decrease in bleeding from puncture sites 90. A nurse in a prenatal clinic is caring for an adolescent client is now in her third trimester of pregnancy. The nurse identifies that the client is at an increased risk for the which of the following? Postpartum depression 91. A nurse is planning dietary intervention for a client who is immobile due to pelvic and femur fractures. Which of the following should the nurse include in the plan? Provide a high-protein diet 92. A home health nurse is providing teaching about self-administration of insulin to a client who is newly diagnosed with DM. Which of the following statements by the client a need for further teaching? I will gently massage the injection site following administration 93. A school nurse is assessing a child who has scabies. Which of the following is an expected finding? Red, itchy papules on the child’s groin area 94. A nurse is caring for a client who is postoperative and at risk for development of DVT. Which of the following should the nurse identify as increasing the risk of developing venous stasis? Prolonged bed rest 95. A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding? Constipation 96. A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? Graft-versus-host disease 97. A nurse is providing education to the mother of a toddler who has pertussis. which of the following statements by the parent indicates the teaching has been effective? If I get pregnant, I should check with my provider about receiving a pertussis booster. 98. A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding 99. A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? pertussis 100. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? Pulse oximeter 101. A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? Observe the client’s level of mobility 102. 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 10-year-old client who has pneumonia and is receiving respiratory treatments 103. A nurse in a residential mental health facility is planning care for a new client who has OCD. Which of the following is appropriate for the nurse to include in the plan of care? Gradually decrease the time allowed for ritualistic behavior 104. A nurse delegates tasks to an LPN and AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? Measure the amount of gastric drainage every 2 hr. 105. A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching? cleanse the skin around the stoma with a moisturizing soap 106. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions by the nurse is appropriate? Monitor for abdominal ascites 107. A nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following information should be included in the teaching? Store non-washable items in plastic bags for 14 days 108. A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the following actions by the client indicates a need for further teaching? Places the walker 2 feet forward with each step 109. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel AP requires the nurse to intervene? Offers oral fluids to the client 110. A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder cancer. For which of the following finding should the nurse notify the provider? A dusky-colored stoma 111. A nurse is providing teaching for the parents of a school-age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, “We are unable to say anything to convince him that is impossible.” Which of the following is an appropriate suggestion? Encourage the child to be involved with the soccer team as the coach’s assistant or team manger 112. A nurse is taking care of a client who has a diagnosis of HIV. Which of the following client statement should the nurse address first? I am lonely because I don't have anyone to talk to you. 113. A nurse is caring for a client who has I left femur fracture is a skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following action is appropriate by the nurse? Increase the amount of traction 114. A nurse educator is discussing about modes of transmission with nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission? Transmission of West Nile Virus from a mosquito bite 115. A nurse is creating an activity plan for a home-bound older adult client. In the planning the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process. Which of the following age-related physiologic changes should the nurse consider in the plan? Decreased blood oxygenation 116. An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? A child who reports diplopia and nausea and was unconscious at the scene but is now awake 117. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? premedicate the client with the prescribed analgesic 118. A nurse is electronically documenting assessment findings for a client. Which of the following is an example of subjective data? The client reports a pain level of 6 on a scale from 0 to 10 119. A nurse notice smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? Close the fire doors on the unit 120. A nurse is caring for a client who has a diagnosis of antisocial personality disorder. The nurse should expect the client to demonstrate which of the following? Poor impulse control 121. 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 in in duration. Which of the following actions should the nurse take? Prepare the client for a cesarean section 122. A nurse is planning care for a child who is unresponsive and increased ICP. Which of the following actions should the nurse take? Pad the side rails of the bed 123. A nurse is planning care for a client who takes haloperidol the treatment of schizophrenia. Which of the following should the nurse include in the plan of care? Screen the client for tardive dyskinesia 124. A nurse is caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, “Am I dying?” Which of the following actions should the nurse take first? Obtain a pulse oximetry reading 125. A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? Tinnitus 126. A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurses to facilitate the client’s grief process? Acknowledging the reality of the newborn’s death 127. A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include in the teaching? Sleep with the head of bed elevated 128. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurse to offer as an evening snack? Low fat yogurt 129. A nurse is admitting an infant who has bacterial meningitis. Which of the following actions should the nurse take first? Administer cefazolin 130. A client asks the nurse if it is safe for him to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? Shellfish allergy 131. A nurse is analyzing the cardiac rhythms of four telemetry clients in the coronary care unit. Identify the rhythm strip that the nurse should recognize as indicative of a client who should be receiving warfarin. rhythm C 132. A nurse in a postpartum unit is caring for several clients. After receiving a change of shifassess first? A client who is 3 days postpartum and has not had a bowel movement since prior to admission 133. A nurse is teaching a family about hospice care. Which of the following appropriate for the nurse to include in the teaching? Hospice care encourages the family to coordinate health care services 134. An infection control nurse is reviewing care procedures for four clients. Which of the following requires the nurse to intervene? A client who has pulmonary TB is placed in a positive pressure room. 135. A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Urine output of 250ml/hr 136. A nurse is providing teaching for the client who has a new prescription for lithium carbonate. Which of the following should the nurse include the teaching? Diarrhea is an indication of toxicity. 137. A nurse is caring for a client who is receiving a blood transfusion at 125ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride IV 138. A nurse is caring for an adolescent client who has no previous history of a seizure disorder admitted after having a 3-minn tonic-clonic seizure 2 weeks after sustaining a mild concussion. The client is scheduled to have an electroencephalogram (EEG) in the morning. For breakfast, the client orders coffee and a donut. Which of the following nursing actions is appropriate at this time? Explain that the client may not have coffee prior the EEG 139. At the beginning of the shift, a team leader delegates the following tasks to the assistive personnel (AP) have four clients, distribute fresh water and obtain the morning vital signs. At noon, the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future? Set a clear time from for the completion of each task 140. A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care? Provide the client with an alternating pressure mattress 141. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? Raise the side rails on the bed 142. A nurse is performing postmortem care on an older adult client. Which of the following action is appropriate to take? Lower the head of the bed to a supine position 143. A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following actions should the nurse take first? Stabilize the cervical spine 144. A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of TB? Mantoux test 145. A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize? A client who has a Glasgow Coma Score of 4 146. A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings? Pinna below the outer canthus of the eye 147. A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? Restrict dietary calcium intake 148. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following suggestions should the nurse recommend? Eat a bedtime snack containing carbohydrates 149. An immunity health nurse is planning to make home visits to several clients who all live within a few miles’ radius of the office. Which of the following clients should the nurse plan to visit first? A legally blind client who has diabetes mellitus and whose insulin syringes need to be prefilled for the coming week. 150. A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? “Notify your provider if you experience muscle weakness.” 151. A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. difficle. Which of the following action by the nurse is appropriate? Place the client on contact precautions 152. A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo 153. A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set? The client will develop a personalized meal plan. 154. A nurse is caring for a preschool-age child who has a short leg, plaster cast applied 1 hr ago. Which of the following is an appropriate interventions? Support the affected leg on a pillow. 156. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? Consistent contractions last 80 seconds. 157. A home health nurse is reviewing treatment goals with a client who has DM. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? HbA1C 158. A nurse is preparing to obtain informed consent for a colonoscopy from a client who does not speak English. Which of the following actions should the nurse take? Ask the health care interpreter to explain the procedure 159. A nurse manger is presenting an inservice for newly licensed nurses about advance directives. Which of the following statements by a new nurse indicates a need for further teaching? “Advanced directives must be notarized to be legally implemented.” 160. A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? “It communicates y wishes for end-of-life care.” 161. A home health nurse is doing an in-home assessment for an older adult client who is at risk for falls. which of the following assessment findings should the nurse identify as a potential hazard for the client? Electrical cords secured to the baseboards 162. 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? Clear fluid drainage from the nares 163. A nurse documents that a client recovering from a closed head injury assumes a decerebrate posture in response to stimuli. Which of the following illustrations indicates this client’s positioning? Posture D 164. A nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse to the postpartum unit? A client who is 2 days postoperative following a colon resection 165. A nurse is caring for a client who has a newly implanted sealed internal radiation devices to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? Maintain the client on bed rest for 72 hr. 166. During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following? Decreases the level of anxiety 168. At the start of the evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Constipation 169. A nurse is discussing the Z-track administration of hydroxyzine hydrochloride with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? “This technique decreases the risk of subcutaneous infiltration.” 170. A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plain of care? Provide high-calorie nutritional supplements. 171. A nurse is evaluating the results of the above urinalysis done for a preschool age child. The nurse should identify that these findings are consistent with which of the following renal disorders? Large albumin Nephrotic syndrome 172. A nurse is preparing to administer vancomycin to a client who has as infected wound. The nurse should plan to for which of the following adverse reactions? Ototoxicity 173. A nurse is teaching a client who has a low-literacy level about home management of diabetic mellitus. Which of the following actions is appropriate? Show the client an educational video. 174. A nurse is assessing a client who is 2 hr postoperative following insertion of a chest tube connected to a chest drainage system as depicted in the program above. Which of the following is an expected finding? Fluctuation of the fluid level in chamber “b” 175. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer, the client has two minor children and a limited support system. Which of the following is the priority nursing action? Inform the client of available community resources. 176. A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include? Pain relieved by position change 177. A nurse in a mental health clinic is reviewing the history and physical for a 17-year old client who has a new diagnosis of social phobia. Which of the following is an expected finding? The client reports minimal alteration in performance at a part time job. 178. A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr. Which of the following assessment finding indicates to the nurse that the IV sire needs to be changed? The area around the IV sire is reddened. 179. A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering dose, which of the following laboratory values should the nurse evaluate? Thyroid hormones 180. A nurse is assessing a client who is postoperative3 following abdominal surgery. The client states, “I feel like my incision ripped open,” The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? Place the client in low-Fowler’s position. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? Hepatitis A