ATI RN Comprehensive Online Practice 2019 B with NGN

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? (A) Creatinine 1.1 mg/dL (B) Albumin 2.8 g/dL (C) Triglycerides 100 mg/dL (D) Alkaline phosphatase 118 units/L - Albumin 2.8 g/dL [The expected reference range for albumin is 3.5 to 5 g/dL] (A creatinine level of 1.1 mg/dL is within the expected reference range of 0.5 to 1.1 mg/dL for a female client, and 0.7 to 1.3 mg/dL for a male client) (A triglyceride level of 100 mg/dL is within the expected reference range of 35 to 135 mg/dL for a female client, and 40 to 160 mg/dL for a male client) (An alkaline phosphatase level of 118 units/L is within the expected reference range of 30 to 120 units/L. An elevated alkaline phosphatase level is an indication of liver or bone disorders, with a decreased level indicating malnutrition) Burkholderia cepacia lung infection: what type of precautions will be initiated? - Contact isolation precautions A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique? (A) Hold hands folded below the waist after donning sterile gloves. (B) Pick up and pour solutions with the palm of the hand covering bottle labels. (C) Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. (D) Maintain sterile objects within the line of vision. - Maintain sterile objects within the line of vision. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? (A) Perform ADLs for the client to promote rest. (B) Allow for frequent rest periods throughout the day. (C) Use heat to reduce joint inflammation. (D) Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. - Allow for frequent rest periods throughout the day. [The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion] (The nurse should allow the client to perform their own ADLs to promote the client's joint mobility and independence) (The nurse should use ice to reduce joint inflammation and heat to alleviate joint discomfort) (The nurse should not administer more than 3 g of acetaminophen to the client each day to reduce the risk of injury to the client) A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. NURSE NOTES: 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Vital Signs 0600: Temperature 37.8° C (100° F)Heart rate 104/minRespiratory rate 26/minBlood pressure 88/56 mm HgOxygen saturation 90% on 2 L via nasal cannula Diagnostic Results 0645: Hematocrit 25% (37% to 52%)Hemoglobin 8.3 g/dL (12 to 16 g/dL)WBC count 18,000/mm3 (5,000 to 10,000/mm3)Retic - [ ] Administer IV fluids: Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. [ ] Use humidification with oxygen therapy [ ] Assess peripheral circulation hourly is correct [ ] assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection (Using a blood pressure cuff on the client's arm can cause venous occlusion and increased pain. Alternatives to monitoring blood pressure should be explored when caring for a client who has sickle cell crisis) A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? (A) A client whose family requests hospital-based hospice care (B) A client who requires transfer to a skilled care facility (C) A client who qualifies for telehealth for pacemaker diagnostics (D) A client whose caregiver requests adult day care services - A client whose caregiver requests adult day care services [The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services] (A nurse should assist in the coordination of care for a client who requires transfer to a skilled care facility, which might require a referral for other disciplines such as physical and occupational therapy) (The nurse should assist in the facilitation of telehealth for the client to receive home-based pacemaker diagnostics through the use of electronic communications) A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? (A) Assess fluid intake every 24 hr. (B) Ambulate three times a day. (C) Assist with deep breathing and coughing. (D) Monitor the incision site for findings of infection. - Assist with deep breathing and coughing. [The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia] (Another action is the nurse's priority) Nurse Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to x 3. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision upon inspection intact, no redness, swelling, or drainage noted. Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or shower the day after surgery. Instructed the client to avoid lifting 2.3 kg (5 lb) or more for 1 week. Diet as tolerated. - [ ] Apply heat for abdominal pain as needed - related to CO2 retention [ ] The dressing should be clean, dry, and intact to prevent infection [ ] Encourage deep breathing exercises every hour (medication for nausea should be provided as needed and is contraindicated for scheduled administration) A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? (A) Determine the client's reading skills. (B) Instruct the client on the technique for esophageal speech. (C) Provide the client with an alphabet board. (D) Show the client how to use an artificial larynx. - Determine the client's reading skills. [The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost] A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? (A) "I have experienced physical discomfort when intimate with my partner since my diagnosis." (B) "I wish other women would stop socializing with my partner." (C) "I told my doctor that I would like to start a support group for other women who are sick in my community." (D) "I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness." - "I told my doctor that I would like to start a support group for other women who are sick in my community." [This statement indicates that the client is demonstrating altruism by reaching out and helping others] How do you record reading from a peak expiratory flow meter? - Record the highest of the three readings How far do visitors have to be from a client who has a sealed radiation implant? - 1.8 m (6 feet) A nurse is providing phone advice for a client who is pregnant. Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Advised client to eat small frequent meals of nongreasy, dry, sweet or salty foods, such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea and vomiting worsens. Week 10 of gestation: Spoke with client over the phone. Client reports a 6.8 kg (15 lb) weight loss over the past month. Client states nausea continues, making it difficult to eat. They describe a diet of water, toast, and pretzels because other foods are unappealing. They report tolerating a cup of black coffee each morning. Advised client to be seen by the provider today. Complete the following sentence by using - When prioritizing hypotheses, the nurse should identify that the client is at risk for developing "metabolic acidosis" due to "excessive weight loss." The intake and retention of food is not meeting the client's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue which increases the release of nonvolatile acids into the blood stream. A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (A) "I will decrease my intake of high-fiber foods." (B)"I will apply hydrocortisone cream if I develop a rash on my face." (C) "I will sleep flat on my back if I develop back pain." (D) "I will wear a supportive bra overnight." - "I will wear a supportive bra overnight." [The nurse should teach the client that wearing a supportive bra even while sleeping can promote comfort by providing support to enlarged breasts during pregnancy] (The nurse should teach the client to increase, rather than decrease, their intake of high-fiber foods to prevent constipation) (The nurse should teach the client that hormonal changes during pregnancy can result in increased pigmentation of the face, but hydrocortisone cream will not resolve hyperpigmentation) (The nurse should teach the client to relieve back pain with moderate exercise, sleeping on a firm mattress, and wearing low-heeled shoes. The nurse should also teach the client to sleep on their side to promote placental perfusion) Intestinal blockage nursing interventions: - (1) Administer IV fluids (2) Assist client to semi-Fowler's position (3) Monitor - bowel sounds at least twice daily - Measure urine output due to NPO status Precautions for neutropenic patient undergoing chemo? - (1) Avoid raw fruits (2) Restrict the client's visitors to healthy adults to reduce risk of infection (3) Check client's temp. every 4 hr (4) Keep a disposable gloves in the client's room to reduce the risk of contamination RBC range for men and women: - (1) Male: 14-18 g/dL (2) Female: 12-16 g/dL Acromegaly is at what risk factor according to the bone structure? - Risk of Osteoarthritis Define these alterations in speech: (1) Tangentiality (2) Flight of ideas (3) Word salad (4) Perseveration - (1) Tangentiality: - Speaker doesn't continue to speak about the main topic but instead talks about subject hat don't relate to the main topic (2) Flight of ideas - Speaker talks continuously with sudden, frequent topic changes (3) Word salad - Speaker uses words mixed together w/ little meaning or significance to the listener or the speaker (4) Perseveration: - speaker repeats phrases over & over to avoid answering questions How long do you limit suctioning for a patient who had a stroke 6 hr ago and who is at risk for ICP? - Limit suctioning the client's airway to 15 seconds at a time to reduce the risk of hypoxia & increased ICP What 6 actions should the nurse take for a patient experiencing postpartum hemorrhage? [ ] firmly massage the uterine fundus [ ] provide emotional support [ ] administer methylergonovine [ ] Administer terbutaline [ ] weigh the perineal pads [ ] administer oxygen [ ] inserting an indwelling urinary catheter - All except terbutaline A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? - [ ] "You will give the medication every 8-12 hr" [ ] "Shake the medication bottle well before each dose is given" [ ] "Store the medication in the refrigerator" is correct [ ] "Report diarrhea to the provider immediately" [ ] discard any unused medication after 14 days A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? (A) Hypoxemia (B) Tension pneumothorax (C) Malignant hypertension (D) Atelectasis - Tension pneumothorax [monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins] (A client who is receiving mechanical ventilation is at risk for hypotension resulting from increased chest pressure and decreased blood return to the heart) What's a Romberg test? - (1) The nurse should inform the client that the Romberg test will be performed once with eyes open and once with eyes closed. (2) A Romberg test is performed to assess balance and motor function A nurse is caring for a client who is postoperative following administration of general anesthesia. Vital Signs 0830: Temperature 36.9° C (98.5° F)Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Pulse oximetry 89% on room air Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair. Apical pulse 134/min and irregular Client reports dyspnea. Diagnostic Results 0835: Arterial blood gases (ABGs)pH 7.30 (7.35 to 7.45) PCO2 64 mm Hg (35 to 45 mm Hg) HCO3- 26 mEq/L (21 to 28 mEq/L) PO2 80 mm Hg (80 to 100 mm Hg) The patient is experiencing malignant hyperthermia upon recognizing client cues of tachycardia, tachypnea, hypotension, & irregular heart rhythm. What are the nursing interventions? - take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis (1) Therefore, the nurse should prepare to administer dantrolene and administer oxygen. (2) The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? (A) Amount of vaginal bleeding (B) Amount of urinary output (C) Pain level (D) Fundal height - Amount of vaginal bleeding [The first action the nurse should take using the nursing process is to assess the amount of vaginal bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the nurse's priority] How often should a nurse change IV tubing from a TPN? - at least once every 24 hours A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? (A) Organizing the work environment (B) Delegating assigned tasks appropriately (C) Making a list of activities to complete (D) Rewarding yourself for accomplishing goals - Making a list of activities to complete [Therefore, the nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities]