ATI RN Comprehensive 2021 verified exam

1. A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention?: elevate the leg 2. A nurse is teaching about child safety measures. What statement indicates understanding?: avoid sun exposure 10am-2pm 3. A home health nurse is teaching about infection prevention to a cancer pt on chemo. Which statement indicates understanding?: "I'll walk short dis- tances throughout the day" 4. A nurse is providing dietary teaching to the parents of a 6 month old. What instructions should the nurse give?: introduce new foods over 5-7 days 5. A charge nurse is planning care for a client in mechanical restraints. What interventions?: provide a staff member to stay with the client continuously 6. A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage?: perform a rapid needs assessment 7. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following requires manager intervention?: tells the hospi- tal chaplain a client's diagnosis 8. A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor. What action should the nurse take?: continue observing the fetal heart rate 9. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate staff acceptance, what should the nurse manager do first?: provide information about scheduling issues to staff 10. A nurse is planning teaching about allowable foods for a client with uric acid-based urinary calculi formation. What foods should the nurse recom- mend?: oranges 11. A charge nurse is teaching a newly licensed nurse how to identify true labor. What should the nurse include in the teaching?: the cervix transitions to an anterior position 12. A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client can sign the informed consent?: the client an accurately describe the procedure 13. A charge nurse assigns a new nurse to a client with a chest tube.The new nurse expresses concern d/t limited experience with monitoring drainage. What should the charge do to teach about chest tubes?: ask the nurse about their knowledge of the procedure 14. A nurse is teaching a client about a new prescription for estradiol. For which of the following adverse effects should the nurse tell the client to monitor and contact the provider?: headaches 15. A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is experiencing a grand mal seizure. Available is 5mg/mL. How many mls should the nurse administer?: 0.6mL 16. A nurse is caring for a 12 hour post op on a PCA for pain control and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information.: an Ap who is assisting a client to bed 17. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. What intervention should the nurse include in the plan?: withhold the varicella vaccine 18. A nurse is providing teaching about improving nutrition for a client who has MS. Which instructions should the nurse include?: -a speech pathologist -rest before eating -thicken beverages before eating 19. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which finding is the priority for the nurse to provide to the provider?: temp 102.9f 20. A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and a BP of 90/44mm Hg. What med should the nurse anticipate administering?: Flumazenil 21. A nurse is caring for an older adult client in the PACU following general anesthesia. What finding should the nurse report to the provider: audible stridor 22. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a male client. Which technique should the nurse use to maintain aseptic technique?: set the tray on the table at waist height 23. A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take?: clear objects from the client walking area 24. A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which instruction should the nurse include?: install a raised toilet seat at home 25. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?: low back pain 26. A nurse is caring for a child who is experiencing a tonic-clonic seizure. What action should the nurse take?: place the child in a side-lying position 27. A nurse is administering meds to a client who has a percutaneous gas- trostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent the tube from clogging?: flush the tube before meds 28. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?: decreased central vision 29. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following?: clangassociation 30. A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child returns to school. Which of the following responses should the nurse make?: when crusts have formed on every lesion 31. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which client statement indicates the client under- stands the teaching?: "I should report a change in the color of my stools" 32. A nurse is assessing a child with CF. Which finding is priority to report to the provider?: hemoptysis 275mL in 24 hours 33. When caring for a child a nurse plans to use nonpharm interventions to enhance pain med effectiveness. Which of the following strategies incorpo- rates visualization techniques to help decrease the child's discomfort?: blow- ing bubbles to "blow the hurt away" 34. An AP and a nurse are turning a patient on their R side. Which AP action requires the nurse to intervene?: place a pillow 35. A nurse on a mental health unit has a patient refusing IM lorazepam. What is the nursing action?: document the refusal 36. A nurse has 4 patients. What should the nurse delegate to the AP for meals?: alzheimers w/ aphasia