ATI RN Comprehensive 2019 A

A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention? - elevate the leg A nurse is teaching about child safety measures. What statement indicates understanding? - avoid sun exposure 10am-2pm A home health nurse is teaching about infection prevention to a cancer pt on chemo. Which statement indicates understanding? - "I'll walk short distances throughout the day" A nurse is providing dietary teaching to the parents of a 6 month old. What instructions should the nurse give? - introduce new foods over 5-7 days A charge nurse is planning care for a client in mechanical restraints. What interventions? - provide a staff member to stay with the client continuously A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage? - perform a rapid needs assessment A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following requires manager intervention? - tells the hospital chaplain a client's diagnosis A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor. What action should the nurse take? - continue observing the fetal heart rate A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate staff acceptance, what should the nurse manager do first? - provide information about scheduling issues to staff A nurse is planning teaching about allowable foods for a client with uric acidbased urinary calculi formation. What foods should the nurse recommend? - oranges A charge nurse is teaching a newly licensed nurse how to identify true labor. What should the nurse include in the teaching? - the cervix transitions to an anterior position A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client can sign the informed consent? - the client an accurately describe the procedure A charge nurse assigns a new nurse to a client with a chest tube. The new nurse expresses concern d/t limited experience with monitoring drainage. What should the charge do to teach about chest tubes? - ask the nurse about their knowledge of the procedure A nurse is teaching a client about a new prescription for estradiol. For which of the following adverse effects should the nurse tell the client to monitor and contact the provider? - headaches A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is experiencing a grand mal seizure. Available is 5mg/mL. How many mls should the nurse administer? - 0.6mL A nurse is caring for a 12 hour post op on a PCA for pain control and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information. - an Ap who is assisting a client to bed A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. What intervention should the nurse include in the plan? - withhold the varicella vaccine A nurse is providing teaching about improving nutrition for a client who has MS. Which instructions should the nurse include? - -a speech pathologist -rest before eating -thicken beverages before eating A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which finding is the priority for the nurse to provide to the provider? - temp 102.9f A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and a BP of 90/44mm Hg. What med should the nurse anticipate administering? - Flumazenil A nurse is caring for an older adult client in the PACU following general anesthesia. What finding should the nurse report to the provider - audible stridor A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a male client. Which technique should the nurse use to maintain aseptic technique? - set the tray on the table at waist height A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take? - clear objects from the client walking area A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which instruction should the nurse include? - install a raised toilet seat at home A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? - low back pain A nurse is caring for a child who is experiencing a tonic-clonic seizure. What action should the nurse take? - place the child in a side-lying position A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent the tube from clogging? - flush the tube before meds A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? - decreased central vision A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? - clang association A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child returns to school. Which of the following responses should the nurse make? - when crusts have formed on every lesion A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which client statement indicates the client understands the teaching? - "I should report a change in the color of my stools" A nurse is assessing a child with CF. Which finding is priority to report to the provider? - hemoptysis 275mL in 24 hours When caring for a child a nurse plans to use nonpharm interventions to enhance pain med effectiveness. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? - blowing bubbles to "blow the hurt away" An AP and a nurse are turning a patient on their R side. Which AP action requires the nurse to intervene? - place a pillow A nurse on a mental health unit has a patient refusing IM lorazepam. What is the nursing action? - document the refusal A nurse has 4 patients. What should the nurse delegate to the AP for meals? - alzheimers w/ aphasia A mental health nurse is conducting the first of many meetings with a client whose partner recently died. The nurse should perform which action to establish trust in the orientation phase of the nurse-client relationship? - establish the termination date A nurse is caring for a client at 28 weeks gestation. The client asks what's causing her constipation. Which response should the nurse make? - enlarged uterus compresses the intestines A nurse manager reviews falls occur most often between 0530 and 0730. Which action should the nurse take in root cause analysis? - investigate environmental factors A nurse is caring for an immediately post op total vaginal hysterectomy. Which action should the nurse take first? - vital signs A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for organ donation. Which information should the nurse plan to include? - the family can have the child in an open casket A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? - "You will receive fingersticks for blood glucose testing" A nurse is caring for a client with a closed femur fracture and has had a fiberglass leg cylinder cast for 24 hours. Which of the following assessment findings should the nurse identify as the priority? - the client's heel is red and tender A home health nurse is providing teaching to a client that has hep A.Which of the following instructions should the nurse include? - use hydrogen peroxide to clean kitchen surfaces Intermittent Urinary Catheterization - 'straight cath' A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse take first? - Identify health-related issues within the community A nurse is caring for a client who has generalized anxiety disorder and is going to start alprazolam. Which action should the nurse take? - initiate fall precautions A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? - dry the newborn A nurse in a mental health facility is planning care for a client who has anorexia nervosa. Which intervention should the nurse include in the plan of care? - Supervise the client during and