ATI RN LEADERSHIP PROCTORED EXAM 2019 | Combined VERSIONS 1, 2 & 3 | 100% Revised and Graded A+ Answers 2024

ATI RN LEADERSHIP PROCTORED EXAM 2019 | Combined VERSION 1, 2 & 3 | 100% Revised and Graded A+ Answers. ATI Leadership Proctored Exam 1. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? 2. A nurse is preparing to discharge a client who has end stage heart failure. The clients partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take? 3. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? 4. A nurse is supervising assistive personnel who’s feeding a client with dysphagia. Which of the following actions by the AP should the nurse identify as correct technique? 5. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? 6. A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following action should the nurse take? 7. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following response by the nurse is appropriate? 8. A nurse in a long-term care facility is caring for a client and witnessed the assistive personnel position him in bed with excessive force. Which of the following actions should the nurse take? 9. A nurse is assessing a client who has meningitis. Which of the following finding should the nurse report to the provider immediately? 10. A nurse is caring for a client who wanders through the halls yelling obscenities at staff other clients and visitors. Which action should the nurse take? A) Administer sedatives B) Keep the client in her room with the door closed C) D) Place the client in a wheelchair with a lap tray 11. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and had difficulty completing care for his assigned client. Which of the following intervention is appropriate? Decreasedilevelioficonsciousness Contact ithe inurseimanager I iunderstand,iand iit’sinot itoo ilate ito ichangeiyourimind. Contactisocial iservicesiaboutithe ideliveryiof ithe ioxygeniequipment. “Ainurseicanidiscloseiinformationito iaifamilyimemberiwith itheiclient’s ipermission.” Instructingitheiclient ito iplace itheir ichinito ichest iwhileiswallowing Socialiworker Contactitheicaseimanager ito idiscuss idischargeioptions Aiclientiwho iis iat i35 iweeks iof igestation iandihasiaibiophysicaliprofileiof i6 Contactifamilyimembersito icomeisit iwithithe iclient 12. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced AP. Which of the following assessment should the nurse make before delegating care? 13. A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? . 14. A nurse manger observes an assistive personnel incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first? 15. A nurse manager is leading discussion about ethical dilemmas. Which of the following situations should the nurse manager include as an example of an ethical dilemma? A) a nurse witnesses another nurse administer incorrect medication B) a visitor experiences minor burns at a facility after receiving…. C) D) a client receives operation on the wrong side of the body 16. A nurse a caring for a client who request information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information? 17. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statement by the newly licensed nurse indicates an understanding of the teaching? 18. A nurse in the emergency department is assessing a client who is unconscious following a motor- vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? 19. A nurse enters a clients room to witness an informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take? 20. A case manager is preparing a discharge plan for a client following coronary artery bypass graphing surgery. Which of the following client issues should the nurse address first? 21. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department? Pertussis 22. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take SATA. A. Place a copy of the completed report in the client’s medical record Inadequateifoodisupply Informithe iproviderithat ithe iclientirequiresiclarificationiabout ithe iprocedure Transportitheiclient ito ithe ioperating iroomiwithoutiverifyingiinformediconsent. I ishouldiencryptipersonalihealthiinformationiwhen isending iemail. Anievidence-basedinursingijournal Helpithe iAPitransferithe ipatient Hasidataibeenicollectediaboutispecificiclient ineedsirelatedito iturning? Recommendithat ihe itake itime ito iplaniat ithe ibeginningiofihisishift. aiparentiwants ia i14-year-oldiadolescentito ireceiveiradiationitreatmentiagainstihis iwill Aisufficientisupplyiof ipersonaliprotectiveiequipment B. Make a copy of the incident report for personal record keeping C. D. E. Obtain and order from the client’s provider to complete the report 23. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit? 24. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? 25. A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? 26. A nurse working on a medical-surgical unit is managing care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients? 27. A nurse enters the hallway and discovers a visitor looking at a clients medical information on the computer. Which of the following actions should the nurse take first? 28. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? 