ATI Predictor Comprehensive Assessment 2019 A

ATI Predictor Comprehensive Assessment 2019 A A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding o ...

ATI Predictor Comprehensive Assessment 2019 A A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching? a. I will avoid crushing this medication A nurse is assessing a client who is receiving enteral feeding via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client’s findings? a. Switch to a lactose-free formula. A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include? a. Empty your ostomy pouch when it is half full A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home which of the following instructions should the nurse include? a. Apply cold compresses too painful areas A nurse is teaching about Safe Handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching? a. I should boil tap water for 2 minutes and call it before I mix it with powdered formula A nurse is assessing a child who is post-operative following a tonsillectomy. Which of the following findings should the nurse identify as the priority? a. Frequent swallowing A nurse is teaching a client who is pregnant about non-stress testing. Which of the following statements by the client indicates an understanding of the teaching? a. During this test, I will punch a button if the baby moves A nurse is monitoring a client who is receiving a transfusion of packed RBC's. The client reports chills, headaches, low back pain, and a feeling of tightness in his chest. The nurse should identify that the client has developed which of the following types of transfusion reactions? a. Acute hemolytic A nurse is caring for a client who is in the latent phase of Labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated two centimeters, 25% effaced and -2 station. Which of the following interventions should the nurse implement? 1. Request the provider prescribe a pudendal nerve block A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching? a. You should wear a snug fitting bra continuously for 72 hours A nurse is preparing to administer medication to a client. What are the following identifiers should the nurse use to identify the client? a. Room numberA nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a seated position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension? a. The clients systolic blood pressure decreases by 25 mmHg While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm of the ventilator sounds. Which of the following actions should the nurse take? a. Look for a leak in the tubes cuff A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first? a. Position the sterile drape leaving the perineum exposed A nurse is planning to administer packed RBC's to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take? a. Monitor Vital Signs every hour throughout the transfusion A new nurse in an acute mental health facility is teaching a client about potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might not feel light-headed but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles? a. Beneficence A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN? a. Irrigation of the external ear canal A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take? a. Observe the client for 1 hour after meals A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referral should the nurse anticipate for the client? a. Physical therapist A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using Progressive relaxation? a. Tighten the muscle group, then release tension and move to the next one A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contraction. The client's blood pressure is 88 over 50 mmhg and her abdomen is rigid. The nurse should identify these findings as indicating which of the following complications? a. Placenta abruption A home health nurse is planning care for an older adult client who has a vision loss and takes medication throughout the day. Which of the following actions should the nurse include in the plan? a. Use container Lids of different shapes to indicate times of AdministrationA nurse is planning care for a client who has a history of urinary tract infections UTIs and requires placement of an indwelling catheter. Which of the following actions should the nurse take to help minimize the client's risk of acquiring a UTI? a. Whoop the tubing so that is lower than the collection bag b. keep urine a bag at bladder level when ambulating c. secure the catheter to the client’s thigh d. obtain urinary samples by disconnecting the tubing connections A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching? a. I will wear a yellow wristband, so everyone knows I'm at risk for falling A nurse is caring for a client who is taking disulfiram for alcohol-use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor? a. Headache A nurse at the health department is providing anticipatory guidance to a parent of a one month or a year-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of two months? a. Rotavirus A Nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend? a. Scrambled eggs A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend? a. Tdap A nurse is caring for a client who is postoperative following a mitral balloon valvuloplasty. Which of the following areas should the nurse auscultate to assess for mitral areas of the heart? (you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications? a. Flumazenil Mitral Valve AreaA nurse is admitting a client to the medical-surgical unit. The patient self-determination act requires the nurse to perform which of the following actions during the admission process? Document in the client's medical record is a client has advance directives A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic Ileus? a. Abdominal distension A nurse is performing an administered admission assessment of a school-age child who has spina bifida. the parents state that a child is allergic to latex. The nurse should assess further for cross sensitivity to which of the following Foods? a. Bananas A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take? a. Ensure that the side rails are up on the client's bed A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take? a. Note whether the client has a living will A client on an acute mental health unit states to a nurse, tie a bow. Row the boat. Now I know. Whoa! I see you, you the