after eating A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner is priority? - "My husband doesn't know I;ve already moved out and filed for divorce" A nurse is assessing a client who has MS. Which manifestation should the nurse expect? - nystagmus A nurse is interviewing a client who is now without a home d/t natural disaster. After ensuring the clients safety, what's the nurses first action? - Determine the client's perception of the personal impact of the crisis A nurse is administering enoxaparin. Where? - SubQ A nurse is assessing a client who has skeletal traction for a femur fracture. Which should the nurse identify as the priority? - upper chest petechiae A nurse is assessing a client w/ sickle cell anemia. Manifestation of vaso-occlusive crisis? - hematuria A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Assessment finding priority? - confusion A nurse is providing teaching to the parent of a child who has a permanent trach. Steps of trach care: - 1. remove inner cannula 2. remove soiled dressing 3. clean w/ saline 4. change the trach collar A nurse in an ER is assessing a client that took MDMA. What should the nurse expect? - diaphoresis A nurse is teaching a client who is to start taking misoprostol and is currently on long-term NSAIDs for arthritis. The nurse should provide what information? - serum pregnancy test A nurse is caring for a client with a potassium level of 3. What manifestation should the nurse monitor for? - decreased DTR A nurse in an ER is planning discharge for a client who has experienced intimate partner violence. Which action should the nurse take first? - develop a safety plan A nurse is caring for a client at 37 weeks gestation and is experiencing abruptio placentae. Which finding should the nurse expect? - persistent uterine contractions A nurse is caring for a client in the manic phase of bipolar. Expected manifestations? - grandiose delusions "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out". The client demonstrates which defense mechanism? - sublimation Foods high in vitamin A - raw carrots A nurse is teaching the parent of a school-age child about administering ear drops. Parent response indicating understanding? - pull the top of the ear up and back A nurse is caring for a client that requires PT after discharge. First nursing action? - involve the client in selecting their PT provider A nurse is planning care for a client receiving HD from an AV fistula in the R arm. Which intervention should the nurse include in the plan of care? - auscultate for bruit A nurse is providing teaching for a client about newborn safety. Which statement should the nurse include in the teaching? - hot water heater temp 120F or less A nurse is caring for a newborn with herpes simplex virus (HSV). Which isolation precautions? - contact A home health nurse is planning care for an older adult client who has impaired vision. Which intervention in the plan of care to prevent injury at home? - mark the edges of stairs for contrast A nurse is initiating discharge planning for a client who has a stroke and is experiencing R side weakness. Nurses first action? - Request PT referral A nurse is reviewing lab findings of a client experiencing chest pain. The nurse should identify that an elevation in which lab indicates myocardial cell tissue injury? - Troponin T 5,000U SubQ heparin, available 10,000U/mL. How much to administer? - 0.5mL A nurse in an outpatient clinic is working with a client that has PTSD and asks for recommended nonpharm therapy. What should the nurse recommend to help alleviate distress? - guided imagery A nurse manager is preparing a newly licensed nurse's performance appraisal. Which method should the manager use to evaluate time management skills? - maintain regular notes about the nurses time management skills A nurse is caring for four clients at the beginning of a shift. After report, which client should the nurse attend to first? - confused client getting out of bed A night shift nurse is giving change-of-shift-report to the day shift nurse on a client ready for discharge. Priority information to oncoming nurse? - the client needs assistance transferring from bed to w/c A nurse is assessing a client who has a stage II pressure injury. Expected would characteristics? - partial thickness skin loss A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. Which client statements shows understanding of teaching? - "I should watch for dry mouth and constipation" A charge nurse is preparing to administer 0900 meds and is told by pharmacy the meds are not available. First charge nurse action? - inform the nurse manager A nurse is caring for a client that vomits on a reusable BP cuff. Nurses action? - place the BP cuff in a labeled bag for decontamination A nurse is assessing a 2hr old newborn. Report to MD? - axillary temp 36.2C (97.2F) A nurse manager is on a planning committee to develop an emergency preparedness plan. Which action takes place first when implementing an emergency preparedness plan? - notify the incident commander A nurse is preparing to administer 15U regular insulin along with 20U NPH. Which action plan should the nurse take? - inject 20U air into NPH insulin vial A charge nurse overhears 2 staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which action should the charge nurse take? - tell the nurses to stop the discussion A nurse is assessing a client who is 2hrs post op following a cardiac cath. Report to MD? - neuro status A nurse is providing client education to a postpartum client who has decided to bottle feed their newborn. Instructions to prevent the discomfort of engorgement? - ice packs on the breasts for 15 minutes several times per day A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? - a client who has DM and repeat admissions for DKA A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates understanding of the procedure? - keeps the HOB elevated to 45 degrees for 1hr after feedings A nurse is assessing a client during the immediate postpartum period. Which finding requires immediate intervention? - boggy uterus A nurse is caring for a newborn whose parents ask why their baby is receiving vitamin K. The nurse explains vitamin K prevents: - bleeding A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? - avoid venipunctures when possible A nurse is assessing a 2 month old infant during a well-baby exam. Which of the following actions should the nurse take to assess the infant's rooting reflex? - stroke the cheek A nurse is teaching a client that has a new prescription for digoxin about manifestations of toxicity. Which finding should the nurse include in the teaching? - nausea A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Expected finding? - protein A nurse working on a med-surg unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's parents. Nursing action? - ask the caller for verification of their identity A nurse is caring for a client who has end stage Alzheimer's Disease. The adult child of the client says 'I don't know why I bother to visit my mother anymore". Nurse response? - "It seems like you feel your visits are a waste of time" A nurse is assessing a client who has antisocial personality disorder. Expected manifestations? - lack of remorse