ATI Comprehensive B questions with correct answers Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? Correct answers - Ask another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8 Correct answers - Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina Correct answers - Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider Correct answers - Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take Correct answers - Auscultate the apical pulse and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool Correct answers - Insert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine Correct answers - Broccoli, Yogurt, Cream Cheese
Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse document in the client's medical record? Correct answers - Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? Correct answers - A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain. Can indicate peritonitis from a ruptured appendix.
Community health nurse providing teaching on home safety for older adults Correct answers - Have grab
bars installed around your bathtub and toilet. School age child with scald burns on both hands and wrists suspected abuse Correct answers - Contact child protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion Correct answers - Explore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational Correct answers - I will wear a supportive bra overnight
Discharge instructions to client to received home oxygen therapy Correct answers - Wear clothing made with cotton fabrics while oxygen is in use.
Preparing an educational session about advocacy to a group of nurses Correct answers - Advocacy is a leadership role that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and decreased urinary output Correct answers - Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis Correct answers - Infuse IV fluids
Client teaching about the basal body temp method for birth control Correct answers - Your body temperature might decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent Correct answers - Proceed with provision of medical care
Client who has fluid volume overload. Which tasks can nurse delegate to UAP Correct answers - Measure the client's daily weight
Checking for Chvostek's sign Correct answers - The nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8 Correct answers - Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina Correct answers - Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider Correct answers - Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take Correct answers - Auscultate the apical pulse and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool Correct answers - Insert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine Correct answers - Broccoli, Yogurt, Cream Cheese
Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse document in the client's medical record? Correct answers - Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? Correct answers - A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain. Can indicate peritonitis from a ruptured appendix.
Community health nurse providing teaching on home safety for older adults Correct answers - Have grab
bars installed around your bathtub and toilet. School age child with scald burns on both hands and wrists suspected abuse Correct answers - Contact child protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion Correct answers - Explore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational Correct answers - I will wear a supportive bra overnight
Discharge instructions to client to received home oxygen therapy Correct answers - Wear clothing made with cotton fabrics while oxygen is in use.
Preparing an educational session about advocacy to a group of nurses Correct answers - Advocacy is a leadership role that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and decreased urinary output Correct answers - Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis Correct answers - Infuse IV fluids
Client teaching about the basal body temp method for birth control Correct answers - Your body temperature might decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent Correct answers - Proceed with provision of medical care
Client who has fluid volume overload. Which tasks can nurse delegate to UAP Correct answers - Measure the client's daily weight
Checking for Chvostek's sign Correct answers - The nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia.
