ATI Comp Practice A w/ NGN Exam 2024

A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Vital Signs • Temperature 37.7° C (99.8° F) • Heart rate 82/min • Respiratory rate 16/min • Blood pressure 127/80 mm Hg • Oxygen saturation 99% on room air Assessment Height 157.5 cm (62 in) Weight 90 kg (198 lb) Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity. Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale. Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching. Reports that right lower extremity pain has been intermittent for about the last 2 months. Denies current left lower extremity pain. - Potential condition: varicose veins Actions to take: apply compression stockings and elevate extremity Parameters to monitor: Edema and pruritis of right lower extremity A nurse is caring for a preschooler on the pediatric unit. Provider Prescriptions Day 1, 2350:Admit for observation. Obtain vital signs every 4 hr and PRN. Administer oxygen 2 L/min via nasal cannula to maintain oxygen saturation above 95%.Initiate saline lock. Administer ceftriaxone 250 mg IV every 12 hr. Administer acetaminophen oral suspension 240 mg every 4 hr PRN for temperature greater than 38° C (100.4° F). Place on regular diet and encourage oral fluids of preschooler's choice. Monitor intake and output every 8 hr. Assessment Day 2, 0030:Preschooler lying on bed, awake and alert. Breath sounds with wheezing auscultated on expiration on the right side. Nonproductive cough with no retractions or nasal flaring observed. Abdomen soft and nondistended, bowel sounds active in all four quadrants. Preschooler reports headache and pain in abdomen. Rates pain in abdomen as a 2 on a 0 to 10 FACES pain scale. Vital Signs D - Administer epinephrine IM. Administer 0.9% sodium chloride IV. Monitor vital signs frequently. Discontinue the IV medication. A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. History and Physical Client is G2P2 at 38 weeks of gestation Diagnosed with preeclampsia at 32 weeks of gestation Scheduled repeat cesarean birth Diagnosed with gestational diabetes mellitus at 29 weeks of gestation Nurses' Notes 1500: Dressing dry and intact. Fundus firm midline at umbilicus. Scant lochia rubra. Client rates incisional pain as a 3 on a scale of 0 to 10, denies need for analgesia. Indwelling urinary catheter removed.1700: Client reports headache with pain rated at 4 on a scale of 0 to 10. Analgesic administered.1800: Client reports blurred vision and nausea. Rates pain from headache as a 6 on a scale of 0 to 10. Deep tendon reflexes 4+, clonus positive. Vital Signs 1500: Temperature 36.6° C (97.9° F)Heart rate 86/minRespiratory rate 18/minBlood pressure 155/90 mm HgOxygen saturation 98% on room air1800: Heart - The client is at risk for developing seizures as evidenced by blood pressure. A nurse is caring for a client who has schizophrenia in an inpatient facility. Medication Administration Record 0730:Clozapine 100 mg PO daily Aripiprazole 5 mg PO daily Multivitamin PO daily Laboratory Results 0730:Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Vital Signs 1230: Temperature 37.6° C (99.7° F)Heart rate 98/min Respiratory rate 20/min Blood pressure 142/92 mm Hg Oxygen saturation 100% on room air 1500: Temperature 37.1° C (98.8° F) Heart rate 104/min Respiratory rate 24/min Blood pressure 150/90 mm Hg Oxygen saturation 100% on room air Nurses' Notes 0730:Client sleeping. Lungs clear to auscultation bilaterally. Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Family at bedside. Family states client is diagnosed w - ENTER ANSWER A nurse is caring for a client who is in the spinal cord injury (SCI) unit. Nurses' Notes Day 1, 1700: Client admitted to SCI 3 days ago following C7 injury.Urinary output 800 mL in indwelling urinary catheter over last 12 hr.Day 2, 0600: Client has nonproductive cough. Urinary output 100 mL in indwelling urinary catheter over last 6 hr. Vital Signs Day 1, 2200: Temperature 37.2° C (99.0° F) Heart rate 74/min Respiratory rate 20/min Blood pressure 110/60 mm Hg Oxygen saturation 95% on room air Day 2, 0600: Temperature 37.8° C (100° F) Heart rate 54/min Respiratory rate 26/min Blood pressure 96/60 mm Hg Oxygen saturation 90% on room air Physical Examination Day 1, 1700: Lung sounds diminished in lower lobes. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Skin is cool, pale, and dry to touch. Day 2, 0600: Adventitious lung sounds auscultated in lower lobes bilaterally. - The nurse should first address the client's oxygen saturation followed by the client's urinary output. A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? - Fiber attention deficit hyperactivity disorder (ADHD) - ENTER ANSWER intellectual disability (ID) - ENTER ANSWER 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? - Double-bag soiled dressings in plastic bags for disposal. A nurse is caring for a 68-year-old client who is 2 days postoperative following surgical repair of a left hip fracture. Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. Last bowel movement 5 days ago. Client reports usual pattern is one bowel movement daily. Oral fluid intake 1,950 mL/24 hr. Urine output 1,820 mL/24 hr. 1900: Client reports nausea and constant abdominal pain as 5 on a scale of 0 to 10 throughout abdomen. Pain began after eating dinner. Physical Examination 1300: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in lower quadrants. Skin warm and dry to touch in trunk and all extremities. Pedal pulses strong and equal bilaterally. Capillary refill less than 3 seconds in toes bilaterally. 1900: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds i - Potential condition: Intestinal obstruction Actions to take: IV fluids and semi-fowlers position Parameters to monitor: bowel sounds and urine output A nurse is caring for a 3-year-old child who has a gastrostomy tube. Nurses' Notes Day 1, 0700:Child sleeping in bed. Gastrostomy tube site clean. Parents at bedside. 0900:Child consumed water with no difficulties. Parents at bedside. Day 2, 0900:Child alert. Completed bolus feeding. Flushed site with 100 mL of tap water before and after feeding. Child tolerated feeding well with no vomiting, reflux, or abdominal pain noted. 1100:Called to child's bedside by parent. Parent reports child had episode of diarrhea. Perineal care provided.1115:Nurse inspects gastrostomy tube and observes clear drainage around the tube site. Site cleansed with soap and water. 2000:Child alert. Completed bolus feeding. Flushed site with 100 mL of tap water before and after feeding. Child tolerated feeding well with no vomiting, reflux, or abdominal pain noted. Redness and clear drainage noted to gastrostomy tube site. Vital Signs Day 1, - The child is at risk for developing skin breakdown and an infection A nurse is caring for a newborn. History and Physical 41 weeks of gestation Spontaneous vaginal delivery with meconium-stained amniotic fluid at 1350Apgar 7 at 1 min and 9 at 5 min Birth weight 2,500 g (5 lb 8 oz)Birthing parent urine toxicology positive for marijuana use during pregnancy Birthing parent blood type A, Rh negative Group B streptococcus β-hemolytic: positive (negative) Birthing parent received 3 doses of intravenous antibiotics while in labor Nurses' Notes 1400: Newborn placed skin-to-skin on parent's chest with light blanket over top. Lusty cry. Acrocyanosis noted. Newborn rooting and attempting to latch onto the breast. 