ATI - Comprehensive C

1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? - Document the client's condition every 15 minutes 2 A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? - Administer analgesics on a scheduled basis for the first 24 hr 3. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? - A client who has a hip fracture and a new onset of tachypnea 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? - Wear gloves to apply the patch to the client's skin 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? - A client who was just given a glass of orange juice for a low blood glucose level 6. 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 history of gastroesophageal reflux disease 7 A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values? - Serum glucose level- increased 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? - Administer calcium gluconate IV 9. Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form ofcalcium gluconate available when administering magnesium sulfate by IV. A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? - Previous violent behavior Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? - Place the cap from the solution sterile side up on clean surface 11. 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? - Eat a light snack before bedtime 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? - Identify environmental hazards in the home 13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? - "What high school did you graduate from" 14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? - HbA1c level less than 7% 15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? - The client is showing evidence of phenytoin toxicity 16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? - Increase in frequency of swallowing (may indicate bleeding) 17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? - Monitor the child's cardiac status 18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? - Use of tobacco decreases the level of athletic ability 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? - Serum potassium- diuretic that retains potassium= hyperkalemic risk 20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? - "I will let the client know that I am available as the interpreter." 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? - A two day old newborn who has a respiratory rate of 70 (30 - 60 is normal) 22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia - A client who has fractured left tibia and pallor in the affected extremity 23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? - Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported 24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? - Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? - Potato pancakes 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? - Disorganized speech 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? - Apply an orthotic to the clients foot 28. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? - Provide anticipatory guidance classes to parents through public schools 29. A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? - Below the knee amputation 30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? - Platelets 100,000/mm3 (150,000-300,00 risk for bleeding) 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? - Prealbumin 10 mcg/dl (normal: 16-40) 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? - A client who is postoperative following a bowel resection with an NGT set to continuous suction 33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? - Continue the monitor the fetal heart rate (Not a problem- absent or late are a problem) 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? - Compare the current infusion with the prescription in the client's medication record. 35. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? - WBC count 2,900 /mm3 (Agrunlocytosis - 4,800-15,000 normal range) 36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? - You may breastfeed unless your nipples are cracked or bleeding. 37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? - Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? - Initiate seizure precautions 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. - Document the client's conditions every 15 minutes 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? - Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) – - Let's talk about your mom's cancer and how things will progress from here. - Tell me how you are feeling about your mom dying. - You sound like you have questions about your mom dying. Let's talk about it. 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? - A client who received a Mantoux test 48 hours ago and has induration 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? - Clarify the source of the referral 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? - You have the right to decide who receives information 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 90.7 (200 lb). The nurse should identify the weight of the following total percentage? - 7.5% 46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? - Pour water from a squeeze bottle over the client's perineal area. 47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? - Avoid hot tub while wearing the patch 48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? - Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) 49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? - We should establish our roles in the initial session. 50. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) – 1. Transport the client to another area of the nursing unit 2. Activate the facility's fire alarm system 3. Close all nearby windows and doors 4. Use the unit's fire extinguisher to attempt to put out the fire 51. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? - Whole grain bread 53 A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? - Heightened perceptual field 54. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (SATA) – Tremors Diaphoresis Inability to concentrate 55. 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? - Weak femoral pulses 56. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? Primary - before it happens Secondary - screening Tertiary - already happened - Teach parenting skills to families at risk for abuse 57. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? - Applying a condom catheter for a client who has a spinal cord injury 58. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? - "I will avoid food and beverages that contain caffeine" 59. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? - Instruct the client on the use of esophageal speech (I think) 60. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? - Perform chest compressions during cardiac resuscitation 61. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings is a potential contraindication for using lavender? - The client has a history of asthma 62. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? - Urinary retention 63. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? - Hypertension 64. A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) – - Explain the procedure - Expected outcome of the procedure - Potential complications - Possible alternative treatments 65. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? - "You should not have this procedure if you are allergic to iodine." 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso- constrictive crisis. Which of the following actions should the nurse include in the plan of care? - Initiate IV fluid replacement 67. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? - Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion 68. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? - Explain the risks of leaving 69. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? - "I think the baby should be sleeping through the night by now. 70. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? - Sunken fontanels and dry mucous membranes 71. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? - Request a female translator interpreter through the facility 72. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? - Vitamin b12 level 73. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? - Perform post mortem care