ATI PN Comprehensive Online Practice 2020 A with NGN

A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client's meal tray? Spaghetti noodles with red sauce A nurse is collecting data from a client who has chronic hepatitis. In which of the following locations should the nurse expect the client to point to indicate hepatic tenderness? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A nurse is assisting with teaching a group of local residents at a community health fair about the Dietary Approaches to Stop Hypertension (DASH) diet. Which of the following statements by a resident indicates an understanding of the teaching? "I will keep my intake of sodium less than 2,300 milligrams per day." Rationale: DASH principles include limiting daily sodium intake to less than 2,300 mg/day. Individuals who have an increased risk for hypertension, such as clients who have kidney disease and diabetes, should reduce intake of sodium to 1,500 mg/day. A nurse is reinforcing teaching about a high-protein diet with a client who has HIV. Which of the following foods should the nurse recommend as containing the highest amount of protein per serving? 2 Tbsp peanut butter The nurse should recommend 2 Tbsp of peanut butter because it contains approximately 7g of protein. A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe haemophilia A. Which of the following statements by the parents indicates an understanding of the teaching? "I will soak my child's toothbrush in warm water to soften it before my child uses it." A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include? ANS: Administer by subcutaneous injection RAT: The nurse should include that enoxaparin should be injected into the subcutaneous tissue A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase.' Which of the following client findings indicates a therapeutic effect of this medication? ANS: Reports a decrease in the number of stools RAT: Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which result in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic response to the medication A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to which of the following interprofessional team members? ANS: Occupational therapist RAT: The nurse should identify the need for a referral to an occupational therapist to teach the client how to use special eating utensils A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion? My doctors glasses have lasers that will burn holes in my brain if i look at them. rationale: The client's statement demonstrates a belief that is contrary to reality that someone intends to cause them harm using unrealistic means. Therefore, the nurse should identify this statement as a delusion of persecution. When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia, A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include? apply capsaicin cream four times daily, rationale: The nurse should instruct the client to apply capsaicin cream topically to provide warmth and relieve joint pain. The client should apply the cream no more than four times daily to avoid skin irritation. A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include? ANS: "Apply a water-based lubricant around the nostrils to prevent irritation." RAT: The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy A nurse in a provider's office is collecting growth and development data from a 7-month-old infant during a well-child visit. Which of the following images should the nurse identify as an indication of expected gross motor skills for the infant? A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first? ANS: Complete a fall risk assessment on the client RAT: The first action the nurse should take when using the nursing process is to collect data from the client. By completing a fall risk assessment, the nurse can identify the client's risk for falls and can then assist in planning interventions to prevent client injury A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first? ANS: Gloves RAT: The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE. A client in a mental health facility unjustly accuses a nurse of stealing money from their room. Which of the following therapeutic responses should the nurse make? ANS: "Tell me how you decided who took your money." RAT: This response by the nurse is an example of therapeutic communication, in which the nurse validates the client's concern by encouraging them to describe their perception Complete the following sentence by using the list of options. The nurse should plan to first collect data about the newborn's : followed by the newborn's: When generating solutions, the nurse should identify that expiratory grunting and nasal flaring are unexpected findings in a newborn and indicate respiratory distress. The presence of meconium-stained amniotic fluid increases the risk that the newborn will develop meconium aspiration syndrome. Therefore, the first action the nurse should take is to collect data about the newborn's respiratory rate, followed by the heart rate. The nurse should perform noninvasive data collection techniques, such as observing the respiratory rate, before more invasive techniques that might stimulate the newborn, such as auscultating the heart rate, to avoid alteration of data. A nurse is receiving change-of-shift report for four clients. The nurse should plan to collect data from which of the following clients first? ANS: A client who has asthma and had frequent exacerbations on the previous shift RAT: When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experienced several exacerbations of asthma on the previous shift, which can result in an obstruction of the client's airway A nurse in a provider's office is caring for a client who is at 34 weeks of gestation. Which of the following instructions should the nurse anticipate providing to the client? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Monitor your blood pressure using your right arm daily, rationale: Based upon the client's statements, assessment, and laboratory findings, the nurse should identify the client has manifestations of preeclampsia. The nurse should instruct the client to monitor their blood pressure daily using the right arm each time so readings are consistent. