NURSING 493 HESI EXIT EXAM

NURSING 493 HESI EXIT EXAM baluga VERSION 2 - 2020 1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give acetaminophen to control the child’s fever B. Monitor the client’s cardiac status (Peds p120) c. Administer antibiotics via intermittent IV bolus for 24 hrs d. Provide stimulation with children of the same age in the playroom 2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? a. “Do you recognize the voices as belonging to anyone you know?” B. “I understand the voices are frightening you, but I do not hear any voices.” c. “That can’t be true. The only voices in this room are yours andmine.” d. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” Rationale: try to reorient the client back toreality. 3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an understanding of advance directives? (Select all that apply.) a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnessesit) b. “I have the right to refuse treatment.” (Leadership p38) c. “My doctor will need to approve my advance directives.” (just needsto write a prescription) d. “My health care proxy can make medical decisions for me.” (Leadership p38) e. “I can’t change my advance directives once submitted.” (yes you can) 4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrive. Which of the following statements by the nurse isappropriate? a. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give the sibling) b. “Teach your son to change the baby’s diapers.” (Allow older siblingsto help in providing care for the infant) c. “Tell yourson to kiss the baby.” (Maternity p126: Let the sibling be one of the first to see the infant) Don’t force interactions betch d. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s arrival) 5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should the nurse include in the teaching? a. Limit total daily sodium intake to 4 to 5 grams B. Obtain most calories from complex carbohydrates c. Consume a high-protein diet (Sufficient amount of protein, high potassium, low sodium) d. Avoid intake of soy products. Rationale: Excess of protein should be avoided because a very high protein diet may cause tubular damage to the kidneys asthe kidneys will have to filter more of the proteins. But moderate protein intake (about 1 gm/kg body weight) is mandatory to compensate for the protein loss inthe urine.6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse? a. “Did you think about removing yourself from the situation when you became angry?” b. “Why do you get angry when things don’t go your way?” c. “How do you think others feel when you express anger?” D. “What are you thinking about when you express anger?” (assessing the underlying issue of aggression) 7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a. Wear a dosimeter film badge while in the client’s room. (Med Surgp583) b. Ensure family members remain at least 3 feet from the client (should be at least6ft) c. Limit each of the client’s visitors to 1 hr per day. (should be 30minutes) d. Remove dirty linens from the room after double bagging. Keep in the room 8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? talaga a. Sit at or below the client’s eye level during feedings (Funds p215: Observe for aspiration and pocketing of food in the cheeks or other areas of the mouth) b. Talk with the client during her feeding c. Discourage the client from coughing during feedings (encourage pt to cough to prevent aspiration) d. Instruct the client to lift her chin when swallowing (tuckchin) 9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findingsindicates moderate dehydration? a. Bradypnea B. Oliguria (Funds p343) c. Diaphoresis d. Excessive tears 10. A nurse is providing teaching to a parent of a child who has varicella. Which ofthe following statements should the nurse include in the teaching? a. “Your child can return to school after a negative titerresult.” b. “Your child can return to school 24 hours after beginning antibiotics.” c. “Your child can return to school once the lesions have crusted over.” d. “Your child can return to school once the fever hassubsided.” 11. A nurse is providing information for a client who has a new prescription forsimvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Muscle weakness - rhabdomyolysis b. Edema c. Weight loss d. Fever Rationale: Simvastatin Although mild muscle pain is a relatively common side effect ofstatins,some people who take statin medicationsto lower their cholesterol may have severe muscle pain. Thisintense pain may be a symptom of rhabdomyolysis, a rare condition that causes muscle cells to break down. The most common signs and symptoms of rhabdomyolysis include: " Severe muscle aching throughout the entire body" Muscle weakness " Dark or cola-colored urine The higher the dose of statins, the higher the risk of rhabdomyolysis becomes. The risk also increases if certain drugs — including cyclosporine (Sandimmune) and gemfibrozil (Lopid) — are taken in combination with statins. However, the risk of developing rhabdomyolysis from statin therapy is very low, around 1.5 for each 100,000 people taking statins. Rhabdomyolysis or milder forms of muscle inflammation from statins can be diagnosed with a blood test measuring levels ofthe enzyme creatinine kinase. If you notice moderate orsevere muscle aches afterstarting to take a statin, contact your doctor. If you have signs and symptoms of rhabdomyolysis, stop taking your statin medication immediately and seek medical treatment right away. If necessary, your doctor may take steps to help prevent kidney damage and other complications. 12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is receiving warfarin and has an INR of3.3 b. A client who had an NG tube inserted 6 hrs ago and has abdominal distention c. A client who is 4 hrs postoperative following a thyroidectomy and reportsfullness in the back of the throat (edema can lead to respdistress) d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL 13. A nurse is receiving report on four postpartum clients. Which of the following clientsshould the nurse plan to attend to first? a. A client who reports changing her perineal pad every 2 hrs b. A client who reports abdominal pain during breastfeeding c. A client who has a urine output of 250 mL in 6hrs D. A client who has hyporeflexia while receiving magnesium sulfate 14. A nurse is providing nutritional teaching regarding appropriate food choicesto a client who has a new diagnosis of uric acid calculi. Which of the following should the nurse include in the teaching? a. Roast beef b. Chicken breast c. Low-fat yogurt (avoid purine foods: organ meats & shellfish & poultry) d. Tuna fish 15. A nurse in the emergency department is caring for a client who has a full-thickness burn of the thorax and upper torso. Aftersecuring