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A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?
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Ensure the state health department has been notified.
0 Administer antitoxin.
0 Educate the family to avoid sharing personal belongings.
Q Assess for skin necrosis.
NTINUE
Question: 2 of 180
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A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take.
Exhibit 1 Exhibit 2
l9. Provide frequent rest periods for the client.
Nurses' Notes 1S] Restrict the client's sodium intake.
'EJ Advise the client to avoid the use of soap and alcohol-based lotions.
0900:
D Place the client on a low-carbohydrate diet.
The client reports experiencing a loss of appetite and shortness 0 Place the client under contact isolation.
of breath within the last month or so. The client reports
experiencing weakness, abdominal pain, severe itching, and
'f9 Instruct the client to avoid blowing their nose forcefully.
mood changes. The client has had alcohol use disorder for the '-g Assess the client's level of orientation.
past 10 years and sometimes drinks alcohol uncontrollably.
The client is alert but disoriented to time. Their abdomen is
bloated and they have redness of the palms of the hands.
Excoriated areas on the upper thorax and shoulders are
present. Sciera are yellow.
1230:
Administered antacids, spironolactone, and colchicine per
provider's prescription.
,Question: 2 of 180
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Iii
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take.
Exhibit 1 Exhibit 2 Exhibit 3
0 Provide frequent rest periods for the client.
0 Restrict the client's sodium intake.
0 Advise the client to avoid the use of soap and alcohol-based lotions.
0930:
0 Place the client on a low-carbohydrate diet.
Temperature 37.3° C (99.1 ° F) 0 Place the client under contact isolation.
Heart rate 84/min
Respiratory rate 20/min
0 Instruct the client to avoid blowing their nose forcefully.
BP 138/88 mm Hg 0 Assess the client's level of orientation.
Oxygen saturation 93% on room air
1600:
Temperature 37 ° C (98.6° F)
Heart rate 80/min
Respiratory rate 20/min
BP 130/85 mm Hg
Oxygen saturation 94% on room air
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Question: 2 of 180
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A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take.
Exhibit 1 Exhibit 2 Exhibit 3
0 Provide frequent rest periods for the client.
Laboratory Resu Its 0 Restrict the client's sodium intake.
0 Advise the client to avoid the use of soap and alcohol-based lotions.
1200:
0 Place the client on a low-carbohydrate diet.
Hgb 9.5 g/dl (14 to 18 g/dl) 0 Place the client under contact isolation.
Hct 38% (42% to 52%)
0 Instruct the client to avoid blowing their nose forcefully.
Bilirubin 5.3 mg/dl (0.3 to 1.0 mg/dl)
Creatinine 1.8 mg/dL (0.6 to 1.3 mg/dL) 0 Assess the client's level of orientation.
Platelet count 100,000/mm3 (150,000 to 400,000/mm3)
1800:
Alanine aminotransferase ALT 51 units/L (4 to 36 units/L)
Aspartate aminotransferase AST 48 units/L (0 to 35 units/L)
Alkaline phosphate ALP 151 units/L (30 to 120 units/L)
Blood total protein 15 g/dL (6.4 to 8.3 g/dL)
, Question: 3 of 180
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A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the
nurse perform first?
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Administer an antiemetic medication.
Evaluate functioning of the suction device.
0 Provide oral hygiene care.
�
0 Replace the NG tube.
Question: 4 of 180
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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which
of the following actions should the nurse take first?
Q Initiate a requisition for a replacement CPM device.
Q Report the defect to the equipment maintenance staff.
� Remove the device from the room.
Q Ensure the device inspection sticker is current.
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A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the
sterile solution?
0 Remove the cap and place it sterile-side up on a clean surface.
0 Place sterile gauze over areas of spilled solution within the sterile field.
0 Hold the bottle in the center of the sterile field when pouring the solution.
0 Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Hold the bottle with the label in the palm of the hands so that the solution does not run down the label.
ATI Fundamentals pg. 50 (Practices That Maintain A Sterile Field (Procedure Section)
, iii
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A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the
nurse include in the plan?
• 0 0 • • 0 0 • 0 • • • 0 • • • • • • 0 • 0 • 0 • • • • 0 • 0 • • • 0
0 Wear loose-fitting underwear.
0 Take a bubble bath after intercourse.
0 Drink four 240 ml (8 oz) glasses of water each day.
0 Void every 5 to 6 hr during the day.
iii
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Question: 7 of 180 Pause Remaining: 00:05:00
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A nurse is caring for a newborn. Drag words from the choices below to fill in each blank in the following
sentence.
Exhibit 1 Exhibit 2 Exhibit 3 • 0 0 • • o • • • •
The client is at risk for developing Tacget 1 and
Vital Sig�
Target 2
0640:
Temperature 36.7° C (98.1 ° F) axillary Findings
Heart rate 154/min
hypoglycemia �
Respiratory rate 68/min
BP 72/48 mm Hg
bronchopulmona �
rydysplasia �--.........
0650:
trans1en1
Heart rate 156/min tachypnea of the +
� ----
newb.orn +
Respiratory rate 72/min
tachycardia �
0700:
Temperature 37° C (98.6° F) axillary
Heart rate 156/min (Normal HR for newborn = 110(Pink book)/120-160/min)
Respiratory rate 76/min (Normal RR for newborn = 30-60/min)