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include? ANS: Apply the stockings in the morning RAT: The nurse should instruct the client to apply the elastic stockings in the morning and remove them at the end of the day before bedtime A nurse enters a client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse take first? Assist the client to a nearby waiting area. *The greatest risk to the client is injury from the fire. Therefore, the priority intervention is to remove the client from immediate danger. After removing the client from the room, the nurse should then activate the fire alarm system, confine the fire by closing doors and windows, and extinguish the fire, if possible, using a fire extinguisher. A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take? ANS: Provide the client with a handheld event marker to record fetal activity RAT: The nurse will provide the client with a handheld event marker for use in documenting fetal movement. The client will press the button everytime they feel the fetus move throughout the test, which is then logged on the paper tracing recording the heart rate and activity of the fetus A nurse is evaluating the safe use of electrical equipment by a newly hired assistive personnel (AP). Which of the following actions by the AP demonstrates an understanding of the proper use of electrical equipment? ANS: Grasps the plug of a device in the client's room to pull it straight out from the wall RAT: The nurse should recognize that by grasping the plug, rather than the cord, the AP is demonstrating an understanding of proper equipment use and preventing risk of injury from electronic equipment. For which of the following assessment findings should the nurse notify the provider? Select all that apply. When analyzing cues, the nurse should identify that a partial-thickness pressure injury over the sacral area, aching/cramping in the left calf, and capillary refill of 4 seconds are unexpected findings 3 days postoperative for a total left hip replacement and can indicate complications of immobility, such as skin breakdown and deep vein thrombosis. These findings should be reported to the provider. A nurse is reviewing the critical pathway of a client who is 4 days postoperative following a total knee arthroplasty. The client's vital signs are oral temperature 39.1° C (102.4° F), heart rate 116/min, respiratory rate 24/min, and blood pressure 152/92 mm Hg. Which of the following actions should the nurse take? Document the findings as a variance. Whenever a client does not meet the goals or outcomes in the critical pathway due to unexpected findings or a need for additional interventions, the nurse should document the details as a variance in the critical pathway. In this case, it is a negative variance. If the client progresses faster than the pathway specifies, it is a positive variance. A licensed practical nurse is assisting with preparation of a client for insertion of a peripherally inserted central venous catheter (PICC). Which of the following actions should the nurse take? ANS: Witness the client's signature on the informed consent form. RAT: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse should witness the client's signature on the consent form after ensuring the client has an understanding of the procedure, including its risks and benefits A licensed practical nurse (LP) is reviewing client assignments for the upcoming shift. Which of the following clients should the LPN ask the charge nurse to reassign to a registered nurse (RN)? A client who has a new colostomy and requires the development of a teaching plan A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend to the charge nurse for discharge? ANS: A client who has pneumonia and is currently receiving oral antibiotics RAT: The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation A nurse is caring for an older adult client who is experiencing difficulty sleeping. Which of the following actions should the nurse take? ANS: Offer the client a snack of whole grain crackers before bedtime RAT: The nurse should provide the client a light carbohydrate snack, such as whole grain crackers, before bedtime A nurse in a long-term care facility is documenting the care of an older adult client. Which of the following information should the nurse include in the weekly nursing care summary? ANS: Hydration status RAT: Older adults are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client's hydration status and include this information in the weekly nursing care summary A nurse in a long-term care facility is collecting data from a client who has been receiving betaxolol to treat glaucoma. Which of the following findings is an adverse effect of this medication? ANS: Bradycardia RAT: Betaxolol is a beta blocker that can produce systemic effects, such as bradycardia A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A and is incontinent of stool. Which of the following infection control precautions should the nurse instruct the AP to use? ANS: Contact RAT: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of stool, then contact precautions are indicated A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients should the nurse recommend for treatment first? a client who is experiencing shortness of breath after taking amoxicillin Complete the following sentence by using the lists of options. The client is at risk for developing delayed wound healing ~ due to glucose level A nurse is administering morning medications to a client. The client questions the nurse regarding a medication that they do not recognize. Which of the following actions should the nurse take first? ANS: Verify the prescription in the client's medical record RAT: The first action the nurse should take when using the nursing process is to collect more data. By verifying the prescription in the client's medical record, the nurse can ensure that the medication is prescribed for the client A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DR) prescription. After leaving the client's room, which of the following actions should the nurse take first? Check for documentation that the provider spoke with the client about the DNR. A nurse in a provider's office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (Select all that apply.) ANS: Store the child's clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 min. Dry bed linens and clothing in a hot dryer for at least 20 min. RAT: Transmission of lice occurs via contact with personal items. Boiling hair care items in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by washing in hot