the client’s airway, which of the following is the nurse’s priority intervention? a. Preventing infection b. Offering emotional support c. Providing pain management D. Initiating IV fluid resuscitation repeat 16. A nurse is caring for a client who will undergo a procedure. The client statesshe does not want the provider to discussthe results with her partner. Which of the following is an appropriate response for the nurse to make? a. “The provider will be tactful when talking to your partner.” B. “You have the right to decide who receivesinformation.” c. “Is there a reason you don’t want your partner to know about yourprocedure?” d. “Your partner can be a great source of support for you at thistime.”17. A nurse is providing teaching about dietary recommendationsto the parents of a school-age child who has acute kidney injury. Which of the following recommendations should the nurse include in the teaching? a. Provide low-calcium foods b. Provide high-phosphorus foods C. Provide low-potassium foods d. Provide high-sodium foods Rationale: P. 380 MS PHOSPHATE , POTASSIUM, SODIUM AND MAGNESIUM NEEDTO BE RESTRICTED 18. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Apply a warm compress to the operative site every 4 hr b. Offer small amounts of clear liquids 6 hrs followingsurgery c. Give cromolyn nebulized solution every 8 hr D. Administer analgesics on a scheduled basis for the first 24hrs 19. A nurse is assessing a client who is 8 hr postpartum and has been unable to void. Which of the following actions should the nurse take first? a. Pour warm water over the client’s perineum b. Offer the client a sitz-bath c. Insert a sterile catheter d. Administer an analgesic 20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin. Which of the following statements by the nurse is appropriate? a. “Limit foods that contain folic acid while taking thismedication.” b. “You should expect a change in the color of your stool while taking this medication.” c. “Increase your intake of vitamin D while taking this medication.” - phenytoin complication (bone pain and weakness) d. “Plan to take this medication with antacids.” 21. A nurse is assessing a client who sustained fracturesto both legsin a motor-vehicle crash. Which of the following findings indicates the client is experiencing a fat embolism? a. !"#"$%&'" )* #%" $%"+# '*,'-,)."* /01'$#&$" #"+# 2345 6 b. Decreased pedal pulses c. Pain unrelieved by opioid analgesics d. Crepitus at the knee joint 22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching? a. “You will have a Doppler transducer applied to your abdomen during the test.” b. “You should massage one of your nipples to stimulate contractions of your uterus.” c. “You will need blood work before and after the test.” d. “You should avoid eating or drinking for 4 hrs before thetest.” 23. A home health nurse is assessing a client who has amyotrophic lateralsclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? TALAGA a. Changes in appetiteb. Daily fluid intake c. Swallowing ability - aspirations precautions d. Prescribed medications 24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the following statements should the nurse include in the teaching? a. “Eat a diet rich in fresh fruits and vegetables.” B. “Wear disposable gloves under gardening gloves while working with house plants.” c. “Children may visit as long as they’ve recently received a live influenza vaccination.” d. “Check your temperature weekly.” BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID 25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? a. Maintain the client in supine position for the first 24hrs b. Secure the drain to the bedding c. Reset the vacuum by compressing the container d. Position the affected extremity below the level of theclient’s heart 26. A nurse is providing discharge instructionsto a client who is 1-day postoperative vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding for the dietary teaching? a. “It should take me 30 to 60 minutes to eat ameal” b. “I will be limited to pureed foods for the next 6 months.” (weeks) c. “I should eat three meals per day.” d. “Vomiting is common and I will have to learn to live withit.” SERVE TO RESTRICT AND DECREASE FOOD INTAKE HELPS TO PROMOTE WT. LOSS 27. A home health nurse is visiting a client whose partnerstatesthat she is overwhelmed by caring for him. When suggesting respite care, which of the following explanationsshould the nurse provide? a. “Respite care offers financial resources to help care for yourhusband.” b. “Respite care includes volunteers who will perform household tasks.” c. “Respite care provides clinicians to work with you in caring for your husband.” D. “Respite care allows for time away from caring for your husband.” 28. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take duringcollection? a. Obtain the urinalysis specimen before the culture specimen. b. Collect 2 mL or urine for each specimen. c. Drain the specimen from the drainage bag. D. Clamp the catheter distal to the injection port. 29. A nurse is caring for four clients. Which of the following clients should the nurse care for first? a. A client who has hypothyroidism and isstuporous b. A client who has a burn requiring a sterile dressingchange c. A client who received a chemotherapy treatment and reports nausea d. A client who had an appendectomy 2 days ago and has diminished bowel sounds Rationale: MyxedemaComa. Myxedema coma is a rare, life-threatening complication of untreated hypothyroidism. Symptoms include a severe drop in body temperature (hypothermia), delirium, reduced lung function, slow heartrate, constipation, urine retention, seizures, stupor, fluid build-up, and finally coma. It is uncommon, but may develop in untreated patients subjected to severe stress, such as infection, surgery, or extreme cold. 30. A nurse is caring for a client who states he recently purchased lavender oil to use when he getsthe flu. The nurse should recognize which of the following findings as a potential contraindication to using lavender? a. The client has a history of alcohol use disorder b. The client has a history of asthma- Lavender is known to decrease inflammation - IT HELPS ON ASTHMA c. The client takes Vitamin C daily D. The client takes furosemide twice daily- Lavender reduced blood pressure, furosemide does the same 31. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of theteaching? a. “I won’t cross my legs when I sit in a chair.” b. “I don’t need to use a walker when walking around my house.” c. “I will stay in bed for 3 days after returning home before starting leg exercises.” d. “I will bend over at my hips to tie my shoes.” bend at yourknees 32. A nurse is assessing a client who is experiencing a pulmonary embolism. Which ofthe following manifestations should the nurse expect? a. Hypertension B. Dyspnea c. Bradycardia d. Frothy sputum 33. A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse determines that cranial nerve XI is intact when the client performs which of the following actions? a. Shrugs his shoulders CN 11 = Accessory or spinal b. Frowns symmetrically c. Sticks his tongueout d. Identifies a sourtaste 34. A nurse is preparing to administer lactated Ringer’s 500 mL IV to infuse over 4 hrs. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole noumber. Use a leading zero if applicable. Do not use a trailing zero.) 31 gtt/min 4x60= 240mins 500/240 = 2.08 x 15 gtt = 31.25 or 31 35. A nurse is teaching an adolescent who has type 1 diabetes mellitus. Which of the following goalsshould the nurse include in the teaching? a. HbA1c level greater than 8% B. HbA1c level less than 7% c. Blood glucose level less than 60 mg/dL before breakfast d. Blood glucose level greater than 200 mg/dL at bedtime 36. A nurse is caring for a client who develops a lower left leg deep-vein thrombosis following surgery. Which of the following actions should the nurse take? a. Apply warm, moist compresses to the affected extremityb. Check for the presence of a Homan’ssign c. Form a 5 cm (2 in) cuff at the top of the antiembolism stocking d. Massage the left lower extremity 37. A nurse working in an acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. Euphoric mood (bipolar) b. All-or-nothing thinking c. Hypochondriasis D. Disorganized speech 38. A nurse is developing a nutritional care plan for a client who has COPD with severe dyspnea. To promote intake, which of the following instructions is appropriate to include in the plan of care? TALAGA a. Administer a bronchodilator after meals b. Ambulate the client before each meal c. Offer the client three large meals each day D. Limit fluid intake with meals 39. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?TALAGA a. WBC 9,800/mm3 b. Creatinine 0.9 mg/dL c. Fasting blood glucose 108 mg/dL D. Potassium level 5.2 mEq/L 40. A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? TALAGA a. Social worker b. Respiratory therapist c. Speech-language pathologist d. Occupational therapist 41. A nurse in an oncology clinic receives a call from the partner of a client who has pancreatic cancer. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make? a. Community outreach center = is a safe and productive place for youth to interact with peers and participate in activities to promote positive youth development. b. Respite care c. Skilled nursing facility d. Restorative care Rationale: Taking care of an older or ill family member can be enormously rewarding — but it can be physically and emotionally draining as well. That’s why it’s important for caregivers to seek occasional respite from their responsibilities. Whether it’s for a few hours a week to run errands or a few weeks a year to take a much-needed vacation, respite care offers you the chance reduce stress, restore energy and keep your life in balance. 42. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Click on the “Exhibit” button below for additional client information. There are three tabs that contain separate categories ofdata.)a. Massage the affected extremity every 4 hr (don’t massage = candislodge emboli) b. Administer acetaminophen c. Withhold heparin IV infusion - not enough info, anticipate giving Heparin, but check labs and hx beforehand otherwise the patient might be harmed/killed d. Position the client with the affected extremity lower than the heart (elevate affected leg) 43. A nurse preceptor is working with a newly licensed nurse to care for a client who has vancomycin-resistant enterococci (VRE). Which of the following actions by the newly licensed nurse requires the nurse preceptor to intervene? a. Taking a blood pressure machine out of the client’s room to use on another client b. Cleaning her hands with alcohol-based antiseptic after delivering a meal to the client c. Instructing the client to dispose ofsoiled facial tissuesin the wastebasket in his room d. Wiping a client’s over bed table with hydrogen peroxide following a dressing change 44. A nurse in a health clinic is developing written material to teach adult clients how to manage their blood pressure. Which of the following strategies should the nurse use in creating the material? a. Create material using a 12-point fontsize b. Type information in capital letters c. Use words with one or two syllables D. Write information at a seventh-grade reading level 45. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heartrate b. Place the client in a side-lying position prior to assessing the fetalheart rate c. Perform Leopold maneuvers prior to auscultating the fetal heart rate (only 3 months = not fully developed) d. Measure the fundal height to determine the placement of the ultrasound stethoscope 46. A nurse in a mental health facility received change-of-shift report on four clients. Which of the following clients should the nurse plan to assess first? a. A client placed in restraints due to aggressive behavior b. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety c. A newly admitted client who has a history of 4.5 (10 lb) weight loss in the past 2 monthsd. A client who will be receiving his first ECT treatment today 47. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should recognize that atrial fibrillation places the client at risk for which of the following? a. Pulmonaryemboli b. Cardiactamponade c. Hemothorax d. Widened pulse pressure 48. A nurse is teaching a client who istrying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Iron b. Calcium c. Folate d. Zinc 49. A nurse is caring for a client who is not ambulatory. Which of the following interventionsis appropriate to prevent contracture? a. Place a towel roll under the client’s neck B. Align a trochanter wedge between the client’s legs c. Apply an orthotic to the client’s foot d. Position a pillow under the client’s knees 50. A nurse is caring for a client who has a thoracic spine injury. Which of the following actions is appropriate for the nurse to take when turning the client? a. Apply an immobilizing collar on the client prior to movement (keep neutralspine/position) b. Instruct the client to keep his arms at his side when altering positions c. Place a pillow under the client’s knees when changing positions d. Use a sheet when repositioning the client onto his side 51. A nurse isteaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate? a. “Tighten your muscles before relaxing them when using muscle relaxation techniques.”- only one that makes sense. b. “Imagine a situation that has been stimulating for you when practicing guided imagery.” (Funds p229: Imagery--focusing on a pleasant thought to divert focus)- is stimulating relaxing..? c. “Talk to someone who you admire as the first step in using mindfulness techniques to relax.” d. “Breathe in through your mouth and out through your nose when using deep breathing exercises.” 