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A nurse is caring for a client who is at 33 weeks gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. contractions b. Hypertention c. Epigastric pain d. vomiting Answer: a. Contraction Rational: Amniocentesis -Can't be done before 16 weeks, not enough amniotic fluid. -maternal risks: hemorrhage, feto maternal hemorrhage, infection, contractions/labor, abruptio placentae, damage to intestines or bladder, amniotic fluid embolism -fetal risks: death, hemorrhage, infection, direct injury from the needle, miscarriage, and preterm, leakage of amniotic fluid 2. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Stay in bed at least 1 hr if unable to fall asleep. b. Take a 1 hr nap during the day c. Perform exercises prior to bedtime d. Eat a light snack before bedtime Answer:D. Eat a light snack before bedtime Rational:Consume a light snack of carbohydrates at bedtime 3. A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular tachycardia. Which of the following actions should the nurse first take determining the client does not have a palpable pulse? a. Assess heart sounds b. Defibrillate c. Establish IV access d. Administer Epinephrine Answer:B. Defibrillate Rational: The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone. If the client is pulseless or nonresponsive, the client is unstable and defibrillation is used 4. A nurse is admitting a client who is one week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client the client’s partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s admission data? a. Have the client’s child translate b. Allow the client’s partner to translate c. Request a female interpreter through the facility d. Ask a nursing student who speaks the same language as the client to translate. Answer: C. Request a female interpreter through the facility Rational: We been told not to use family members if not facility interpreters 5. A nurse is caring for a client who is febrile(fever). To reduce the client’s fever, the nurse applies cooling. Which of the following indicates the client is having an adverse reaction to the cooling? a. Flushing b. Tachycardia c. Restlessness d. Shivering Answer: D. shivering Rational: Hypothermia is the adverse reaction of cooling system for a febrile patient s/s of hypothermia: shivering, slurred speech, weak pulse drowsiness, confusion, loss of memory 6. 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? The Answer should be: ensure that the lower extremity is elevated. Rational: DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus 7. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietitian? a. An older adult client who has BMI of 24 b. A client who has a nonhealing leg ulcer c. An older adult client who had presbyopia d. A client who has an albumin level of 3.7 g/dl Answer:B. A client who has a nonhealing leg ulcer Rational: type of patients that can be referred to dietitian are the ones that present: Physical S&S Malnutrition Hair is dull, brittle, dry, or falls out easily Swollen glands of neck and cheeks Dry, rough, or spotty skin Poor or delayed wound healing or sores Thin appearance with lack of subcutaneous fat Muscle wasting Edema of lower extremities Weakened hand grasp Depressed mood Abnormal heart rate/rhythm and BP Enlarged liver or spleen Loss of balance and coordination Presbyopia: farsighted 8. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Eat 1g/kg of protein per day b. Take magnesium hydroxide for indigestion c. Drink at least 3 L of fluid daily. d. Consume foods high in K+ Answer: A. Eat 1g/kg of protein per day Rational: Protein intake and hemodialysis protein is not routinely restricted. Magnesium hydroxide. Please don’t chose this anwer! -Magnesium is excreted by the kidneys, and patients with CKD should not use OTC products containing magnesium. The other mediations are appropriate for a patient with CKD. 9. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. Sitting in high-fowlers position during the feeding b. History of gastroesophageal reflux disease (GERD) c. Receiving a high osmolality formula d. A residual of 65ml 1 hr postprandial Answer: B. History of gastroesophageal reflux disease (GERD) Rational: Pt with higher Risk of aspiration a in clients with GERD
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NGN ATI COMPREHENSIVE EXIT EXAM RETAKE
EXAM LATEST (237 Q&A) 100% Verified
1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
Thenurse should monitor the client for which of the following complications?
a. Vomiting
b. Hypertension
c. Epigastric pain
d. Contractions
2. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
a. Stay in bed at least 1 hr if unable to fall asleep
b. Take a 1 hr nap during the day
c. Perform exercises prior to bedtime
d. Eat a light snack before bedtime
3. A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client’s partner and 10-year-
old child are accompanying her. Which of the following actions should the nurse take to
gather the client’s admission data?