nurse should document that the client is exhibiting which of the following speech alterations? a. Clang Association A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client BMI is 17.2. The nurse should document that the clients wait status is being within which of the following categories? a. Underweight A nurse is planning post-operative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside? a. Tracheostomy tray A nurse is providing discharge teaching to a client who has Gerd. Which of the following information should the nurse include? a. Avoid consuming foods containing chocolate A nurse is part of a task force planning to audit a facilities nursing unit concerning adherence to hand hygiene protocols. Which of the following steps should the task force take first? a. Determine the accepted standards for hand hygiene A nurse is planning educational materials for a client who has a new pacemaker. Which of the following information should a nurse include? a. Keep mobile phones 4 inches from the pacemaker generator A nurse is providing discharge teaching to a client who is 1-day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching? a. Avoid using the affected arm for eating A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care? a. Monitor the fetal heart rate throughout the procedureA nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay? a. Runs with a wide stance A nurse in an emergency department is administering naloxone to a client who had a heroin overdose. The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose? a. Increase respiratory rate A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, I'm afraid they will give me drugs that put me to sleep. Which of the following statements should the nurse make? a. Why do you think your provider will prescribe you medication’s that will make you sleep? A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure? a. I can expect my eyelids to be bruised after this procedure A nurse is planning care for a client who is undergoing brachytherapy for a low dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care? a. Limit each of the client’s visitors to two hours per day A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include? a. Apply the patch prior to traveling A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate? a. Droplet A nurse is planning assignments for an upcoming shift. Which of the following tasks should the nurse delegate to an assistive Personnel? (select all that apply.) a. Record a client's intake after each meal b. Transfer a client to physical therapy c. Obtain the client's Vital Signs every 4 hours A nurse is interpreting a cardiac Rhythm strip from a client who has recurrent episodes of syncope. Which of the following images indicates the client has atrial fibrillation? A community health nurse is planning an educational program on Lyme disease or the general public. Which of the following statements should the nurse include in the program? a. Remove embedded Ticks by squeezing the body with tweezersA nurse is admitting a client to the medical-surgical unit. The patient self-determination act requires the nurse inform which of the following actions during the admission process? a. Document in the client's medical records if the client has advance directives A nurse is teaching a client how to care for his behind the ear hearing aid. Which of the following statements by the client indicates an understanding of the teaching? a. I'll disconnect the battery when I remove my hearing aids a nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest? a. Give your son a little gift from his new sister A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider? a. Potassium 3.9 mEq / L A nurse is teaching a class about using niacin to reduce LDL cholesterol. The nurse should include in the teaching that which of the following conditions is a contraindication for receiving this medication? a. Active liver disease a school nurse is using the Weber test to check a child. Which of the following actions should the nurse take? a. Place a vibrating tuning fork on the top of the child's head A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of Labor. Which of the following findings is a contraindication for administration of this medication? a. Transverse fetal lie A nurse is reviewing the results of laboratory screenings for a nine-month-old infant. Which of the following results should the nurse report to the provider? a. Iron 74 mcg / dL. A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to Monitor and Report immediately as indicating serotonin syndrome? a. Excessive sweating A community health nurse is developing a plan of care for an older adult client who has Type 2 diabetes mellitus and lives independently in a Royal area. Which of the following interventions should the nurse include? a. Instruct the client about the use of Telehealth services A nurse in a provider's office is monitoring the laboratory results of a client who has type 1 diabetes mellitus. Which of the following results and the case of the client demonstrates acceptable glycemic control? a. Hba1c 6.8% A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including the preschoolers’ diet? a. A corn tortilla with black beansA nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (the steps into the box on the right, placing them in the order of the performance. Using all the steps.) a. 2 nd - Remove the old dressing b. 4 th - Cleanse the site with povidone-iodine c. 1 st - Mask self and the client d. 5 th - Apply precut gauze pads to the site e. 3 rd - Create a sterile field A case manager is performing a home visit for a client following a stroke. The client’s partner is providing care in the home. The client's partner states that she sometimes feels exhausted. For which of the following referral should the case manager recommend for the caregiver? a. Respite care A nurse is reviewing the laboratory results of a client who is receiving Total parenteral Nutrition. Which of the following results should the nurse identify as an identification for the client has developed a common complication of this nutritional therapy? a. Capillary glucose 198 mg / DL a nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. Patient can resume control of health care after a temporary loss of competency A nurse is assessing a client for an allergy spider administering the