ATI Comprehensive - Predictor review Questions and answers

ATI Comprehensive - Predictor review Questions and answers 1. A nurse is assessing a client who has left-sided heart failure. Which of the following symptoms should the nurse identify as the highest priority? Jugular distention Frothy pink sputum Hepatomegaly Weight gain 2. A nurse in the emergency department is assisting with the suturing of a laceration to the client’s face. Which of the following actions should the nurse take? Pour the sterile cleansing solution holding the bottle 10 cm (4 in.) above the sterile field Pull the top flap of the suture tray towards the body when opening. Place the bottle of local anesthetic 5 cm (2 in) inside the sterile field border. Drop the suture package on to the sterile field from a distance of 30 cm (12 in). 3. A nurse is assessing a client 1 hr following delivery and notes that her uterus is boggy and….to the umbilicus. Which of the following actions should the nurse take first? Massage the fundus. Assess lochia Take vital signs Give oxytocin (Pitocin) IV bolus. 4. (missing) 5. . A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse? Urinary output greater than fluid intake Report of dry mouth Glasgow Coma Scale score of 15 Bloody drainage on the nasal dressing measuring 3 cm 6. A nurse in an emergency department is caring for a client who has multiple wounds due to a crash. Which of the following interventions are appropriate? (Select all that apply). Apply direct pressure to bleeding wounds. Clean lacerations and abrasions with hydrogen peroxide. Administer 650 mg aspirin PO as needed for pain. Cover wounds with a sterile dressing Determine date of last tetanus toxoid vaccination. 7. A nurse is planning care for four clients. Which of the following clients is the highest priority? A client who has frequent incontinence A client who has dry, black eschar on the heel A client who has a reddened skin area with blanching around the coccyx A client who is wearing an arm cast and reports numb fingers 8. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the clients should the nurse identify as the priority? A client who has massive head trauma A client who has an open fracture of the lower extremity A client who has full-thickness burns to the face and trunk A client who has indication of hypovolemic shock 9. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care? Assist the client to a supine position. Recommend prophylactic acyclovir (Zovirax) for the client's family. Initiate droplet precautions for the client. Perform a Glasgow Coma Scale every 24 hr. 10. A nurse is caring for a client who is unconscious and has an advanced directive indicating no extraordinary measures. The client's son wants everything possible done for his father. Which of the following is an appropriate statement by the nurse? "I will notify the health care provider of your wishes." "Have you talked about this with your family?" _X_ "We have to honor your father's wishes." "Have you discussed this with your minister?" 11. A nurse is assessing a client brought to the hospital's psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. The nurse recognizes these signs and symptoms as being consistent with which of the following? Alzheimer's disease Depression Substance intoxication X Schizophrenia 12. A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile (C. difficile) of the following infection control precautions is appropriate? Place the client in a negative pressure room. _X Place the client in a private room Wear a face shield prior to entering the room. Use an alcohol-based hand rub following client care. 13. A nurse is caring for a client who sprained his left ankle 12 hr. ago. Which of the following orders given by the provider should the nurse clarify? Elevate the affected extremity using two pillows. Apply heat to the affected extremity for 45 min. on and then 45 min off. Assess the affected extremity for sensation, movements and pulse every 4 hr. Wrap the affected extremity with a compression dressing. 14. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? Remove the disposable gown after leaving the toddler's room. Place the toddler in a room with negative air pressure. Use a designated stethoscope when caring for the toddler. Wear an N95 respiratory mask while caring for the toddler. 15. A nurse is developing a discharge care plan for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to avoid sitting in one position for prolonged periods. avoid crossing the legs beyond the midline. splint the affected area. X_ perform weightbearing exercises. 16. A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess first? A client who had a barium enema 2 days ago and reports constipation A client who has anorexia and peripheral edema. A client who has Addison's disease with a blood glucose level of 75 mg/dL A client who had a hip arthroplasty reports and erythema in his calf. 17. A nurse working in a long-term care facility is caring for an older adult client who has dementia. The client is often agitated and frequently wanders the halls. which of the following interventions should the nurse include in the plan of care? Maintain nutritional requirements by offering finger foods Confront the client regarding unacceptable behavior. Stimulate the client by leaving the television on throughout the day. Give the client several choices when scheduling activities. 18. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the foods should be included when initiating feeding? ---- Toast - Oatmeal - Beef Broth - Apple juice 19. A Nurse is performing a skin assessment on a client with risk factors for Development of skin cancer. The nurse should understand that a suspicious lesion is ? -X--asymmetric, with variegated coloring ---brown, with a wart-like texture ---firm and rubbery ---scaly and red 20. A nurse is providing dietary teaching for a client who has hepatic encephalopathy. Which of the following food selections indicates the client understands the teaching ? ---Rice with black beans ---three-eggs omelet with low-sodium ham ---turkey sandwich and milkshake ---Cottage cheese and tuna on lettuce 21. A nurse is caring for a client who has just received the first dose of Lisinopril (Zestril) which is the appropriate nursing intervention ? ---Monitor the client's oxygen saturation. ---Place the client on continuous cardiac monitoring. ---Encourage foods high in potassium. -x--Provide standby assist when the client gets up from bed 22. A Charge nurse is providing teaching to a newly licensed nurse on how to clean up surface contaminated with blood .Which of the following agents should the nurse include in the teaching ? ---Isopropyl alcohol ---Chlorine bleach ---Hydrogen peroxide ---Chlorhexidine 23 (missing) 24. A nurse is receiving report on four clients. Which of the following clients should the nurse assess first? --- A client who has an ileal conduit and mucus in the pouch ---A client who had a transurethral resection of the prostate (TURP) with red-tinged urine in the Bag ---A client who has an arteriovenous fistula that vibrates when palpated ---A client who has chronic kidney disease with cloudy dialyze outflow 25. A nurse in an emergency department is performing a neurologic assessment on a client who has a close head injury. Which of the following cranial nerves should the nurse assess to determine if the client has impaired peripheral vision? ---Seventh cranial nerve ---Eighth cranial nerve ---Tenth cranial nerve ---Second cranial nerve 26. A nurse is obtaining informed consent from a client who is to begin chemotherapy. The client asks if she will be able to have children after completion of the treatment .Which of the following is an appropriate response by the nurse? ---I will have the oncologist return to answer your questions. ---You should focus on your treatment at this time. ---I will give you written information about the risks of chemotherapy ---Chemotherapy has risk of causing infertility 28. A nurse is caring in a mental health facility. The client's daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? ---I'm sure your father doesn't blame you ---Why are you feeling this way -x--I'd like to know more about what's bothering you ---You did the right thing by bringing him here 29. A nurse is planning to provide teaching to a young adult client who has insomnia, Which of the following should the nurse include in the teaching ? ---Keep bedroom cool at night ---Consume a high-carbohydrate snack at bedtime ---Take s short nap during the day ---Exercise an hour before bedtime 30 (missing) 31. A nurse is discussing the social character of play with the parents of a 5 year old. Which of the following should be included when discussing associative play ? ---Playing a board game with other children ---Playing dolls with another child ---Watches others children perform a puppet show ---plays alone while stacking blocks 32. A nurse is caring for a school age child following a cardiac catheterization . which of the following is the priority nursing action? ---Reinforce the dressing at the insertion site ---Check the child's pulse distal to the insertion site ---Assist the child to void ---Offer clear liquid to the child 33. A nurse on a medical-surgical unit is receiving report on four client which of the following client should the nurse assess first ? --- a client who is receiving warfarin (Coumadin) and has am INR of 3.3 --- A client who has acute kidney injury ,a creatinine of 4 mg/dL and BUN of 52 mg / dL --- A client who had a NG tube inserted 6 hr ago and has abdominal distention X-- A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat. 34 (missing) 35. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin (RhoGAM) the client is gravida 2, para 2, and her blood type is AB negative .The newborn's blood type is B positive. Which of the following statement is a appropriate? ---You should receive Rhogam within 72 hours of delivery ---Rhogam is not necessary since this is your second pregnancy ---You only need to receive Rhogam if you have a positive blood type ---Both you and your baby should receive Rhogam at your 6-weeks appt 36. A nurse is caring form an older adult client who has a prescription for sertraline (Zoloft) to treat depression, Which of the following statements by the client indicates an understanding of the medication treatment plan? ---I will be able to stop taking this medication when I feel better ---I understand I may experience difficulty sleeping while on this medication ---I should decrease my sodium intake while on this medication ---I can expect to urinate frequently while on this medication 37. A nurse is teaching a client who has type2 diabetes mellitus is to start therapy with glipizide (Glucotrol) before meals? Which of the following findings should the nurse instruct the client to monitor and report to the provider? ---Bleeding gums ---Dry couch ---Palpitations ---Insomnia 38. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness .The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox? ---descending paralysis ---ptosis of the eyelids ---bloody diarrhea ---Rash in the mouth 39 (missing) 40. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching ? ---Apply a warm compress to the irradiated site ---Use a washcloth to bathe the treatment area --- Wear clothing over the area of radiation treatment ---Remove dye marking after each radiation treatment 41. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate (Imdur) Which of the following should the nurse identify as a contraindication to the medication? ---Glaucoma ---Hypertension ---Migraine headaches ---Polycythemia 42. A nurse administers a dose of metoclopramide (Reglan) to a client prior to a chemotherapy treatment the client develops uncontrolled contractions of the head and neck muscle .Which of following medication should the nurse administer? ---Diphenhydramine (Benadryl) ---Hydromorphone (Dilaudid ) ---Amitriptyline (Elavil ) ---Albuterol sulfate (Proair HFA) 43 A nurse is performing change -of-shift assessments on four clients . Which of the following findings should the nurse report to the provider first ? ---A client who has gastroenteritis and lethargic and confused ---A client who has cystic fibrosis and has a thick productive cough and reports thirst -x--A client who has sickle cell anemia and reports pain 15 min after receiving oral analgesic ---A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL 44. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following intervention should the nurse perform ? ---Position the head of the bed at 30o during the feeding ---Mix the client's medications with the tube feedings ---Give 100mL of water with every feeding ----Obtain gastric residuals every 24hr 45. A nurse is completing a dietary assessment for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find? Fasting from meat occurs during Hanukkah. Shellfish is commonly consumed in the diet. Meat and dairy products are eaten separately. Leavened bread may be eaten during Passover. 46. A nurse is conducting an in-service for a group of nurses who work in the emergency department. For which of the following childhood diseases should the nurse initiate airborne precautions? Mumps Whooping cough Scabies Measles 47. A nurse is caring for a full-term newborn immediately following delivery. Which of the following actions should the nurse take first? Weigh the newborn. Instill erythromycin ophthalmic ointment in the newborn's eyes. Place identification bracelets on the newborn. Dry the newborn. 48. A nurse is caring for four clients. Which of the following clients should the nurse care for first? A client who had an appendectomy 2 days ago and has diminished bowel sounds A client who has hypothyroidism and is stuporous A client who received a chemotherapy treatment and reports nausea A client who has a burn requiring a sterile dressing change 49. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? A client who had a cerebrovascular accident 2 days ago and needs help toileting. A client who had a myocardial infarction 3 days ago and reports chest discomfort A client who has awoken following a bronchoscopy and requests a drink A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry 50. A nurse is providing discharge instructions about engorgement for a client who has decided not to breastfeed. Which of the following statement by the clients indicates a need for further instruction by the nurse? "I will apply cold compresses to my breasts." "I will manually express breast milk." "I can wear a support bra." "I can take a mild analgesic."