ATI RN Comprehensive Predictor 2019 Practice A Updated 2023/2024

ATI RN Comprehensive Predictor 2019 Practice A A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms?ANS Sublimation Rationale: The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior. Displacement occurs when a client transfers emotions of a particular situation to another nonthreatening situation. Regression occurs when a client reverts to a childlike pattern of behavior that might have been exhibited previously. Suppression is the denial of a disturbing feeling or situation. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take?ANS Initiate fall precautions for the client Rationale: The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy. The nurse should encourage the client to increase fluid intake while taking alprazolam because an adverse effect of this medication is constipation. Urine discoloration is not an adverse effect of alprazolam. Therefore, monitoring the client's urine is not necessary. Alprazolam does not affect temperature regulation. Therefore, monitoring the client's temperature as often as every 2 hr is not necessary. 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 has the ability to sign the informed consent?ANS The client is able to accurately describe the upcoming procedure Rationale: The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene?ANS Places a pillow under the client's right arm. Rationale: The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include?ANS Introduce new foods one at a time over 5 to 7 days. Rationale: The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies. A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement?ANS Contact Rationale: The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take firstANS Massage the uterus to expel clots Rationale: Using the EBP approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching?ANS "Secure the retainer clip at the level of your baby's armpits" Rationale: The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs. A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies. "Which of the following actions should the nurse take? (SATA)ANS -Refer the client to a community based social workers -Initiate a consult with a home health care provider -Give the client information about local support groups Rationale: -A social worker is necessary to help a client with self-care, as well as assist in locating agencies who can help the client face challenges with self-care and paying for necessary ostomy supplies -A home health nurse can assist the client in learning to care for the colostomy as well as provide medication management and emotional support -A client who has cancer and a new colostomy can get help with coping from a support group and possibly receive assistance obtaining supplies from local agencies A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?ANS Investigate environmental factors that might be contributing to client injury during these hours. Rationale: When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem. A nurse is caring for a client who has terminal illness and requests lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make?ANS "I will provide you with information about medical treatment to include in your living will" Rationale: The nurses' responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themself by providing information about what end-of-life preferences to document. A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect?ANS Rapid speech Rationale: Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns A night shift nurse is giving a change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse?ANS The client needs assistance when transferring from the bed to a wheelchair. Rationale: The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse?ANS Boggy uterus Rationale: When using urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi have formed at the placenta. A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first?ANS Develop a safety plan with the client Rationale: The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering.ANS Flumazenil Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client's respirations with a bag valve mask. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plant of care to prevent injury in the home?ANS Mark the edges of the stairs for contrast Rationale: Marking the edges of stairs with paint or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first?ANS Provide information about scheduling issues to the staff. Rationale: The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by guardian indicates an understanding of the teaching?ANS "I should have my child avoid sun exposure between 10 am and 2 pm" Rationale: To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN?ANS Insertion of a nasogastric tube Rationale: The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?ANS Axillary temperature 36.2 C (97.2 F) Rationale: The expected reference range for the axillary temperature of newborn is between 36.5 C to 37.5 C (97.7 F to 99.5 F). An axillary temperature of 36.2 C (97.2 F) or below in a newborn who is 2 hr old indicates cold stress and should be reported to the provider. Acrocyanosis, or slightly blue hands and feet, is an expected finding for a newborn who is 2 hr old. A respiratory rate of 40/min is within the expected reference range of 30 to 60/min for a newborn who is 2 hr old. An apical pulse of 136/min is within the expected reference range for a newborn who is 2 hr old. The newborn pulse rate can range from 80 to 100/min when asleep and up to 180/min when crying. A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following?ANS Bleeding The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?ANS Involve the client in selection of a physical therapy provider/ Rationale: The nurse should involve the client in the referral process, including selection of the physical therapist and the location. A nurse in an emergency department is assessing a client who reports taking MDMA. Which of the following should the nurse expect?ANS Diaphoresis Rationale: Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects. Lethargy, bradycardia, and cough are not expected findings of MDMA. A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take?ANS Place the BP cuff in a labeled bag to send it for