29. A nurse is caring for a client who is unconscious and whose partner is their healthcare surrogate. The partner wishes to discontinue the client’s feeding tube, but another family member tells the nurses they want the client to continue receiving treatment. Which of the following responses should the nurse make? 30. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? Battery 31. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (select all that apply.) 32. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines? icounseloriCase imanager iMentalihealth Nutritionalitherapist As ithe ihealthcareisurrogateitheiclient’sipartnerican imakeitheidecision Askithe iclient’sisonito igo ito ithe iwaiting iarea. Closeitheidocumentationiprogramion ithe icomputer Aiclientiwho iis ireceivingihepariniandihasianiaPTTiofi34 iseconds Reinforcingidietaryiteachingiwith iaiclientiwhoihasiheartidisease Proceediwith itreatmentiwithoutiobtaining iwritteniconsent Pi CA ipump Aiprimigravidaiclientiwhoiisi1 iday ipostoperativeifollowingiaiCesareanisectioniandihas ia identifyithe imedicationinameiand itheidoseiadministeredito ithe iclientiin ithe ireport Includeithe itimeitheimedicationierror ioccurrediinithe ireport 33. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? 34. A nurse is caring for a client who has cancer. The client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make? 35. A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent? A) A client who has a deep partial thickness burn on the lower extremities B) A client who has an open fracture of the femur D) A client who has a peri fatal ecchymosis 36. A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client’s partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? 37. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? 38. A nurse manager is receiving report and is faced with the following situations that requires intervention. Which of the following should the nurse manager address first? a. A nurse on the previous shift wrote an incident report about a medication error. b. Two staff members have called to say they will be absent. c. Transport assistance is unavailable to take a client to occupational therapy. d. 39. A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. Which of the following actions should the nurse take first? 40. A nurse is receiving a verbal prescription from the provider for a client who is having increase pain. The nurse should transcribe which of the following prescription in the client’s medical records? It isn’t the two with the 4o and not the one that says 10.0 mgIt’s like “Morphine sulfate 10 mg IV q 4 hr for pain” 41. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority? 42. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? Physicalitherapist Aiclientiwhoireportsishortnessiof ibreathiandileft ineckiandishoulderipain Determineithe ireasonsithe inursesiareinotitakingischeduledibreaks. Reportithe iinfectionito ithe ilocalihealthidepartment Whetherithe iclientiunderstandsithe iriskiof irefusing ithe iprocedure I icannotiprovideithis iinformationito iyouiwithoutiyourimother’siconsent Useicleanigloves irather ithanisterileiglovesifor icolostomyicare. “I iwill ihaveia iclientiwho iis ion iairborneiprecautionsiwear ia imaskiwheniout iof iher iroom.” Theiemergencyidepartmentinurseiis iwaitingito igive ireport ion iainewiadmission. iC) i Aiclientiwhoihas ianiasymmetricalithorax Socialiservices 43. A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates and understanding of the teaching? 44. A nurse is caring for four clients. Which of the following clients should the nurse assess first? irestlessness 45. A nurse is developing a discharge plan for a client who is post-operative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to obtain the clients prescription? A) Home health B) Physical therapy C) Occupational therapy D) (Pg 26) 46. A nurse is working on a quality improvement team that is assessing an increase in client falls at a facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? 47. A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag color should the nurse instruct the group to apply to a client who has full thickness burn on 72% of his body? 48. A nurse has just completed assessment charting on an electronic medical record for an assigned client. An assistive personnel who just measured the clients vital signs asked to chart them while the nurse is still logged in. Which of the following actions should the nurse take? 49. A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus. the client tells the nurse she has decided to go home. Which of the following action should the nurse take? 50. A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth? a. b. Providing medication reconciliation c. Developing client treatment protocols d. Establishing communication between providers 51. A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse? A) a client who is scheduled for an endoscopy later today and requires enema B) C) a newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin Haveithe iclientisignithe iagainstiMedicaliAdviceiform. Logioutisoithe iassistiveipersonnelicanilogiin ito idocumentithe ivitalisigns. Black i -- iKNOWiTOiASSESSiREDiFIRST Identifyiclients iwho iareiatiriskifor ifalls. I iwill iwear iaisurgicalimaskiwithin i3ft iof ithe iclient Ai iclient iwho ihas iAlzheimer’sidisease iand ibacterial ipneumoniaiandia inewionset iof aiclientiwho ihas iaimyocardialiinfarctioniandiwill ibe itransferringito ia iunitifromithe iPCC Assessingiclientineeds Prepareito iadministeriantibioticsito ithe iclient. “Aihealthicareiproxyicanimakeidecisions ifor iyouiwheniyouiareiunableito ido iso.” D) a newly admitted client who has sickle cell anemia requires a development of an initial plan of care 52. A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? 53. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change of shift report? 54. A nurse on a medical surgical unit is evaluating an assistive personnel use of infection control precaution. Which of the following actions by the assistive personnel indicates correct use of precaution? 55. A nurse on a med surg unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make? 56. A nurse is teaching newly licensed nurse about client confidentiality. The nurse should include that which of the following examples represents a violation of client confidentiality? 57. A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report? 58. A nurse is preparing a teaching session with a client who speaks a different language than the nurse. Which of the following interventions should the nurse plan to take? 59. A charge nurse witnessed an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? 60. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following client is the highest priority? 61. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? 1. Have the client sign a consent for treatment 2. Notify risk management before initiating treatment 3. Proceed with treatment without obtaining written consent (Implied Consent) 4. Aiclientiwhoihasiperipheralivascularidiseaseiandihasianiabsentipedalipulseiinithe irightifoot. Discussithe iissue iwith itheiAP Provideianiinterpreteriwhen iobtainingiconsentifromithe iclient “Theiclientiisicurrentlyiinithe iradiologyidepartmentiforiaichestix-ray.” Informingihousekeepingistaff ithat ithe iclientiis iin ithe idialysisiunit. APiremovesiherigloves ibefore ileavingithe iroomiofiaiclientiwho ihas iMRSA Theitimeithe iclientireceivedihis ilast idoseiofipainimedication Contact ithe iclient’s inextiof ikinito iobtainiconsentifor itreatment 62. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be insertedib. c. Assess the client for urinary retention. d. Obtain a provider’s prescription for a blood alcohol level. 63. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? 1. 2. Ambulating a client who is scheduled for discharge later in the day 3. Administering morphine IV bolus to a client who is hr postoperative 4. Admitting a new client who has chronic back pain to the unit 64. A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? 1. Withhold the benzodiazepine but continue the opioid. 2. Contact the provider about replacing the opioid with an NSAID. 3. Administer the benzodiazepine but withhold the opioid. 4. 65. A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client’s ring? 1. 2. Tape the ring securely to the client’s finger. 3. Place the ring in the bag with the client’s clothing. 4. Agree to keep the ring for the client until after surgery. 66. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. b. Irrigate the exposed area with water c. Remove the client’s clothing d. Report the incident to OSHA 67. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit? 1. A client who is post term and is receiving oxytocin for labor induction 2. A client who gave birth to her first child and requires instruction on breastfeeding techniques ambulating 4. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion 68. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? 1. Treat the client’s injuries within 30 min 2. 3. Provide treatment for minor injuries 4. Allow the client to die without further intervention 3i . i Aiclientiwhoiisi2 idays ipost-operativeifollowingiaicaesareanibirthiandiis ihavingidifficulty Provideitreatmentifor ilife-threateningiinjuries Donipersonaliprotectiveiequipment Placeitheiclient’s iring iin ithe ifacilityisafe. Continueithe imedicationidosagesithat irelieveithe iclient’sipain. Reinforcingiteachingiwith iaiclientiwho iis ilearningito iself-administeriinsulin iDocumentithe iclient’sirefusaliinitheichart. 69. To receive a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using? 1. Compromising 2. Cooperating 4. Collaborating 70. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority? 1. iseconds 2. A client who has COPD and has an oxygen saturation of 90% 3. A client who had a cholecystectomy 6 hr ago and is requesting pain medication 4. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids i3. i Competing Aiclientiwhoihadiaicardiacicatheterizationiwhose icapillaryirefilliin itheigreatitoe iis i4 ATI RN LEADERSHIP PROCTORED EXAM 2019 VERSION 3 ATI RN LEADERSHIP PROCTORED EXAM 2019 VERSION 3 1. A nurse is assessing a school-age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective? a. An increase in venous pressure b. a decrease in peripheral edema c. a decrease in cardiac output d. an increase in potassium levels 2. A nurse is assessing an infant who has acute otitis media. Which of the following findings should the nurse expect (select all that apply) a. Increased appetite b. enlarged subclavian lymph node c. Crying d. Restlessness e. fever 3. a nurse is providing teaching to the parents of an infant who is to undergo pilocarpine lontophoresis Testing for Cystic Fibrosis. Which of the following statements should the nurse include in the teaching? a. We will measure the amount of protein in your baby's urine over 24 hour period b. The test will measure the amount of water in your baby’s sweat c. a nurse will insert an IV prior to the test d. your baby will need to fast for 8 hours prior to the test 4. A nurse in an urgent care clinic is prioritizing care for children. Which of the following children should the nurse assess first? a. A toddler who has nephrotic syndrome and facial edema b. a preschool-age child who has a muffled voice and no spontaneous cough c. a preschool-age child who has diabetes mellitus and a blood glucose of 200 mg/dL d. an adolescent who has Crohn's disease and recent weight loss of 5kg mg (11 lb) 5 .A nurse is providing teaching to the parents of a toddler who is to undergo a sweat chloride test. Which of the following statements should the nurse include? a. The purpose of the test is to determine if your child has Crohn's disease b. the technician will use a device to produce an electrical current during the test c. during the test, your child will be in a room that is cold d. your child sweat will be collected over 24 hours 6. A nurse in the emergency department is caring for an adolescent who is requesting testing for STI. Which of the following action is appropriate for the nurse to take? a. Request verbal consent from the social worker b. contact the client's parents to obtain phone consent c. postpone the testing until the client's parents are present d. obtain written consent from the client 7. A nurse in the emergency department is assessing the toddler who has hyperpyrexia severe dyspnea and drooling which of the following actions should the nurse take first? a. obtain a blood culture from the toddler b. administering antibiotic to the toddler c. insert an IV catheter for the toddler d. prepare the toddler for nasotracheal intubation 8. A nurse is providing teaching to a 10 year old child with scheduled for an arterial cardiac catheterization. Which of the following information should the nurse include in the teaching? a. You will have your dressing removed 12 hours after the procedure b. you will need to keep your legs straight for 8 hours following the procedure c. you will be on a clear liquid diet for 24 hours following the procedure d. you will be on bed rest for 2 days after the procedure 9. 10. A nurse is caring for a preschooler who is post-operative following a tonsillectomy. The child is now ready to resume oral intake which of the following dietary choices should the nurse offer the child? a. sugar-free Cherry gelatin b. vanilla ice cream c. chocolate milk d. lime flavored ice pop 11. A nurse is caring for an infant who has Patent ductus arteriosus. The nurse should identify that the defect is a switch of the following locations of the heart. ( you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer)Answer: B 12. A nurse is caring for a 10 month old child was brought to the emergency department by his parents following a head injury. Which of the following actions should the nurse take first? a. Inspect for fluid leaking from the ears (thinking about CSF leakage severe trauma = urgent, after respiratory status is confirmed) b. assess respiratory status c. check pupil reactions d. examine the scalp for lacerations 13. A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care? a. Assign consistent nursing Staff Care for the infant b. Keep infant in a visually stimulating environment c. use half-strength formula when feeding the infant d. give the infant fruit juice between feedings 14. A nurse is providing teaching about home care to the parent of a child who has scabies. Which of the following instruction should the nurse include in the teaching? a. Wash your clients hair with shampoo containing Ketoconazole b. soak Combs and brushes in boiling water for 10 minutes c. apply petroleum jelly to the affected areas d. treat everyone who came into close contact with a child 15. A nurse is caring for a preschooler who refuses to take a start dose of oral diphenhydramine. Which of the following statements should the nurse make? a. The medication isn't bad it taste like candy b. let me know when you want to take the medication c. the medication will treat your hypersensitivity reaction ( too much “Adult” terminology/ jargon for pre schooler to understand) d. sometimes, when a child has to take medication, they feel sad. 16. A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching? a. Your child should walk the bicycle through intersections b. your child's feet should be three to six inches off the ground when Seated on the bicycle c. you should try to keep the bicycle at least three feet from the curb while riding in the street d. your child should ride the bicycle against the flow of traffic 17. A nurse is caring for a school-age child following the application of a cast to a Fractured right tibia. Which of the following actions should the nurse take first? a. Teach the child about cast care b. Pad the edges of the cast c. administer pain medication d. Elevate the child's leg 18. 19. A nurse is preparing a school-age child for an invasive procedure. Which of the following actions should the nurse plan to take? a. plan for 30 minute teaching session about the procedure b. use vague language to describe the procedure c. explain the procedure to the child when they are in the playroom d. demonstrate deep breathing and Counting exercises 20. 21. A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following actions should the nurse take? -Apply lidocaine gel to the perineum before attaching the bag -Position the opening of the bag over the urethra and the anus -Stretch the perineum taught when applying the bag -Place a snuff fitting diaper over the drainage bag 22. A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care? a. Schedule routine Oral Care every 8 hours b. Cleanse the gums with saline soaked gauze c. more sending me closer with lemon glycerin swabs d. administer oral viscous lidocaine 23. A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden infant death syndrome (SIDS). Which of the following statements by the parent indicates an understanding of the teaching? a. I will have my baby sleep next to me in the bed during the night b. Elmo my baby stuffed animal to the corner of her crib while she sleeps c. I will dress my baby in lightweight clothing to sleep d. I will lay my baby on her side to sleep for her naps 24. A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? a. Increased blood pressure b. Limb withdrawal c. relaxed facial expression d. bradycardia 25. A nurse is caring for a three-month-old infant who has cleft of the soft palate. Which of the following actions should the nurse take? a. discontinue feeding if the client's eyes become watery b. postpone burping the infant until after completing each feeding c. Elevate the infant’s head to a 10 degree angle during feedings d. Feed the infant 177.4 ml (6 oz) of Formula 3 times a day 26. A nurse is caring for a child who has hyponatremia. Which of the following findings should the nurse expect? a. Tetany b. weight gain c. Elevated heart rate d. excessive diaphoresis 27. A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube. Which of the following actions should the nurse take first? a. Set the administration rate on the feeding pump b. flush the tube with water c. check the pH of the gastric secretion d. attach the feeding bag tubing to the end of the NG Tube 28. A nurse is caring for an adolescent who is 1 hour post-operative following an appendectomy. Which of the following findings should the nurse report to the provider? a. Heart rate 63 / minute b. muscle rigidity c. temperature 36.4 Celsius (97.5 Fahrenheit) d. abdominal pain 29. A nurse in a provider's office is preparing to administer immunization to a 12 year old client during a well-child visit. Which of the following immunization should the nurse plan to administer? a. Diptheria, tetanus and pertussis (D-Tap) b. human papillomavirus (HPV) c. Varicella d. hepatitis A 30. Nurse is planning care for an 8 month old infant who has heart failure. Which of the following actions should the nurse include in the plan of care? a. Repeat digoxin dosage is the infant vomit within 1 hour of administration b. Place infant in a prone position c. administer cool, humidified oxygen via nasal cannula d. provide less frequent, higher volume feeding 31. A nurse is planning care for a school-age child who is admitted from the emergency department 12 hours ago. Which of the following interventions should the nurse include to promote adequate sleep for the child? a. Provide the child with video games prior to bedtime to reduce stress b. allow the child to adjust their bedtime to promote autonomy c. leave the lights on in the child's room to promote safety d. follow the child home sleep routine to reduce anxiety 32. A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month old infant. Which of the following actions should the nurse plan to take? a. cover the insertion site with an opaque dressing b. use a 24 gauge catheter to start the IV c. start the IV on the infant’s foot d. change the IV site every 3 days 33. A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a new prescription for digoxin. Which of the following manifestations should the nurse include as an indication of digoxin toxicity? a. Diaphoresis b. Polyuria c. Bradycardia d. jaundice 34. A nurse is preparing to administer amoxicillin 80 mg/kg/day divided into two doses daily to a 2-year-old client who weighs 10 kg (22 lb). Available is amoxicillin suspension 400 mg/5 mL. how many mL of amoxicillin should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 10ml 35. A nurse is reviewing the laboratory results of a child was recently admitted or suspected rheumatic fever. The nurse should identify that which of the following laboratory tests can contribute to confirm this diagnosis (select all that apply) a. partial thromboplastin time (PTT) b. erythrocyte sedimentation rate (ESR) c. blood urea nitrogen (BUN) d. C-reactive protein (CRP) e. anti streptolysin O (ASO) titer 36. A nurse is teaching a group of female adolescents about healthy eating. Which of the following instructions should the nurse include in the teaching? a. Increase the amount of your dietary iron intake b. limit your sodium intake to 3000 mg per day c. consumer 1,500 to 1700 calories per day d. decrease your vitamin D intake once you start to menstruate 37. A nurse is caring for an infant who receives intermittent enteral feeding through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? Select all that apply a. offer the infant a pacifier during readings b. formula to 39° C (102 degrees Fahrenheit ) prior to Administration c. check the for residual volume by aspirating stomach contents d. instill the formula over a period Of 30 and 45 minutes 38. A nurse is planning care for a child who has osteomyelitis. Which of the following interventions should the nurse include in the plan of care? a. Encourage frequent physical activity to increase bone mass b. maintain patent intravenous catheter c. initiate contact precaution for the child d. provide a high calorie low protein diet 40. A nurse is providing teaching to the guardian of a school-age child who has sickle cell disease about management of the illness. Which of the following instructions should the nurse include? a. Apply cold compress to painful areas b. but I shall wear a surgical mask to school c. encourage physical activity as tolerated d. offer fluids of bedtime 41. A nurse is assessing a 5 month old infant. Which of the following findings should the nurse report to the provider? a. Unable to hold a bottle b. exhibits head lag when pulled a sitting position c. absent grasp reflex d. unable to roll from back to abdomen 42. A nurse is caring for a five-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage? a. Flushing of the face b. continuous swallowing c. blood pressure 99/ 56 mmhg d. heart rate 54/ minutes 43. A nurse is discussing coping mechanisms with a parent of a three-month- old infant which of the following therapeutic questions should the nurse ask the parent? a. What do you do when your infant is fussy? b. Are you willing to take new parenting classes? c. Does parenting cause you stress? d. Is it overwhelming when your infant is having a bad day? 44. A nurse is providing teaching about the effects of sun exposure to a parent of a toddler. which of the following responses by the parent indicates an understanding of the teaching? a. my child should wear a wide-brimmed hat b. my child should remain under a beach umbrella umbrella during morning hours c. I should apply 10 SPF sunscreen to my child's entire body d. I should dress my child in loose active clothing 45. A nurse is evaluating a 6 year old child who has cystic fibrosis and has been receiving chest physiotherapy treatment. The nurse should identify which of the following findings as an indication of the therapy has been effective? a. Increased urine output b. increase expectoration c. reduced pain d. increased heart rate 46. A nurse is planning care for a six-month-old infant who has bacterial meningitis. Which of the following interventions should the nurse include in the plan of care? a. Place the infant in a semi-private room b. keep the television on in the room to provide background noise c. Pad the side rails of the crib d. provide for you can range of motion to the neck and shoulders 47. A nurse is reviewing the medical record of a child with cystic fibrosis which of the following should the nurse report to the provider? Click on the exhibit button for additional information about the client. a. heart rate b. HbA1c c. oxygen saturation d. WBC48. 48. A nurse is assessing an infant who has severe dehydration due to gastroenteritis which of the following findings should the nurse expect? a. Increased respiratory rate b. capillary refill of 2 seconds c. Hypertension d. increased urine output 49. A nurse is assessing an infant who has intussusception. Which of the following findings should the nurse expect? a. sausage-shaped abdominal Mass b. board like abdomen c. Constipation d. increased urinary output 50. A nurse is caring for a 14 year old adolescent who has a cast on the right arm and swelling of their right hand. The nurse elevates The Adolescents affected extremity. The nurse should identify that which of the following findings is an indication that the intervention has been effective? a. The Adolescent reports of the cast feels tight b. The Adolescents hands feel cool to touch c. the Adolescent is able to move their fingers freely d. the Adolescent reports feeling tingling in their arms 51. A nurse in a provider's office is assessing the vital signs of a two-year-old child at a well-child visit. Which of the following findings should the nurse report to the provider? a. Respiratory rate 26 / min b. pulse rate 98 / minutes c. temperature 37.2 Celsius (99 Fahrenheit) d. blood pressure 118 / 74 mmhg 52. A nurse is preparing to administer a prescribed medication to a toddler whose parent is nearby. Which of the following actions should the nurse take to identify the toddler? a. check the toddler's room number against