Influenza vaccine. The nurse should identify that an allergy to which of the following Foods is a contraindication to receiving this vaccine? a. Eggs A nurse is caring for a client who has deep vein thrombosis and a new prescription for an antiembolic stocking. Which of the following actions should the nurse take? a. Measure the legs with a tape measure to determine stocking size A nurse is inserting a short peripheral IV catheter for a client who is requires IV fluids. Which of the following actions should the nurse take? a. Select a site proximal to previous venipuncture sites A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. Which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse wears an N95 respirator when performing client care A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider? a. 4 + deep tendon reflexes A nurse is observing an assistive Personnel (AP) measure blood pressure from the right arms of the group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients? a. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take? a. Turn on the faucet in the client's sinkA charge nurse observes smoke coming from a trash receptacle and the units waiting room. Which of the following actions should the nurse take first? a. Evacuate clients from the area A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client receives 0.45% sodium chloride IV at 500 mL over hours for 3 hours. Then at 200 mL/ hour for 3 hours. And then dextrose 5% in water at 75 mL / hour for 2 hours. What is the total volume the nurse should document for the client’s IV fluid intake? (round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 1250_mL A nurse is teaching a client who is at 20 weeks of gestation about how to manage Harbor. Which of the following instructions should the nurse include? a. Eat a high-fiber snack at bedtime A nurse is assessing a client who is taking Digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing Digoxin toxicity? a. Blurred vision A charge nurse is observing an assistive Personnel perform delegated tasks. What of the following actions by the AP requires a charge nurse to intervene? a. Washing hands with alcohol-based hand rub after bathing a client who has c-diffa nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first? a. A child who has acute epiglottitis and is drooling 1. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report? a. Serum creatinine 1.6 mg/dL 2. A nurse is providing discharge instructions about a newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include? a. Use a car seat when traveling by airplane. 3. Math question 4. A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone”. Which of the following responses should the nurse make? a. “Can you give me an example of how others are making you feel this way?” 5. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene? a. Asks security to detain the client until the provider is notified 6. A nurse is a prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client she will undergo which of the following screening tests at 16 weeks of gestation? a. Maternal serum alpha-fetoprotein 7. A nurse is admitting a client who has schizophrenia and experiences occasional auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? a. “Do you understand that the voices are not real?”8. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client’s nutritional requirements? a. Maintain calorie intake at 1,500 per day 9. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Attempt to understand both sides of the issue 10. A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the following actions should the nurse plan to take? a. Measure the tubing from the nose to the distal port 11. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Monitor the FHR via Doppler every 30 min 12. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? a. Measure the client’s vital signs 13. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? a. Excessive sweating 14. A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider? a. Tidaling occurs when the client is breathing 15. A nurse is preparing to administer vancomycin IV to an adult. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? a. “I can startthe medication 30 min earlier.” 16. A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first? a. Determine a client’s current anxiety level 17. A nurse is caring for a client who gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the following medications? a. Calcium gluconate 18. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension 19. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the Aps. Put in order- 1st Review the skill level and qualifications of each AO - 3rd Monitor progress oftasks completion with each AP - 4th Evaluate the APs’ performance of each task - 2nd Communicate appropriate tasks to the APs with specific expectations 20. A nurse is preparing to perform sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? a. Balancing the bottle on the sterile basin while pouring the liquid 21. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. “We should establish our roles in the initial session.” 22. A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of the following factors places the client at risk for aspiration? a. A history of gastroesophageal reflux disease 23. A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is unable to void. Which of the following actions should the nurse take? a. Encourage the client to attempt to void while using a Sitz bath 24. A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications? a. Oxytocin 25. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. “This test should be performed after your baby is 24 hours old.” 26. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Documenting communication with a provider in the progress notes of the client’s medical record 27. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? a. A client who has a hip fracture and a new onset of tachypnea 28. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take? a. Secure the urinary catheter to the client’s thigh 29. A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively? a. Gather supplies prior to completing a dressing change 30. A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which of the following actions should the nurse plan to take? a. Have the client void prior to the procedure