ATI RN Comprehensive Online Practice A with NGN Study Guide Graded A 2023

A nurse is caring for a client who has a fractured femur and has a fiberglass leg cylinder cast for 24 hours. What is the priority assessment finding? - the client's heel is reddened and tender because this could be an early indicator of a pressure injury and the pt is at high risk for pressure injuries why are the other findings not priorities? - cast gets wet: fiberglass casts are waterproof - increase pain when leg is lowered below level of the heart: the leg should be elevated to help reduce edema and pain but preventing pressure injuries is priority - the pt reports itching under the cast: the pt is at risk for dry and itchy skin so the nurse should offer a hair dryer to blow COOL air on the skin, but preventing pressure injury is priority 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 because this helps reduce swelling and relieve pain why are the other instructions incorrect? - allow the newborn to breastfeed temporarily: avoid nipple stimulation because this will increase milk production - relieve pressure by expressing milk daily: avoid expressing milk to prevent further milk production - sleep with a loose fitting bra to prevent nipple stimulation: wear a tight fighting, supportive bra or a breast binder to decrease discomfort caused by engorgement 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 because of the risk of an allergic reaction to the catheter why are the other answers incorrect? - ketonuria: this is the presence of ketones in the urine and occurs - fecal impaction or tachycardia: these conditions do not pose a safety risk during the insertion of an indwelling catheter ketonuria - this is the presence of ketones in the urine and occurs due to fatty acid catabolism caused by hyperglycemia, starvation, high-protein diets, and alcohol use disorder sickle cell anemia - a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape vaso-occlusive crisis - Ischemia and pain caused by sickle-shaped red blood cells that obstruct blood flow to a portion of the body, for example an organ becomes restricted, causing pain, ischemia and often organ damage other s/s: visual disturbance, hematuria, painful swelling extremities, fever, tachycardia, PAIN A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vase-occlusive crisis? - hematuria because it is a manifestation that results from ischemia of the kidneys what answers are not signs of vast-occlusive crisis? - diminished reflexes, hyperglycemia, hearing loss what are other signs of vast-occlusive crisis? painful swelling of the hands and feet, visual disturbances A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? - boggy uterus because this can indicate uterine hemorrhage and this is URGENT why do the other findings not require immediate intervention by the nurse? - intermittent cramping, moderate lochia rubra, and perineal edema are all NONURGENT and are expected findings - excessive lochia rubra and large clots should be reported to the provider - intermittent cramping/afterpainscan be eased by heat and lying prone - perineal edema occurs due to the excessive amount of pressure experienced during vaginal birth, the nurse can offer ice or sitz baths what does the nurse do if the pt has a "boggy uterus" during the immediate postpartum period? - this is URGENT and can indicate a uterine hemorrhage, so the nurse should IMMEDIATELY intervene to stimulate uterine contractions and prevent blood loss, because if the uterus becomes relaxed during the postpartum period the client will rapidly lose blood because no permanent thrombi have formed at the placenta what is lochia rubra? - the first stage of lochia, lasts 3-4 days, dark or bright red blood, flow is similar to a heavy period, small blood clots and mild, period-like cramping are normal A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? - lack of remorse A nurse is assessing a client who has narcissistic personality disorder. Which of the following manifestations should the nurse expect? - sensitivity to rejection A nurse is assessing a client who has bipolar disorder. Which of the following manifestations should the nurse expect? - extreme mood swings A nurse is assessing a client who has borderling personality disorder. Which of the following manifestations should the nurse expect? - self-mutilating behaviors What is misoprostol and what is it used for? - prostaglandin, used for prevention of NSAID induced gastric ulcers by reducing gastric acid secretion so the ulcers can heal and reduces the risk of new ulcer development what are s/e of misoprostol? - uterine contractions (need to ensure patient is not pregnant prior to taking this medication), diarrhea what should a pt avoid when they are taking misoprostol? - magnesium-containing antacids because they increase the risk of diarrhea A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? - performing a rapids needs assessment because this will allow the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage what are the four stages of disaster management? what are examples of each stage? - Prevention: organization and implementation of an immunization campaign, prevent, treat, or contain a disease Preparedness: identify specific roles of disaster workers to be aware of the expectations and responsibilities of ancillary team members Response: perform a rapid needs assessmen Recovery: conducting home visits to identify health hazards, identify a lack of safe shelter, clean water or other potential hazards that result from the disaster scenario with only abnormal finding information: 1 mo. old irritable vomit after each feeding for 3 days firm abdomen hypoactive bowel sounds