52. A nurse is caring for a client who isincontinent and has a stage II pressure ulcer on her coccyx. Which of the following interventions should the nurse implement? a. Reposition the client every 3 hrs(q2hr) b. Use two facility personnel to slide the client up in bed c. Position the client laterally at 30 degrees- don’t wantpiss on open wound d. Apply lotion to the skin every 4 hr (keep dry) 53. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who has preeclampsia and reports a persistent headache - seizureriskb. A client who has pregestational diabetes mellitus and anHbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who is at 36 weeks of gestation with a biophysical profile score of 8 R: ati Maternal newborn p60 Eclampsia is severe preeclampsia manifestations with the onset of seizure activity or coma. Eclampsia is usually preceded by headache,severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning signs of probable convulsions. 54. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (Select all that apply) d. Aspirate the blood sample with large bore needle e. Apply a tourniquet above the catheter insertion site 55. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate? a. “I don’t understand why I am getting this antibiotic.” b. “My arm burns each time that medication isrunning.” c. “My throat feels tight.” anaphylactic shock d. “This medication bag is still full.” 56. A nurse is caring for a client who has schizoaffective disorder and tells the nurse, “I’m the prince of peace and my enemies are coming to take me to another world.” Which of the following responses should the nurse make? a. “Why do you think people will come foryou?” b. “Let’s take a walk around the unit together.” c. “The staff and I will protect you from them.” D. “You are not the prince of peace. Your name is John.”- Reorient John to reality 57. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Perform range-of-motion exercises to the client’s extremities b. Place the client’s right hand in a supination position c. Maintain an NPO status for the client d. Change the client’s position every 2 hr 58. A charge nurse is providing information to a group of nurses on the unit about risk factor for hypoglycemia in newborns. Which of the following risk factors should the charge nurse include in the information? (Select all that apply) a. Anemia b. Infection c. Maternal diabetes D. Prematurity e. Polycythemia 59. A nurse is providing an in-service about client evacuation during a fire. Which of the following clientsshould the nurse instruct the staff to evacuate first? c. Cleanse the port with alcohol b. Flush the catheter with 0.9% sodium chloride after obtaining the blood sample a. Assess catheterpatencya. A client who has a fracture and is in balance suspensiontraction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearingaid D. A client who is ambulatory and receiving oxygen 60. A nurse is providing discharge instructionsfor a client who has a new prescription for clopidogrel following a cardiac catheterization. Which of the following instructions should the nurse include? a. “Your stools will become black and tarry” b. “Take NSAIDs for pain every 6 hours” c. “Plan to discontinue the medication 7 days before any surgery.”- bloodthinner d. “Take medication twice daily with acetaminophen.” R: ati AMS p184: Instruct the client to alter or discontinue regular medications as prescribed by the provider. Medications frequently discontinued for CABG. Diuretics 2 to 3 days before surgery. Aspirin and other anticoagulants 1 week before surgery 61. A nurse is an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of theteaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram.” b. “I will avoid foods containing tyramine while taking fluoxetine.” c. “I will take my lithium on an empty stomach.” D. “I will take the sustained-release methylphenidate every morning.” PHARM 136 62. A nurse is planning care for a client who has stage II Parkinson’s disease. Which of the following actionsshould the nurse include in the plan of care? a. Offer clear liquids with an between meals B. Offer high-calorie nutrition supplements c. Encourage the client to concentrate on looking at his feet whilewalking d. Encourage the client to participate in small muscle dexterity activities 63. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication to the use of metformin? a. Renal insufficiency b. Gluten intolerance c. Seizure disorder d. Polycystic ovary syndrome 64. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Obtain a 12 F catheter b. Apply EMLA cream prior to the procedure c. Discard the first 10 mL of urine D. Don sterile gloves prior to the procedure 65. A charge nurse isteaching a newly licensed nurse about clients designating a healthcare proxy in situationsthat require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include? a. “The proxy should make healthcare decisions for the client regardless of the client’s ability to do so.” B. “The proxy can make treatment decisions if the client is under anesthesia.” LEADERSHIP 37c. “The proxy can make financial decisions if the needarises.” d. “The proxy should manage legal issues for the client.” 66. A nurse is providing teaching to a client who is receiving misoprostol for induction of labor. Which of the following statements should the nurse include in the teaching? a. “You will have oxytocin initiated within 3 hours of administration of the medication.” B. “You will have intermittent fetal monitoring while you receive the medication.” c. “You will lie on your side for 30 minutes after the medication is inserted.” d. “You will have a urinary catheter inserted prior to the placement of themedication.” 67. A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings should the nurse report to the provider? a. Bleeding gums (low platelets r/t HELLP syndrome) Normal hormonechanges b. White vaginal discharge c. Fundal height of 26 cma D. Periorbital edema (gestational hypertension ..not as severe as HELLP syndrome) 68. A nurse is caring for a client who haslung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply) d. !"#$% '(% $")%*' )* # +%,)-./)0#'% /11,2./)0#'% e. 3*+'/4$' 0)+)'1/+ 5(1 #/% ./%6*#*' '1 /%,#)* 7 8%%' 8/1,'(% $")%*'29 8%%' 69. A nurse is planning care for a child who hasincreased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? a. Perform neurological checks every 4 hr b. Performactive range-of-motion exercises c. Maintain the head at a midline position d. Suction the airway frequently 70. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which ofthe following should the charge nurse identify as the purpose of telemetrymonitoring? a. To measure cardiac perfusion b. To identify valve insufficiency c. To measure cardiac output D. To identify dysrhythmias 71. At her first prenatal visit a client asksthe nurse when she will most likely deliver. If her last menstrual period began on March 31, when is the estimated date of delivery (EDD)? a. December 24 B. January 7 - 3 month + 7 days c. December 31 d. January 3 72. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategiesshould the charge nurse use to promote effective negotiation? a. Focus on how the conflict occurred c. Wear a lead apron when providing care b. Limit visitors to 30 minutes per day a. Close the door to the client’s roomB. Attempt to understand both sides of the issue c. Identify solutions prior to negotiation d. Personalize the conflict 73. A public health nurse is managing four projectsfor the community. Which of the following activitiesshould the nurse identify as a primary prevention strategy? a. Providing crisis intervention through a mobile counseling unit b. Conducting mental health screenings at the local community center c. Teaching parenting skills to expectant mothers and their partners d. Referring individuals who have mental health disorders to day treatmentprograms 74. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? a. Return unopened equipment to the supply center b. Stock the room with a 2-day supply of disposable diapers c. Bring in formula as needed D. Leave the unused infusion pump in the room until discharge (return it asap if not used) 75. A nurse in a provider’s office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? TALAGA a. Herpes zoster b. Hypertension c. Obesity d. Hypothyroidism 76. A nurse manager observestwo staff nurses reviewing the computer records of a client who is not under their care. Which of the following actions should the nurse manager take first? TALAGA a. Instruct the nurses to close the client’s computer record b. Request the nurses present an in-service on client confidentiality c. Place documentation of the nurses’ actionsin the personnel file d. Advise the nurses to read the facility’s confidentiality policy 77. A nurse isteaching a client who isto start a new prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? TALAGA a. Monitor for hyperglycemia b. Take with a protein snack c. Change positions slowly - orthostatic hypotension d. Report dark-colored urine 78. A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? a. Wipe the stethoscope with alcohol after leaving the client’sroom b. Place the client in a room with negative airflow C. Wear a gown while providing personal hygiene d. Apply a mask when providing care79. A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The client asksthe nurse about using saw palmetto to relieve the symptoms of BPH. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto? a. Metoprolol B. Clopidogrel - saw palmetto interacts with antiplatelet/anticoagulant medications c. Ipratropium d. Zolpidem 80. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care? a. Weight loss of 5% in 10 days ! Risk for development of pressure ulcer: Recent weight loss- lost 5% of total body weight or 4.5 kg (10lb) practice assessment B. Appearance of pink tissue under eschar c. Hgb 15 g/dL d. Albumin level 4.0 g/dL 81. A nurse is providing preoperative teaching to an older adult female client who is scheduled for a laminectomy and uses supplements. Which of the following supplements should the nurse identify asincreasing the client’s risk for hypotension during surgery? a. Soy B. Black cohosh (increases effects of antihypertensive pharm p.236) c. Probiotics d. Flaxseed 82. A nurse is planning care for a client who isscheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? TALAGA a. Measure the arm circumference above the insertion site daily (assess for edema) b. Schedule an MRI post-procedure to verify placement (x-ray) c. Administer sedation for the procedure d. Use gauze to secure an arm board to the involved extremity 83. A nurse is assessing a client who has fine hair, exophthalmos, and reportsintolerance to heat. Which of the following endocrine disorders is associated with thesefindings? a. Hyperthyroidism b. Hyperparathyroidism c. Hypoparathyroidism d. Hypothyroidism 84. A nurse is providing discharge teaching for a client who has a prescription for captopril. Which of the following adverse effects should the nurse instruct the client to report to the provider? P .151 pharm a. Alopecia b. Headache c. Sore throat- complications of prils=COUGH,NEUTROPENIA,ANGIOEDEMA,HYPERKALEMIA ORTHOSTATIC HYPOTENSION d. Hypoglycemia 85. A nurse is receiving report on four clients. Which of the following clients should the nurse assess first?a. A client who has chronic kidney disease with cloudy dialysate outflow-infection b. A client who has an ileal conduit and mucus in the pouch (non-stop urine and mucus--expected) c. A client who had a transurethral resection of the prostate with red-tinged urine in the bag (expected post op) d. A client who has an arteriovenous fistula that vibrates when palpated (feel the thrill = good circulation) 86. A nurse is caring for a group of clients. Which of the following clients should the nurse assess first? a. A client who has heart failure and reports shortness of breath while ambulating-expected b. A client who had an open cholecystectomy and has green drainage from the T-tube c. A client who has benign prostatic hyperplasia and is unable to urinate-expected D. A client who has abdominal pain and is vomiting coffee-ground emesis R: GI bleeding 87. A nurse is caring for a client who has Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding perniciousanemia? a. Schillingtest b. D-dimertest c. Oral glucose tolerance test d. Thyroid scan R: p 254 ati ams; Schilling test: Measures vitamin B12 absorption with and without intrinsic factor. It is used to differentiate between malabsorption and pernicious anemia. 88. A nurse is reviewing the medical record of a client who has tuberculosis and a new prescription for rifampin. The nurse should notify the provider for which of the followingfindings? a. Irregular heart rate b. Elevated blood glucose level c. History of alcohol use disorder d. Allergy to cephalosporins R: p137 ati ams; Rifampin is hepatotoxic. So is alcohol. 