ATI Comprehensive B Questions And 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 - c