decontamination . Rationale: The nurse should place the BP cuff in a labeled bag before removing it from the client's room and sending it to the proper facility location for decontamination. A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine?ANS WBC count 2,800/mm3 Rationale: Clozapine can cause agranulocytosis, which can be life-threatening. Therefore, a WBC count of less than 3,000/mm3 is a contraindication for the client to receive clozapine. The nurse should withhold the medication and notify the provider of the client's WBC count. A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure sensitive valve. Which of the following information should the nurse include in the teaching?ANS "You should keep the catheter clamped when not in use" Rationale: The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure-sensitive valve that prevents blood reflux. A nurse is conducting visual acuity testing when using the Snellen letter chart for a school age child who has eyeglasses. Which of the following instructions should the nurse give to the child?ANS "You should keep both eyes open during the testing" Rationale: The nurse should instruct the child to keep both eyes open during visual acuity testing. When caring for a child, a nurse plans to use non-pharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?ANS Blowing bubbles with liquid soap to "blow the hurt away" Rationale: Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themself and into the air. Coloring with crayons provides a distraction. A nurse is preparing to administer heparin 5,000 units SQ. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose?ANS 0.5 mL 5,000 units/ 10,000 units = 0.5 mL A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene?ANS The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. Rationale: The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? (Audio)ANS Clang association Rationale: Clang association is an alteration in speech in which the client uses words based on their sound, rather than their meaning. Clients who have neurological disorders can also have this alteration in speech. Echolalia is an alteration in speech in which the client repeats back what someone else is saying. Neologisms are made-up words that have no meaning to others but do have meaning to the client. Word salad is an alteration in speech in which the client jumbles words because of an extreme level of mental disorganization. A nurse is assessing a school age-child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider?ANS Hemoptysis 275 mL/24 hr Rationale: Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report. The nurse should report fever to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. The nurse should report anorexia and weight loss to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. The nurse should report decreased activity to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. A nurse is caring for a client who ha bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first?ANS Move the client to a quiet place away from others. Rationale: The client's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other clients by moving the client to a quiet place away from others. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?ANS Place the skin barrier over the stoma and hold it for 30 seconds. Rationale: The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. A nurse is teaching the parent of a school-age about administering ear drops. Which of the following response by the parent indicates an understanding of the teaching?ANS "I should pull the top of the ear upward and back while instilling the medication." Rationale: The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back. A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider?ANS Neurologic status Rationale: This client is experiencing slurred speech and extremity weakness, which are indications of a stroke, a potential complication of cardiac catheterization. The nurse should report these findings to the provider. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump?ANS Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr. Rationale: The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN solution. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take?ANS Explain to the client why this information will be shared. Rationale: It is the responsibility of the nurse to advocate for the client, provide confidential information, and explain legal requirements. Reporting communicable disease occurrences helps with identifying outbreaks and overall disease trends. A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report?ANS A client's IV pump delivers an inadequate dose of medication. Rationale: The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report include significant complaints about care quality and visitor or client injury. A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?ANS Obtain the client's blood pressure before the nurse administers medication. Rationale: The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of function for an AP. 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?ANS Low back pain Rationale: The nurse should expect low back pain in a client who is having a hemolytic transfusion reaction. The nurse should expect tachycardia, rather than bradycardia, in a client who is having a hemolytic transfusion reaction. The nurse should expect hypotension, rather than hypertension, in a client who is having a hemolytic transfusion reaction. The nurse should expect distended jugular veins in a client who has circulatory overload, rather than in a client who is having a hemolytic transfusion reaction. A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?ANS Initiate oral rehydration therapy for the toddler. Rationale: Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed. A nurse is administering medications to a client who has percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of. the tube?ANS Flush the client's gastrostomy tube with 30 mL of water before administering the medication. Rationale: The nurse should flush the gastrotomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency. A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend?ANS Double-bag soiled dressings in plastic bags for disposal. Rationale: The client should double-bag soiled dressings in plastic bags to prevent the spread of micro-organisms to other household members. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend?ANS Diced steamed carrots Rationale: Diced steamed carrots are a safe food choice for toddlers because they are soft and do not present a choking hazard. A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity?ANS Substernal pain Rationale: The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis. A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?ANS Keeps the head of the bed elevated to 45° for 1 hr after feedings Rationale: The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after feedings to decrease the risk for aspiration. A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect?ANS Blanching of the fingers and toes Rationale: A client who has Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority?ANS "My husband doesn't know that I've already moved out of the house and filed for a divorce." Rationale: A lack of social support and isolation indicates the client is at greatest risk for another suicide attempt. Therefore, this is the priority concern that the nurse should report to the provider. A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make?ANS "When crusts have formed on every lesion." Rationale: The child should return to school once all the lesions have crusted over. Varicella is no longer contagious after crusts have formed on all lesions. A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care?ANS Encourage the parents to bring toys from home. Rationale: To help decrease the toddler's anxiety, the nurse should encourage the family to bring familiar objects from home, such as toys, blankets, and feeding utensils. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?ANS Audible stridor Rationale: Audible stridor, or a high-pitched sound heard in the client's airway indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become life-threatening. The nurse should report this finding to the provider. Anesthesia medications and surgery, especially in older adult clients, are common causes of premature ventricular contractions. The nurse should monitor the frequency of the premature ventricular contractions but does not need to report this finding to the provider. The nurse should report blood pressure changes that are greater than a 15 to 20 mm Hg difference from the client's baseline blood pressure. A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure?ANS Latex allergy Rationale: The nurse should assess the client for a latex allergy prior to the insertion of an indwelling urinary catheter due to the risk of an allergic reaction A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching?ANS "I will walk for short distances throughout the day." Rationale: The client should ambulate for short distances as tolerated throughout the day. This will help to reduce pulmonary stasis and prevent the development of respiratory infections A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make?ANS "It seems like you feel your visits are a waste of time." Rationale: The nurse is using a clarifying technique that facilitates the nurse's understanding of the adult child's feelings A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes?ANS Ask the nurse about their knowledge of the procedure. Rationale: The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?ANS "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." Rationale: By justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization. A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make?ANS "The enlarged uterus compresses the intestines and causes constipation." Rationale: During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation. A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?ANS "Sedation is a common adverse effect of this medication." Rationale: Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition?ANS An adolescent client who has foodborne botulism Rationale: The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Clients who ingest the botulism toxin can develop dysphasia, drooping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment. A nurse is assessing a client who is experiencing autonomic dysreflexia. which of the following findings should the nurse expect? (SATA)ANS -Facial flushing is correct. The nurse should expect a client who has autonomic dysreflexia to have facial flushing. Flushing occurs from the point of the lesion upward. -Nasal congestion is correct. The nurse should expect a client who has autonomic dysreflexia to have nasal congestion. -Headache is correct. The nurse should expect a client who has autonomic dysreflexia to have a severe headache. A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check every 10 min. Which of the following staff members should the nurse assign to collect this information?ANS An assistive personnel (AP) who is assisting a client to return to bed Rationale: Performing a blood pressure check is within the range of function of an AP, and the AP should be available to obtain a blood pressure within the specified time. A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first?ANS Gather more information about the staff nurse's actions. Rationale: The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include?ANS Use hydrogen peroxide to clean kitchen surfaces. Rationale: The client should clean kitchen surfaces with hydrogen peroxide to kill the virus and prevent transmission. The client does not need to wear a surgical mask, because hepatitis A is not an airborne infection. Limiting family visits to 30 min does not reduce the risk of transmitting hepatitis A. Instead, the nurse should encourage safe food handling and appropriate hand hygiene techniques. A client who has pediculosis capitis should seal nonwashable items in a plastic bag for 2 weeks. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?ANS Notify the incident commander. Rationale: The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order. A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?ANS Fever unresponsive to antipyretics Rationale: The nurse should expect a child who has acute Kawasaki disease to have a high fever that is unresponsive to antibiotics or antipyretics. A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging?ANS Decreased lung expansion Rationale: Older adult clients are more likely to have decreased lung expansion due to decreased mobility of the ribs. A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (SATA)ANS -"A speech pathologist will be performing a swallowing study for you." is correct. The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. -"You should rest before eating a meal." is correct. The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued. -"Thicken your beverages before drinking." is correct. The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?ANS Hypertension Rationale: The nurse should assess the client for hypertension, a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching?ANS The cervix transitions to an anterior position. Rationale: In true labor, the cervix transitions to an anterior position and begins to dilate in preparation for birth. A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?ANS Auscultate the affected extremity for a bruit. Rationale: The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency. The nurse should expect to palpate a thrill at the AV fistula, which indicates patency. The nurse should report the absence of a thrill to the provider. The nurse should encourage the client to perform range-of-motion exercises in the affected extremity to maintain muscle strength. The nurse should not perform a venipuncture in the client's affected extremity to prevent circulatory complications. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching?ANS Oranges Rationale: A client who is prone to uric acid calculi formation can eat citrus fruits. A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect?ANS Nystagmus Rationale: Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis. Ptosis is the drooping of the upper eyelids due to a decreased level of acetylcholine and is a manifestation of myasthenia gravis. Masklike face is caused by rigidity of the facial muscles and is a manifestation of Parkinson's disease. Abdominal striae are a manifestation of Cushing's syndrome. A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?ANS Check the insulin dose with another licensed nurse. Rationale: The greatest risk to the client is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for the client A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect?ANS Grandiose delusions Rationale: Clients who are in the manic phase of bipolar disorder typically exhibit behaviors that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose delusions. A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?ANS A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis Rationale: A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support. A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take?ANS Ask the caller for verification of their identity. Rationale: According to HIPAA, if someone requests information about a client it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that nurses cannot release any client information over the phone without the permission of the client. The nurse should ask for verification of the caller's identity to determine if they have been authorized by the client to receive information. According to HIPAA, if someone requests information about a client, it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that they cannot transfer the call or release any client information over the phone without the permission of the client. The client's provider must receive permission from the client to release specific medical information to family members. Therefore, this action by the nurse violates the client's right to privacy. This action by the nurse violates HIPAA because the client's personal health information is protected legally by the facility and the nurse should not disclose information, even in a limited form. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect?ANS Persistent uterine contractions Rationale: The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding. The nurse should expect a client who has placenta previa to experience a relaxed uterus and bright red vaginal bleeding. With abruptio placentae the nurse should expect to find dark red vaginal bleeding. The nurse should expect a client who has preeclampsia to have hyperactive deeptendon reflexes. The nurse should expect a client who has placenta previa to have a fundal height that is greater than expected gestational age. A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?ANS Install a raised toilet seat at home. Rationale: The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation. The client should maintain the hip at an angle less than 90° when sitting to minimize hip flexion and prevent hip dislocation. The client should use a walker to minimize the risk of falls or injury. The client should not have a pillow under the knees when lying down, because it can impede circulation and result in flexion contractures. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection.ANS A is correct. The nurse should recognize that enoxaparin is administered into the subcutaneous tissue, specifically in the periumbilical area B is incorrect. The nurse should identify this as the deltoid site, used for intramuscular injections.C is incorrect. The nurse should identify this as the ventrogluteal site, used for intramuscular injections.D is incorrect. Although the nurse can use the anterior thigh for a subcutaneous injection, enoxaparin must be administered in a different area. A nurse in an outpatient mental health clinic is working with a client who has posttraumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress?ANS Guided imagery Rationale: Helping clients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain. A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals?ANS A client who has Alzheimer's disease and is demonstrating aphasia Rationale: Aphasia impairs the client's ability to communicate but does not interfere with nutritional intake or place the client at an increased risk for aspiration while eating. Therefore, assisting the client with meals is within the AP's range of function. A client who has asthma and an increased respiratory rate is at an increased risk for aspiration and requires assessment by the nurse. Therefore, the nurse should avoid assigning an AP to assist with this client because this could compromise client safety. A client who had a stroke