1430: Newborn lying quietly on parent's chest. No latch achieved. Acrocyanosis noted. Expiratory grunting and nasal flaring present. Skin loose and dry. Scant amount of green stained vernix caseosa noted in skin folds. - The nurse should plan to first assess the newborn's respiratory rate, followed by the newborn's heart rate. A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke this morning on the living room floor trembling and flushed; remembers having intense dreams and was afraid they had a seizure so they called a family member to bring them to the ED. Client reports their average alcohol intake has been "two or three beers" after work each day and "more on the weekends" for the past 6 months. Client reports headache, nausea, agitation, and is noted to be diaphoretic 0800: Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic. History and Physical Alcohol use disorder Delirium tremens Nicotine use disorder Hypertension, diet and exercise controlled. Vit - Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Administer chlordiazepoxide. Administer thiamine. Initiate seizure precautions. Maintain a low-stimulation environment. A nurse is providing phone advice for a client who is pregnant. Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Advised client to eat small frequent meals of nongreasy, dry, sweet or salty foods, such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea and vomiting worsens. Week 10 of gestation: Spoke with client over the phone. Client reports a 6.8 kg (15 lb) weight loss over the past month. Client states nausea continues, making it difficult to eat. They describe a diet of water, toast, and pretzels because other foods are unappealing. They report tolerating a cup of black coffee each morning. Advised client to be seen by the provider today. - The client is at risk for experiencing metabolic acidosis due to the client's weight loss. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? - Allow for frequent rest periods throughout the day. A nurse is caring for a client who is on 24-hr observation. Laboratory Results 0600: Sodium 150 mEq/L (136 to 145 mEq/L) Potassium 5.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 105 mEq/L (98 to 106 mEq/L) BUN 17 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.0 mg/dL (3.0 to 4.5 mg/dL) Glucose 135 mg/dL (74 to 106 mg/dL) Platelet count 99,500/mm3 (150,000 to 400,000/mm3) WBC count 9,500/mm3 (5,000 to 10,000/mm3) Total protein 4.0 g/dL (6.4 to 8.3 g/dL) Albumin 1.5 g/dL (3.5 to 5.0 g/dL) Blood alcohol content (EtOH) 200 mg/dL (0 to 50 mg/dL) History and Physical 0600: Client admitted for 24-hr observation for alcohol intoxication. History of alcohol use disorder per family. Client alert and oriented to person. Client appears lethargic. Diminished lung sounds auscultated in bilateral lower lobes. Heart is tachycardic. Nausea and vomiting for - The client is at risk for hemorrhage due thrombocytopenia . 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? - Provide a staff member to stay with the client continuously. A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? - Nausea A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? - Support the client's left arm on a pillow while sitting. 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? - Avoid venipunctures when possible. A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? - Ask the partner to list specific concerns. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? - A client who channels their energy into a new hobby following the loss of their job A nurse is caring for a client who has a potassium level of 3 mEq/L (3.5 to 5 mEq/L). For which of the following manifestations should the nurse monitor? - Decreased deep tendon reflexes A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant? - Absence of symptoms A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? - Monitor the client's mouth every 8 hr. A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? - Form a committee of staff members to investigate current staffing issues. A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? - Making a list of activities to complete A nurse working on an inpatient mental health unit is caring for a client who is experiencing active suicidal ideations. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment? - Serve meals with plastic utensils. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? - Arrange the lunch tray for a client who has a hip fracture. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? - Nasal flaring A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? - Tells the hospital chaplain a client's diagnosis A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? - Initiate oral rehydration therapy for the toddler. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? - Increased opacity of the lens A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take? - Use 0.9% sodium chloride for irrigation of the NG tube. 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? - Ask the nurse about their knowledge of the procedure. A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take? - Ask another nurse to witness the disposal of the new patch. 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? - An adolescent client who has foodborne botulism A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication? - Reduce environmental stimuli. A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Which of the following information should the nurse plan to include? - The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? - A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain A nurse in an outpatient mental health clinic is working with a client who has post- traumatic 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? - Guided imagery A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol? - Wheezing 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 first? - Massage the uterus to expel clots. A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual maltreatment? - The child exhibits discomfort while walking. 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? - Places a pillow under the client's right arm A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication? - Dry mouth A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? - Aspirate contents from the tube and verify the pH level. A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT? - Short-term memory loss A nurse is reviewing the medical record of a client who has schizophrenia and is scheduled to begin a new prescription for clozapine. Which of the following findings should the nurse identify as a contraindication for this client to receive clozapine? - WBC count 2,800/mm3 (5,000 to 10,000/mm3) A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? - "I will wear a supportive bra overnight." 