their ID band b. check the toddler's ID band against the medical record c. ask the parent to confirm the toddler's identity d. ask another nurse to confirm to toddlers identity 53. A nurse is teaching home care to the parents of a preschool-age child who has heart failure. Which of the following information should the nurse include in the teaching? a. Weight the child once each month month b. withhold digoxin of the child's pulse is greater than 100 / minutes c. provide for periods of rest d. increase the child's oxygen flow rate until the child no longer has cyanosis 54. A nurse in the PACU is caring for a school-age child immediately following a tonsillectomy. Which of the following actions should the nurse take? a. Place the child in a side-lying position b. offer the child ice cream when alert c. instruct a child to drink fluids through a straw d. encourage the child to deep breathe and cough 55. A nurse is reviewing the medical record of a 15 month old child who is scheduled to receive measles, mumps, rubella1. Which of the following findings Should the nurse identify as a contradiction for receiving the vaccine? a. Allergy to neomycin b. upper respiratory infection 2 days ago c. temperature of 37.2 (99 Fahrenheit) d. family history of seizures 56. A nurse is assessing a school-age child cranial nerve function. Which of the following actions should the nurse ask the child to take when assessing the accessory nerve? a. Move their tongue in all directions b. follow a light in the six cardinal position c. shrug their shoulders against mild pressure d. show their teeth while smiling 57. A nurse is performing a cranial nerve assessment on a school-age child. Which of the following findings indicates proper function of the child trigeminal nerve? a. The child montanes balance when standing with eyes closed b. the child correctly identify specific scent c. the child has asymmetrical jaw strength when Biting Down d. the child exhibits a gag reflex when stimulated with a tongue blade 58. A nurse is providing support to a family whose infant died from sudden infant death syndrome (Sid's) which of the following actions should the nurse take? a. Discourage the parents from allowing siblings to view the body b. avoid discussing details of the attempt to revive the infant c. provide a follow-up phone call one week following the infant's death d. acknowledge the family members feelings of guilt 59. A nurse in the emergency department is caring for a child who has a temperature of 39.1 degrees C is (102.4 Fahrenheit) and suspect the diagnosis of bacterial meningitis. Which of the following actions should the nurse take first? Tell me more a. prepare the child for a lumbar puncture b. dim the lights in the child's room (SEIZURE PRECAUTION) c. administering an antipyretic to the child d. Implement droplet precautions for the child 60. A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated? a. capillary refill 1 seconds b. weight loss 7% lower c. Respiratory rate 28/ minute d. bradycardia 61. A nurse is providing teaching to the guardian of a school-age child who has seizure disorder. Which of the following factors should the nurse include as a common trigger that increases the risk of seizure? a. Prolonged headache b. decrease temperature c. lack of sleep d. exposure to second-hand smoke 62. A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes the clients potassium level is 3.2 meq L which of the following assessment findings should the nurse expect? a. Hypertension b. Hyporeflexia c. hyperactive bowel sounds d. Oliguria 63. A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunizations should the nurse include in the plan? a. Respiratory sync functional virus (RSV to call) b. Rotavirus c. measles, mumps, and rubella (MMR) d. pneumococcal conjugate (pcv13) 64. A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include? a. Initiate Airborne precaution b. assess the oral cavity for koplik spots c. administer aspirin for fever d. provide the child with a warm blanket 65. A nurse is planning care for a school-age child who has a new diagnosis of Legg calve perthes disease. Which of the following interventions should the nurse include in the plan of care? a. instruct a child to perform weight bearing exercises b. explain to the child that the disease will last 3 to 6 months c. encourage the guardian to keep their child home from school for one month d. administer ibuprofen to the child for discomfort 66. A nurse is caring for a two-year-old child who has cystic fibrosis and is being discharged from the hospital. The nurse should ensure that which of the following pieces of equipment is available for the child's home? a. steam vaporizer b. suction machine c. continuous positive airway pressure machine d. high frequency chest compression vest 67. A nurse is providing teaching for the parent of a child who has measles. Which of the following information should the nurse include? a. Bathe the child using tepid water b. remove loose crust from the lesions c. give the child aspirin for a fever d. withhold live vaccines for 3 months 68. A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect? a. Steatorrhea b. Rhinorrhea c. weight gain d. visible peristalsis