89. A nurse is caring for a client who requires nasotrachealsuctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the selected order of performance) 1) Turn on the suction and set the pressure 2) Don sterile gloves 3) Insert the catheter during the client’s inspiration 4) Apply suction while rotating the catheter 5) Rinse the catheter to remove secretions 90. A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take? a. Ensure the client has a full bladder just prior to the procedure b. Weigh the client before and after the procedure c. Administer a low-volume hypertonic enema the night before the procedure d. Place the client in a side-lying position for theprocedure 91. A nurse is caring for a child who has sickle cell anemia and is experiencing vaso-occlusive crisis. Which of the following actions should the nurse include in the place of care? TALAGA a. Give aspirin to reduce painb. Start a 24-hr urine collection c. Encourage ambulation d. Initiate IV fluid replacement 92. A nurse manageris planning an in-service program for newly licensed nurses. The nurse managershould instruct to perform medication reconciliation in which of the following situations? On admission & transition of care a. When a client has a new prescription for an enteral feeding b. When a client is referred to physical therapy c. When a client returns to the unit after surgery Before surgery.. d. When a client has completed hemodialysistreatment 93. A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (Select all that apply) a. Honoring family requests to withhold medical information B. Addressing client needs when providing resources c. Encouraging clients to seek further information from the provider D. Promoting health care access e. Making decisions about health care on clients’ behalf 94. A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? a. Decrease the maintenance infusion rate of IV fluid (Administer a bolus of IV fluids to help offset maternal hypotension as prescribed) b. Have protamine sulfate available at the bedside (for heparin overdose) c. Monitor the client for hypertension (monitor for hypotension) D. Reposition the client side-to-side each hour (Maternity p82: Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava) 95. A nurse is caring for a client who has a new prescription for clozapine. Which of the following should the nurse recognize as an adverse effect of thismedication? a. Hypoglycemia b. Diarrhea c. Agranulocytosis d. Urinary frequency 96. A nurse in the emergency department isinterviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first? a. Determine the client’s current anxiety level b. Report the client’s assault to the authorities c. Initiate a referral for client counseling d. Request the client’s permission to contact a family member 97. A charge nurse is teaching a newly licensed nurse regarding herpes simplex virus (HSV) during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “The laboratory will test the cord blood to determine if the newborn has contractedHSV.”b. “The client should avoid acyclovir during pregnancy due to risk to the fetus.” c. “The client should have a cesarean birth if any active lesions arepresent.” d. “The client should avoid breastfeeding until the lesions are healed.” 98. A nurse is providing instruction to a client who is to start therapy with (anti-diabetic). Which of the following statements by the client indicates an understanding of theteaching? a. “I should take this medication even if I miss a meal.” b. “I may experience insomnia while taking this medication.” c. “I may lose weight while taking this medication.” D. “I should take this medication with the first bite of each meal.” 99. A charge nurse is admitting four clientsto an acute care unit. Which of the following clientsshould the nurse place near the nurses’ station? a. A client who has an open wound B. A client who has orthostatic hypotension- risk for falls patient = put them in sight of the nurses for OTC monitoring c. A client who is on fluid restriction d. A client who is in Buck’straction 100. A nurse is preparing information about skin care for a client who has cancer of the prostate and is receiving radiation therapy. Which of the following should the nurse include in the information? a. Clean the perineal area using a washcloth b. Dry the perineal area by using a pattingmotion c. Wear snug-fitting underwear d. Apply heat packs to the affected area as needed 101. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Schedule daily activities b. Develop an hourly time frame fortasks c. Determine goals of the day d. Delegate tasks to the AP 102. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider? a. A client who is 4 hr postoperative and has a heart rate of 98/min b. A client who has a total of 110 mL ofserosanguineous fluid from a Jackson-Pratt drain within the first 24 hr following surgery c. A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm - immunosuppressed d. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing 103. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? a. Advance the catheter into the vein b. Flush the catheter with saline c. Retract the styletd. Release the tourniquet 104. A nurse is caring for a client who isin active labor. The nurse should notify the provider for which of the following findings ? a. Three uterine contractions within 10 min b. Baseline FHR 115/min c. Prolonged decelerations- ABSENT or LATE DECELS are always priority - this may lead to c section emergency d. Moderate variability in the FHR 105. A nurse is providing discharge instructions to the parents of a child who is postoperative following a tonsillectomy. Which of the following instructions should the nurse include in the teaching? a. “You should use a warm-moist vaporizer.” b. “Encourage your child to eat ice cream to promote comfort for histhroat.” c. “You should call your provider if your child has an increase in swallowing.” - bleeding d. “Encourage your child to blow his nose frequently to clearsecretions.” 106. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan totake? a. Recommend to the provider specific acute care clients fordischarge B. Determine the medical needs of incoming clients through the emergency department c. Act as a liaison between the facility and the media d. Call in additional medical-surgical unit nursing care staff 107. A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? a. Ensure the state health department has been notified - national notifiable disease b. Administer antitoxin c. Educate the family to avoid sharing personal belongings d. Assess for skin necrosis 108. A surgeon is obtaining informed consent from a client. When a nurse witnesses the clientsign the consent form, which of the following legal requirements is the nurse confirming? a. The client knows he may no longer refuse the procedure B. The client agreed to the procedure voluntarily c. The nurse explained the risks and benefits of the surgery d. The nurse explained the surgical procedure in detail 109. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findingsshould the nurse expect? a. Heightened perceptual field b. Rapid speech c. Purposeless activity d. Feelings of dread110. A nurse in the emergency department is caring for an adolescent who has acute appendicitis and reports pain at McBurney’s point. The nurse should identify which of the following areas as McBurney’s point? (You will find “Hot Spots” to select in the artwork below. Select only the hot spot that corresponds to your answer.) This was on ATI Practice Assessment A 111. A nurse working with the state health department is reviewing medical recordsforfour clients. Which of the following infectious diseases is a national notifiable disease? a. Hepatitis B b. Human papillomavirus c. Molluscum contagiosum d. Bacterial vaginosis 112. A nurse is verifying informed consent forsurgery from a client who does notspeak the same language as the nurse. Which of the following resources should the nurse use to facilitate communication? a. The client’s family member b. A language application on an electronic device c. A bilingual staff member D. A medical interpreter 113. A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take? a. Have the AP check the medical record for prior blood glucose testresults B. Determine if the AP has the skills to perform the test c. Help the AP perform the blood glucose test d. Assign the AP to ask the client if he has taken his antidiabetic medication today114. A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take? TALAGA a. Store the oxygen tank wrench in a locked cabinet b. Have the client store smaller tanks under his bed c. Ensure that the client is checking the gauge weekly D. Place the oxygen tank away from curtains or drapes 115. A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first? a. “Do the voices cause you to feel anxious?” b. “Can you tune out the voices by listening to music?” c. “What are the voices telling you to do?” d. “Are you also seeing unusual persons or things? 116. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in theteaching? a. “You should not have this procedure if you have a tattoo.” b. “The nurse will ask you to remove any transdermal patches prior to the procedure.” c. “You should not have this procedure if you are allergic to iodine.” - contrast media may be used d. “The nurse will ask you to wear protective eyewear during thisprocedure.” 117. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to anAP? a. Administering oral fluids to a client who has dysphagia b. Documenting the report of pain for a client who ispostoperative c. Applying a condom catheter for a client who has a spinal cordinjury d. Reviewing active range-of-motion exercises with a client who had astroke 118. A client who is having suicidal thoughtstellsthe nurse, “It just doesn't seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse isappropriate? a. “You can trust me and tell me what you are thinking.” b. “I need to know what you mean by misery.” c. “Why do you think your life is not worthit anymore?” D. “Do you have a plan to end your life?” - SAFETY 119. A nurse is providing teaching to a client who has a new prescription for omeprazole. Which of the following adverse effects should the nurse include as a possible risk of long-term therapy? a. Constipation b. Lung cancer c. Tinnitus D. Osteoporosis 120. A mental health nurse is caring for a client who recently attempted suicide. The client states, “I wish I was dead.” Which of the following is an appropriate response by the nurse? a. “Suicide is not the answer to yourproblems.”b. “Don’t worry. Everything will be just fine.” C. “You seem like you’re feeling hopeless.” d. “Did you take your medications today?” 121.A charge nurse is concerned about a recent increase in facility-acquired infections. Which of the following actions should the nurse take first? a. Schedule nursing staff training for infection control procedures b. Revise the current policy for catheter care c. Identify possible precipitating factors related to the infections d. Meet with providers to discuss measuresto decrease the infections Rationale: Assess first by Identifying. 122. A nurse receives change-of-shift report on four clients. Based on the shift information, which of the following clients should the nurse plan to assessfirst? a. A client who had a hip arthroplasty reports pain and erythema in his calf b. A client who had a barium enema 2 days ago and reports constipation c. A client who has anorexia and peripheral edema d. A client who had Addison’s disease with a blood glucose level of 75 mg/dL (low sugarlvl expected for addisons) Rationale: Clinical Manifestation of Post Thrombotic Syndrome, specially seen after surgery such as Arthroplasty. 123. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum creatinine c. Serum potassium D. Liver function test Rationale: Valproic Acid risk for Hepatotoxicity On Practice Q 124. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse performfirst? a. Replace the NG tube B. Evaluate functioning of the suction device c. Provide oral hygiene care d. Administer an antiemetic medication Rationale: Page 302 of MedSurg book. Assess and maintain function of NG tube 125. A nurse in a clinic is reviewing the health history of a client during her first prenatal visit. Which of the following findings indicates a risk for diabetesmellitus? a. Delivery of a low birth-weight infant b. Previous miscarriage C. BMI of 28 d. 1-hr oral glucose tolerance test of 132 mg/dL (140 mg/dL is considered DM per OB ATI Book) Rationale: Page 527 of MedSurg ATI Book. Risk factor of DM is Obesity. 126. A nurse is preparing to administer medicationsto a group of clients using a portable medication cart. Which of the following actions should the nurse take?a. Lock the medication cart prior to entering each client’s room b. Place controlled substancesin the client’s drawers of the medication cart before leaving the medication room (they can take it from the drawer) c. Prepare each client’s medications and place in client drawers prior to beginning medication administration d. Contact the pharmacy to restock the medication cart when the cart if empty Rationale: To prevent lost of medication patient might take it if they have access to it. 127. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a 90 second duration and the fetal heart rate is 170 to 180/min. Which of the following actions should the nurse take? a. Discontinue the oxytocin infusion > 90 seconds duration or > 5 contractions in 10 minutes = uteroplacental insufficiency b. Increase the oxytocin infusion c. Maintain the oxytocin infusion (within all normal parameters,shouldn’t we continue infusion?)(Contractions occurring every 45second, so in 10 minutes that would be 13 contractions.) d. Decrease the oxytocin infusion Rationale: Discontinue if uterine hyperstimulation occurs with contraction frequency more often than every 2 min, contraction duration longer than 90 seconds, contraction intensity results with pressures greater than 90 mm Hg as shown by IUPC, uterine resting tone greater than 20 mm Hg between contractionsshowing no relaxation of uterus between contractions. 