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? - "There's a protocol for reviewing your medical record, and I can initiate the process." 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? - Investigate environmental factors that might be contributing to client injury during these hours. 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? - Mannitol A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? - Time the medication was given A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical sterile technique? - Maintain sterile objects within the line of vision. A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? - Maintain hydration with liberal fluid intake. A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? - Clear objects from the client's walking area. 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? - Flumazenil A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? - Tension pneumothorax 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? - Check the insulin dose with another licensed nurse. 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? - Latex allergy A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? - Elevate the affected leg. A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider? - Irritability when being held A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? - Edema A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? - "I should pull the top of the ear upward and back while instilling the medication." A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? - Decreased hallucinations 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? - Place ice packs on the breasts for 15 min several times per day. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement? - Contact A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? - Apply a cold pack to the client's ankle for 30 min every hour. 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? - "I will bend at my knees when picking an object up off the floor." A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? - "I will provide you with information about medical treatment to include in your living will." A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first? - Observe the client and the situation. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? - Axillary temperature 36.2° C (97.2° F) A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? - aPTT 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? - Notify the incident commander. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT (30 to 40 seconds) values should the nurse expect? - 45 seconds A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? - "Thicken your beverages before drinking." "You should rest before eating a meal." "A speech pathologist will be performing a swallowing study for you." A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? - The client is pacing around the chair in which their partner is sitting. 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? - "I will walk for short distances throughout the day." A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? - Sodium 148 mEq/L (136 to 145 mEq/L) 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? - Insertion of a nasogastric tube 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? - Stroke the infant's cheek. 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? - Decreased lung expansion A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? - Diced steamed carrots A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? - "I should have my child avoid sun exposure between 10 am and 2 pm." 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? - Assess the client for functional limitations. A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? - Rapid decrease in blood pressure 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? - "Secure the retainer clip at the level of your baby's armpits." A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include? - Empty the appliance when it is one-third to one-half full. A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - ENTER ANSWER A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? - "You will receive fingersticks for blood glucose testing." A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? - Serum liver enzyme levels A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum- assisted births? - Cervical laceration A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following actions should the nurse plan to take? - Enter the plasma product number into the client's medical record. A night shift nurse is giving 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? - The client needs assistance when transferring from the bed to a wheelchair. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? - The time of the client's last dose of pain medication A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make? - "Tell me more about your understanding of the options." An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? - The LPN and the AP grasp the client under their arms to lift him up in bed. A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? - Use a reward system to modify the child's behavior. A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? - Insert a lubricated gloved finger and advance along the rectal wall. A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? - Check the client's oxygen saturation level. A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? - Partial-thickness skin loss A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? - Abdominal bloating A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take? - Withhold the heparin infusion. 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? - Continue observing the fetal heart rate. 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? - Fever unresponsive to antipyretics A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? - Amount of vaginal bleeding A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? - "My child has only a small amount of mucus after percussion therapy." A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? - Decreased central vision 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? - "It seems like you feel your visits are a waste of time." 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? - Headaches A nurse is caring for a client who has 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? - Move the client to a quiet place away from others. 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? - "When crusts have formed on every lesion." A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? - "You seem to be having a difficult time right now." A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? - Increase the client's dietary iron intake. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? - Hematuria A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? - Strict adherence to routines