dryer for at least 20 min is an appropriate strategy A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? ANS: A visitor who develops a bruise on their head following a syncopal episode RAT: The nurse should complete an incident report for an injury involving a client or visitor A nurse is reviewing the electronic health records of four clients. Which of the following client conditions should the nurse recognize as reportable to a regulatory agency? A client who is newly diagnosed with tuberculosis Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. When analyzing cues, the nurse should identify that the client is taking a second-generation antipsychotic medication, which can lead to manifestations of tardive dyskinesia, including involuntary tongue movement and foot tremors. Frequent urination and incontinence are adverse effects of aripiprazole and should be reported to the provider. An increase in agitation is a safety risk for the client, staff, and others on the unit and requires immediate de-escalation. A nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take? Moisten the client's conjunctiva with sterile normal saline A nurse is assisting with the care of a client who is postpartum and has a deep-vein thrombosis. The client has been receiving heparin via IV infusion. Which of the following medications should the nurse ensure is readily available? protamine sulfate A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actions should the nurse take? ANS: Assure the client that a family member will stay with the body after death RAT: The nurse should assure the client that a family member will remain with the body until burial A nurse is preparing to administer an IM immunization to a preschooler. Which of the following statements should the nurse plan to make prior to performing the injection? Let's give the medicine to your doll first When preparing a preschooler for a procedure, the nurse should use play to assist the child in understanding the procedure. By using the child's doll and neutral, concrete terms such as "medicine," the nurse can prepare the child for the injection in a nonthreatening way A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color RAT: The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching? ANS: "I should wear a soft scarf around my neck when I am outside." RAT: A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun exposure A nurse is assisting with planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care? ANS: Administer atropine to reduce the client's respiratory secretions RAT: The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle." A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? ANS: A visitor who develops a bruise on their head following a syncopal episode RAT: The nurse should complete an incident report for an injury involving a client or visitor A nurse is reviewing the electronic health records of four clients. Which of the following client conditions should the nurse recognize as reportable to a regulatory agency? A client who is newly diagnosed with tuberculosis Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. When analyzing cues, the nurse should identify that the client is taking a second-generation antipsychotic medication, which can lead to manifestations of tardive dyskinesia, including involuntary tongue movement and foot tremors. Frequent urination and incontinence are adverse effects of aripiprazole and should be reported to the provider. An increase in agitation is a safety risk for the client, staff, and others on the unit and requires immediate de-escalation. A nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take? Moisten the client's conjunctiva with sterile normal saline A nurse is assisting with the care of a client who is postpartum and has a deep-vein thrombosis. The client has been receiving heparin via IV infusion. Which of the following medications should the nurse ensure is readily available? protamine sulfate A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actions should the nurse take? ANS: Assure the client that a family member will stay with the body after death RAT: The nurse should assure the client that a family member will remain with the body until burial A nurse is preparing to administer an IM immunization to a preschooler. Which of the following statements should the nurse plan to make prior to performing the injection? Let's give the medicine to your doll first When preparing a preschooler for a procedure, the nurse should use play to assist the child in understanding the procedure. By using the child's doll and neutral, concrete terms such as "medicine," the nurse can prepare the child for the injection in a nonthreatening way A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color RAT: The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching? ANS: "I should wear a soft scarf around my neck when I am outside." RAT: A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun exposure A nurse is assisting with planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care? ANS: Administer atropine to reduce the client's respiratory secretions RAT: The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle." Drag 1 condition and 1 client finding to fill in each blank in the following The client is at risk for developing peritonitis due to bowel obstruction. A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? ANS: Observe the client's facial expressions during communication RAT: The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying A nurse is reinforcing teaching with an older adult client who has severe left-sided heart failure. Which of the following statements should the nurse make? ANS: "Rest for 15 minutes between activities." RAT: The nurse should instruct the client to increase activity gradually and to rest for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardiac workload. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first? Open sterile packages *When preparing to perform tracheostomy care, the greatest risk to the client is the transmission of micro-organisms. Therefore, the priority action is to open sterile packages. The nurse should have a sterile bowl in which to pour the sterile solution to prevent the contamination of the sterile gloves. A nurse is making assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)? Preform postmortem care for a client who died 1 hr ago