128. A school nurse is performing scoliosisscreenings. The nurse should recognize which of the following clinical manifestations as an indication ofscoliosis? a. Limited range-of-motion of hips b. Exaggerated curvature ofsacrum c. Mild pain in the hip region D. Uneven shoulder and pelvic heights Rationale: Scoliosisis Lateral Curvature of the Spine which can be seen as uneven shoulder and pelvic heights. 129. A nurse is reviewing laboratory results for a client prior to administering zidovudine. Which of the following laboratory values should the nurse monitor? a. Serum potassium B. WBC count c. Blood glucose d. Serumalbumin Rationale: Page 384 of ATI PHARM. Zidovudine is a NRTI which causes suppress bone marrow. 130. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? a. Maintenance of NPO status until therapy is complete b. Removal of vaginal packing c. Ambulation four times daily (Activity is Restricted to prevent dislodgement) d . Insertion of an indwelling urinary catheter Rationale: The client who has cervical cancer will have a vaginal radiation implant. A catheter is needed to prevent displacement of the implant during ambulation.131. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? TALAGA a. Malpractice b. Battery- physical c. Assault- verbal d. Negligence 132. While performing a routine assessment, a nurse noticesfraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first? a. Ensure the device inspection sticker is current b. Report the defect to the equipment maintenance staff c. Remove the device from the room d. Initiate a requisition for a replacement CPM device 133. A nurse is planning to teach a client about ways to prevent recurrent urinary tract infections. Which of the following instructions should the nurse plan to include? a. Void after intercourse b. Drink orange juice c. Soak in a hot tub- no tub, bacteria can creep up theurethra d. Wear nylon underwear 134. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of thefollowing? a. Second-degree heart block b. Ventricular asystole c. Atrial fibrillation- confirm d. Sinus tachycardia 135. A nurse is caring for a client who hassevere hypertension and isto receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse take? a. Keep calcium gluconate at the bedside b. Monitor blood pressure every hour c. Cover the IV bag with opaque material- protect IV container and tubing from light p160 pharm d. Use an in-line filter 136. A nurse isteaching a parent of a child about pediculosis capitis. Which of the following should be included in the teaching? a. “Lice can be transmitted by pets.” b. “The eggslive off the host’s blood supply.” c. “Lice survive up to 48 hours on surfaces.” d. “Applying mayonnaise on your child’s head will remove the lice.”- avoid home remedies 137. A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? (direct thrombin inhibitor, for stroke clients who have atrial fibrillation, DVT) a. “I can crush the medication and mix with applesauce.”- must be takenwhole“Ishould keep the medication in the original container.” b. 6,.&*&+#"1 789.':"*&8 #) #%" $8&"*# /;<=<;>< ><?6@A=< <BB<C@> D EF;6G<!6H Petechiae- monitor forbleeding Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen- for back b. “I can store the medication in the refrigerator.” c. “I should replace any unused medication every 6 months.”- container should be used in 30 days R: Keep dabigatran in the original bottle or blister package- per 138. A charge nurse isselecting clients for discharge to prepare to receive victims from a local disaster. Which of the following clients should the nurse recommend for discharge? given b. A client who has a BUN 105 mg/dL following a CT scan with contrast- malfunctioning kidneys c. A client who reports vomiting and is under observation following a head injury- priority d. A client who has shortness of breath and a B-type natriuretic peptide 230pg/mL- ABC 139. A nurse is admitting an older adult client who istransferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? b. Contact the family regarding the client’s condition c. Inform the transferring agency of the client’s condition d. Notify risk management 140. A nurse in the emergency department is admitting a client who reports ingesting 30 diazepam tablets 20 minutes ago. The client has a respiratory rate of 10/min and is lethargic. After securing the client’s airway, which of the following actions should the nurse take next? a. Evaluate the client for potential suicidal ideation c. Assist the client with ingestion of activated charcoal d. Perform gastric lavage for the client 141. A nurse is providing teaching to a client who has a new prescription for methotrexate. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider? a. Muscle pain b. Pedal edema c. Insomnia R: p474 ati ams Methotrexate can cause bone marrow suppression (leukopenia, thrombocytopenia, anemia). 142. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? a. Using effleurage on a client’s lower abdomen pain c. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30 minutes d. Encouraging a client to use jet hydrotherapy on her lower back for 1 hr R: contraindicated if pregnant p627 ati ams Privately interview the client about her condition- possible abuse/neglect A client who has hemiplegia and is to undergo an annual colonoscopy b. d. a. a. - annual routine, no notable sx d.c. “I will take it 30 minutes before meals.”PROPERLY ABSORBED Inform the client of the risks involved ifshe leaves 143. A nurse is performing assessments on infantsin the newborn nursery. Which of the following findings should the nurse report to the provider? a. A 16-hr-old infant whose blood glucose is 45mg/dL b. A 2-day-old infant who has a small amount of blood-tinged vaginaldischarge c. A 16-hr-old infant who has yet to pass a meconiumstool d. A 2-day-old infant who has a respiratory rate of 70/min R: normal newborn resp is 30-50 144. A nurse is verifying a record of informed consent for a client who isscheduled forsurgery. Which of the following actions should the nurse take? a. Explain the procedure to the client before verifying informed consent-md b. Inform the client about the condition that requirestreatment-md d. Provide information on the informed consent form about the benefits of the surgery- md R: p37 ati leadership ...Having the client sign the informed consent document 145. A nurse is providing teaching for a child prescribed ferroussulfate. Which of the following instructions should the nurse include? a. Take at bedtime b. Take with a glass of orange juice- vitamin C always goes withiron c. Take with a glass of milk d. Take with meals 146. A nurs