a. Have the client’s child translate
b. Allow the client’s partner to translate
c. Request a female interpreter through the facility
d. Ask a nursing student who speaks the same language as the client to translate
4. A nurse is caring for a client who is febrile (High fever). To reduce the client’s fever, the
nurse applies a cooling blanket. Which of the following findings indicates the client is having
an adverse reaction to the cooling?
a. Flushing
b. Tachycardia
c. Restlessness
d. Shivering (Hypothermic)
5. 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? (Exhibit)
,a. Position the client with the affected extremity lower than the heart
b. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
c. Administer acetaminophen
d. Massage the affected extremity every 4 hr
6. A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
a. An older adult client who has a BMI of 24 (18.5-24.9)
b. A client who has a nonhealing leg ulcer (diet isn’t good)
c. An older adult client who has presbyopia (age related far-sightness)
d. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
7. A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily-
d. Consume foods high in potassium- restrict
8. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
a. Sitting in a high-Fowler’s position during the feeding
b. A history of gastroesophageal reflux disease
c. Receiving a high osmolarity formula
d. A residual of 65 mL 1 hr postprandial?
9. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the
following findings is a complication of immobility?
a. Decreased serum calcium levels- increased serum calcium
b. Increased blood pressure- hypotension
c. Swollen area on calf
d. Urinary frequency-
,10. A nurse is providing teaching to a client who has a depressive disorder and a new
prescription for phenelzine. Which of the following foods should the nurse instruct the client
to avoid?
a. Grapefruit
b. Spinach
c. Cottage cheese- cream cheese ok.
d. Smoked salmon
TYRAMINE!
11. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
a. Encourage the client to spend time in the day room
b. Withdraw the client’s TV privileges if he does not attend group therapy
c. Encourage the client to take frequent rest periods
d. Place the client in seclusion when he exhibits signs of anxiety
12. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse ?
a. Influenza
b. Measles, mumps and rubella
c. Human papilloma virus
d. Varicella
13. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the
teaching?
a. Bleeding gums- low platelet
b. Faintness upon rising
c. Swelling of the face
d. Urinary frequency
14. A nurse has received change-of-shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
a. Document client care at the end of the shift
b. Make the client to-do list for the day
c. Skip breaks until the client tasks are completed
d. Focus on several client tasks at a time
15. A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings
should the nurse recognize as an expected finding?
a. The anterior fontanel is open
b. The posterior fontanel is open
c. Both fontanels are the same size
d. Both fontanels show molding
, 16. A nurse is caring for client who has acute diverticulitis (low fiber) . Which of the following
diets should the nurse recommend to the client? Diverticulosis- High fiber
a. High residue
b. Lactose-free
c. Gluten-free
d. Low-fiber
17. A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse include in the plan of care?
a. Administer low-dose heparin
b. Place the client on a full liquid diet
c. Use an incentive spirometer every 3 hr
d. Maintain the client on bed rest
18. 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. Develop an hourly time frame for tasks
b. Schedule daily activities
c. Determine goals of the day
d. Delegate tasks to the AP
19. A nurse is performing an admission assessment for a client who is in the manic phase of
bipolar disorder. Which of the following behaviors should the nurse expect?
a. Performance of ritualistic behaviors- ocd
b. Suspiciousness and distrust- schizo
c. Distractibility and poor judgment
d. Reports of physical discomfort -anxiety
20. A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
a. Weak femoral pulses?- they get upper extremity hyper, lower extremity hypo
b. Frequent nosebleeds- yes
c. Upper extremity hypotension
d. Increased intracranial pressure
21. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
a. “The client might act seductively”- histrionic
b. “The client is overly concerned about minor details”- ocd
c. “The client exhibits impulsive behavior”
d. “The client is exceptionally clingy to others”- dependent