and is to start oral intake is at an increased risk for aspiration and requires assessment by the nurse. Therefore, the nurse should avoid assigning an AP to assist with this client because this could compromise client safety. A client who had diabetic ketoacidosis and is difficult to rouse is at an increased risk for aspiration and requires assessment by the nurse. Therefore, the nurse should avoid assigning an AP to assist with this client because this could compromise client safety. A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?ANS Performing a rapid needs assessment Rationale: Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first?ANS Identify health-related issues within the community. Rationale: The first action the nurse should take when using the nursing process is to assess the clients living in the community to identify the prevalent health problems. A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include?ANS The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. Rationale: Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral. The nurse should discuss organ donation with the parents separately from discussions about the child's impending death. For organ procurement to take place, the organs must remain viable and the donor must remain alive until the retrieval process is set to take place. A pathologist will perform an autopsy following an unattended death, a suspicious death, or at the request of the family following the death of the individual. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider?ANS Temperature 39.4° C (102.9° F) Rationale: The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure. Therefore, the priority finding for the nurse report to the provider is a fever. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?ANS "I will bend at my knees when picking an object up off the floor." Rationale: The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?ANS Decreased central vision Rationale: The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina. Double vision is a manifestation of cataracts. Floating dark spots are a manifestation of retinal detachment. An increase in intraocular pressure is a manifestation of glaucoma. A nurse is planning care for a client who is receiving heparin to treat a deep-veinthrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?ANS Elevate the affected leg. Rationale: The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency. A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching?ANS "Set your hot water heater temperature at or below 120 degrees Fahrenheit." Rationale: The nurse should instruct the client to set the maximum hot water temperature to no more than 49° C (120° F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn. A nurse manager is assisting the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene?ANS Tells the hospital chaplain a client's diagnosis Rationale: Discussing a client's diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPAA. A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex?ANS Stroke the infant's cheek. Rationale: The nurse should stroke the infant's cheek to assess the rooting reflex, which should cause the infant to turn towards that side and suck. The nurse should depress the infant's tongue to assess the extrusion reflex, which should cause the infant to stick out the tongue. The nurse should turn the infant's head to one side to assess the asymmetric tonic neck reflex, which should cause the infant to extend her arm and leg on that side and flex her arm and leg on the other side. The nurse should tap on the bridge of the infant's nose to assess the glabellar reflex, which should cause the infant to close her eyes tightly. A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement?ANS Place ice packs on the breasts for 15 min several times per day. The client should place ice packs on the breasts to reduce swelling and relieve the pain caused by engorgement. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give?ANS "There's a protocol for reviewing your medical record, and I can initiate the process." Rationale: The client's record is the legal property of the facility, but the client has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the client with access to the medical record. A nurse is administering the cyclophosphamide orally to a school-age child who has a neuroblastoma. Which of the following actions should the nurse take when administering this medication?ANS Maintain hydration with liberal fluid intake. Rationale: The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first?ANS Dry the newborn. Rationale: The greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take is to dry the newborn. The Apgar score is an important assessment for determining the newborn's adjustment to extrauterine life. However, this is not the first action the nurse should take. Placing an identification bracelet on the newborn is an important safety measure. However, this is not the first action the nurse should take. Obtaining the newborn's weight is important to help determine the health status of the newborn. However, this is not the first action the nurse should take. A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?ANS Protein Rationale: A client who has glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report. The presence of WBCs in the urine is an expected finding for a client who has a lower urinary tract infection, cystitis, or pyelonephritis. The presence of nitrites in the urine is an expected finding for a client who has a urinary tract infection. The presence of uric acid crystals in the urine is an expected finding for a client who has urolithiasis. A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first?ANS Request a referral for the client to receive physical therapy. Rationale: The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy. A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicate an understanding of the teaching?ANS "We should read a story together every night before bedtime." Rationale: Preschoolers respond to rituals that prepare them for bed, such as hearing a story or taking a bath. A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. which of the followings statements by the client indicates that this therapy is having the desired effect?ANS "I have not vomited as much recently." Rationale: Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body and can be used to alleviate nausea and vomiting. A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care?ANS Avoid venipunctures when possible. Rationale: Clients who have thrombocytopenia have a decreased platelet count and are at risk for bleeding. To reduce the risk for bleeding, the nurse should avoid venipunctures when possible. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take?ANS Inject 20 units of air into the NPH insulin vial. Rationale: The nurse should inject 20 units of air into the NPH insulin vial and withdraw the needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin vial. A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first?ANS Measure the client's vital signs. Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr. A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching?ANS "I should watch for common reactions like dry mouth and constipation." Rationale: The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider>ANS Headaches Rationale: The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care.ANS When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse should instruct the parent to change the tracheostomy collar. A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate?ANS Contact Rationale: The nurse should initiate contact precautions because clients transmit HSV by direct and indirect contact with others and the environment. The nurse should wear gloves when in close contact with the newborn. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?ANS Lack of remorse Rationale: A client who has antisocial personality disorder is more likely to show a lack of remorse. A client who has narcissistic personality disorder is more likely to show sensitivity to rejection. A client who has bipolar disorder is more likely to exhibit extreme mood swings. A client who has a borderline personality disorder is more likely to exhibit self-mutilating behaviors. A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first?ANS Assess the client for functional limitations. Rationale: When using the nursing process, the first action the nurse should take is to assess the client's functional limitations to determine how much the client can assist with the transfer. A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer?ANS 0.6 mL A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?ANS Continue observing the fetal heart rate. Rationale: Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?ANS Determine the client's perception of the personal impact of the crisis. Rationale: The first action the nurse should take using the nursing process is to assess the client. Therefore, the first action the nurse should take is to determine the client's feelings and understanding of the natural disaster and its personal impact. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan?ANS Provide a staff member to stay with the client continuously. Rationale: A staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment, if necessary, due to the risk of injury. A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?ANS Apply suction for 10 seconds. Rationale: The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss. A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure?ANS Mannitol Rationale: The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema. A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take?ANS Tell the nurses to stop the discussion. Rationale: The nurses are violating client confidentiality by having the discussion in a public hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further breach of confidentiality. The nurses are not committing insubordination, because insubordination occurs when an employee disobeys a person in authority such as a manager or supervisor. If the nurse needs to report the incident, the nurse should do so on an incident report, which is not included in the client's medical record. The charge nurse should not discuss the nurses' actions with the client. The nurse should report the situation to the nursing supervisor to investigate and take further action. A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?ANS A client who has significant head trauma and agonal respirations Rationale: The nurse should place a black tag on a client who has significant head trauma and agonal respirations because this client is not likely to recover or will require extensive resources for care. 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?ANS Clear objects from the client's walking area. Rationale: The nurse should plan to clear objects from the client's walking area because CN II is the optic nerve and a deficit can result in visual impairment which can lead to falls. A nurse is teaching a client who is to start taking misoprostol and currently is on longterm therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information?ANS Complete a serum pregnancy test before taking the medication. Rationale: Misoprostol can induce uterine contractions. Clients of childbearing age must rule out pregnancy before taking misoprostol. Misoprostol tends to cause diarrhea rather than constipation. Misoprostol does not coat the stomach. Misoprostol reduces gastric acid secretion so ulcers can heal and reduces the risk of new ulcer development. Magnesium-containing antacids increase the risk of diarrhea and the client should avoid these when taking misoprostol. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan?ANS Withhold administering the varicella vaccine to the child. Rationale: A child who has severe immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed. A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect?ANS Partial-thickness skin loss Rationale: The nurse should expect to see partial-thickness skin loss or blister formation in a client who has a stage II pressure injury. A client who has a stage III pressure injury is likely to have visible subcutaneous tissue. A client who has a stage IV pressure injury is likely to have tendon exposure. A client who has a stage IV pressure injury is likely to have muscle damage. A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect?ANS Pulsus paradoxus Rationale: The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension. A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify