ATI PN Comprehensive Online Practice 2020 A

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? ANSWER 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 QUESTION A nurse is caring for a client who is receiving telemetry. which of the following ECG findings should the nurse report to the charge nurse? ANSWER PR interval 0.24 seconds. QUESTION A nurse in an urgent care clinic is collecting data from four clients. which of the following clients should the nurse recommend for treatment? ANSWER a client who is experiencing shortness of breath after taking amoxicillin. QUESTION A nurse is assisting with the transfer of a client to a long term care facility. the nurse should review which of the following sections of the electronic medical record to locate information about the clients personal health insurance? ANSWER admission sheet. QUESTION A nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. which of the following statements should the nurse make? ANSWER you should increase your fluid intake after this procedure. QUESTION A nurse is reinforcing teaching about puberty with a group of prepubescent female clients. Which of the following information should the nurse include in the teaching? ANSWER you will likely gain weight before you start to get taller. QUESTION A nurse is assisting with a discussion about STI's with a group of adolescents at a health fair. which of the following statements should the nurse make? ANSWER an infection with gonorrhoea may result in infertility. QUESTION A nurse in a providers office is caring for client who is at 34 weeks of gestation. Which of the following instructions should the nurse anticipate providing to the client? ANSWER monitor your blood pressure using your right arm daily. QUESTION A nurse is preparing to administer amoxicillin 875 mg PO every 12 hours. The amount available is amoxicillin oral suspension 400 mg/5mL. How many mL should the nurse administer per dose? ANSWER 11. QUESTION 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? ANSWER B. QUESTION A nurse is monitoring a client who is receiving lactated ringers 500 mL over 4 hr. the drop factor of the manual IV tubing is 10gtt/mL. The nurse should check that the manual IV infusion is delivered at how many gtt/min? ANSWER 21. QUESTION A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include? ANSWER apply capsaicin cream four times a day. QUESTION A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first? ANSWER ANS: Obtain a set of the client's vital signs RAT: The first action the nurse should take when using the nursing process is to collect data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the nurse can identify the need for intervention QUESTION 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? ANSWER ANS: ContactRAT: 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 QUESTION A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the electronic health record to locate information about the client's personal health insurance? ANSWER ANS: Admission sheet RAT: The nurse will find client data, such as date of birth, occupation, and the client's source of health insurance, on the client's admission sheet QUESTION A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider? ANSWER ANS: Generalized petechiae RAT: Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of the newborns who has a nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the newborn's body can indicate infection or a decreased platelet count and should be reported to the provider QUESTION A nurse in a provider's office is obtaining the health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority for the nurse to ask? ANSWER ANS: Do you know if you're allergic to iodine? RAT: The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies QUESTION A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider? ANSWER ANS: INR 5.0RAT: The international normalized ratio (INR) is a measurement of the body's blood clotting ability. A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value QUESTION 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? ANSWER 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. QUESTION 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? ANSWER ANS: I will soak my child's toothbrush in warm water to soften it before my child uses it. RAT: The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge-tipped disposable toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity QUESTION A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion? ANSWER ANS: A client hits another client because they thought the other client was talking about them RAT: The nurse should request a prescription for seclusion for a client who hits another client to protect the client and others from physical injury QUESTION A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? ANSWER ANS: Coronary artery disease RAT: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension QUESTION A nurse is assisting with the care of a school-age child immediately following surgery. The child weights 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider? ANSWER ANS: 250 mL of sanguineous drainage over the last 3 hr RAT: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active haemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately QUESTION A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. Which of the following findings should the nurse report to the provider as an indication of hyperglycaemia? ANSWER ANS: Polyuria RAT: The nurse should identify polypuria as an expected finding of hyperglycaemia and report this finding to the provider QUESTION A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? ANSWER ANS: I will dispose of my needles in a plastic laundry detergent container. RAT: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container. QUESTION A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take? ANSWER ANS: Encourage the client to reminisce about the past RAT: The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicit feelings of happiness QUESTION A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider? ANSWER ANS: PR interval 0.24 seconds RAT: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval can indicate a heart block; therefore, the nurse should report this finding provider QUESTION A nurse on a medical unit is reviewing a client's medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent form? ANSWER ANS: Lumbar puncture RAT: The nurse should identify that a client needs to provide consent for general treatment as well as a separate written informed consent for any treatment that has an element of risk, such as a lumbar puncture QUESTION A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following instructions should the nurse include? ANSWER ANS: Use lower-body strength RAT: The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back QUESTION A nurse is participating in a quality improvement study about the effectiveness of client pain management on the unit. Which of the following strategies should the nurse use to collect data? ANSWER ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr after administration RAT: The nurse should collect data from clients' charts about pain ratings before and after pain management interventions QUESTION A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching? ANSWER ANS: Your HIV status will be shared with members of your health care team. RAT: The diagnosis of HIV or AIDS is shared with every member of the health care team who provides direct care for the client, just like any other diagnosis QUESTION A nurse is planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the client's room? ANSWER ANS: Suction catheter RAT: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway QUESTION A licensed practical nurse (LPN) 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)? ANSWER ANS: A client who has a new colostomy and requires the development of a teaching plan RAT: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client's need for a teaching plan regarding the new colostomy and request that this client be reassigned to an RN. The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established QUESTION 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? ANSWER 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 QUESTION A nurse is preparing to perform blood glucose monitoring for a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first? ANSWER ANS: Hold the finger for testing in a dependent position RAT: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen QUESTION 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? ANSWER 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 QUESTION 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.) ANSWER ANS: Store the child's clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 mi. 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 QUESTION A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination? ANSWER ANS: Use intermittent urinary catheterization for the client at regular intervals RAT: A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch. QUESTION A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take? ANSWER ANS: Tell the client they should not experience any discomfort RAT: The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This non-invasive procedure should not cause the client any discomfort QUESTION A nurse is caring for a client who is crying and states that their provider informed them that they have a tumor and will need a biopsy. Which of the following responses should the nurse make? ANSWER ANS: What have you done to help yourself get through stressful situations before?RAT: This is a therapeutic response. The nurse is aware that the client is under stress and encourages comparison to investigate whether they have experience dealing with a stressful situation QUESTION A nurse is caring for a newborn who is 12 hr old. The nurse should expect the newborn's stool to have which of the following characteristics within the first 24 hr following birth? ANSWER ANS: Dark greenish-black and viscous RAT: The first stool passed by a newborn is the meconium that develops in utero. It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood QUESTION A licensed practical nurse is assisting with preparation of client for insertion of a peripherally inserted central venous catheter (PICC). Which of the following actions should the nurse take? ANSWER 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 QUESTION 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? ANSWER ANS: Spaghetti noodles with red sauce RAT: The nurse should identify that spaghetti noodles with red sauce is appropriate for a client who adheres to a kosher diet. QUESTION 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? ANSWER 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 QUESTION 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 IV infusion. Which of the following medications should the nurse ensure is readily available? ANSWER ANS: Protamine sulfate RAT: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin QUESTION A nurse is reinforcing teaching with a client about how to replace their two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest? ANSWER ANS: Hold the skin taut while removing the barrier RAT: Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin QUESTION A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following resposes should the nurse make? ANSWER ANS: What is your current understanding about the purpose of AA? RAT: The nurse should identify the client's understanding about the purpose of AA to provide further information about the program and meetings and to facilitate a referral if needed. For treatment to be successful, the nurse should involve the client in the care decision-making process. This ensures the treatment program meets the client's individual needs and demonstrates caring by the nurse QUESTION A nurse is performing a dressing change for a client who is 3 days postoperative. Which of the following findings should the nurse report to the provider? ANSWER ANS: Yellow-green drainage at the incision line RAT: Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the provider QUESTION A nurse is providing comfort to the partner of a client who has died. Which of the following statements should the nurse make? ANSWER ANS: Journaling about your relationship might help with the grieving process. RAT: Journaling provides a means for the client to identify thoughts and feelings and to recognize and come to terms with the positive and negative aspects the client's relationship with their partner QUESTION A nurse is assisting with an educational session for newly licensed nurses about partner violence. Which of the following characteristics should the nurse include as placing a vulnerable person at risk for partner violence? ANSWER ANS: Recent confirmation of pregnancyRAT: The nurse should include pregnancy as a characteristic placing a vulnerable person at risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship due to the attention the child receives QUESTION A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury. Which of the following instructions for safe lifting technique should the nurse include? ANSWER ANS: You should hold a box close to your body when lifting it up. RAT: The client should hold the box as close to their body as possible to maintain balance and prevent injury QUESTION 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? ANSWER 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 QUESTION A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect? ANSWER ANS: The client calls their partner to ask what they should wear each day RAT: Clients who have dependent personality disorder have problems making everyday decisions without input from others QUESTION A nurse is caring for a client who is scheduled for a mastectomy the following day. The client is tearful and tells the nurse that they are not ready to have this procedure done at this time. Which of the following responses should the nurse make? ANSWER ANS: Would you like for me to talk to the surgeon with you? RAT: The nurse should advocate for the client's needs by offering to talk to the surgeon with the client. The nurse should also offer moral support and encourage the client to express their concerns and make a more informed decision QUESTION A nurse is documenting client care in the medical record. Which of the following entries should the nurse make? ANSWER ANS: Client remains NPO until x-ray procedure is complete. RAT: The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation NPO, which is an accepted abbreviation for nothing by mouth. QUESTION 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? ANSWER ANS: Observe the client's facial expressions during communicationRAT: 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 QUESTION A nurse is collecting data from a client who reports recent methamphetamine use. Which of the following manifestations should the nurse expect? ANSWER ANS: Dilated pupils RAT: The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance QUESTION 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? ANSWER 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 QUESTION A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client? ANSWER ANS: Walking outside with a staff member RAT: During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the one-on-one nature of the activity provides the client with a sense of security QUESTION 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? ANSWER 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. QUESTION A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching? ANSWER ANS: Strain the urine to collect stone fragments RAT: The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation QUESTION A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider? ANSWER ANS: Muscle pain RAT: The nurse should instruct the client to report findings of muscle pain or tenderness to the provider. These findings can be manifestations of myopathy, or muscle injury, which is a potential serious adverse effect of atorvastatin QUESTION A nurse is caring for a client who is recovering from a motor vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make? ANSWER ANS: I cannot give you this information. You will need to speak with your employee. RAT: Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclosed in a health care setting. The nurse should inform the employer they will need to speak with the client directly QUESTION A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take? ANSWER 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 QUESTION 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? ANSWER 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 QUESTION 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? ANSWER 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. QUESTION A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following positions should the nurse plan to place the client durign the procedure? ANSWER ANS: Upright with arms resting on the overbed table RAT: The nurse should position the client upright with arms resting on the overbed table to widen the intercostal spaces and improve access to the pleural fluid QUESTION A nurse is talking with a client who says the provider agreed to initiate a do-notresuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first? ANSWER ANS: Check for documentation that the provider spoke with the client about the DNRRAT: The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements QUESTION A nurse is observing a client who is in the first stage of labor. Which of the following interventions should the nurse recommend for this client? (Select all that apply.) ANSWER ANS: Squatting using an exercise ball. Counter pressure to the sacral area. Pelvic rocking. RAT: Squatting using an exercise ball can help relax the pelvis and perineal area and can relieve pain during contractions. Counter pressure to the sacral area can help decrease pain by relieving pressure on the spinal nerves caused by the fetus's occiput. Pelvic rocking can relieve backache during the first stage of labor. To perform this motion, the client hollows their back and then arches it to relieve back pain. QUESTION A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? ANSWER 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 QUESTION A client is requesting information from a nurse about creating a health care proxy. Which of the following statements should the nurse make? ANSWER ANS: The person you appoint will make health care decisions for you if you cannot do so yourself. RAT: The nurse should instruct the client that a health care proxy designates a surrogate to make health care decisions when the client is no longer able to make decisions for themselves. QUESTION 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? ANSWER 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 QUESTION A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take? ANSWER ANS: Flush the feeding tube with water before and after administering the medication RAT: To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration QUESTION A nurse is planning care for a 5-year-old child who is 8 hr postoperative following a tonsillectomy. Which of the following interventions should the nurse include in the plan of care? ANSWER ANS: Administer PRN analgesics regularly for the first 24 hr. RAT: The nurse should administer analgesics for the first 24 hr even if they are ordered on an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics regularly provides a steady state of analgesia. With pain being managed, children are more likely to consume fluids, remain hydrated, and avoid delayed discharge or readmissions for fluid volume deficit. QUESTION A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include? ANSWER ANS: You should increase your fluid intake while receiving this medication through the PCA pump. RAT: The client should increase their fluid intake to prevent or relieve the adverse effect of constipation while receiving morphine through the PCA pump QUESTION A nurse is using the FLACC scale to determine the pain level of an 11-month-old infant who is postoperative. Which of the following factors should the nurse consider when using this pain scale? ANSWER ANS: Level of activity RAT: The nurse should consider the infant's activity level when using the FLACC pain scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolability (C). QUESTION 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? ANSWER 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 QUESTION A nurse is caring for a newborn who is 1 hr old. The mother received fentanyl 30 min before birth. For which of the following adverse effects should the nurse monitor the newborn? ANSWER ANS: Respiratory depression RAT: Fentanyl, an opioid agonist, rapidly crosses the placenta, and it is present in fetal blood within 1 min. The nurse should monitor the newborn for respiratory depression, which is an adverse effect of fentanyl QUESTION A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen? ANSWER ANS: The client takes the medication once daily at bedtime RAT: Montelukast, a leukotriene modifier, is taken once a day for maintenance at bedtime QUESTION 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? ANSWER 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. QUESTION A nurse in a paediatric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect? ANSWER ANS: The toddler is inadequately dressed for the weather RAT: Inappropriate dress is a suggestive finding of physical neglect. The nurse should collect further data for other indicators of physical neglect QUESTION A nurse enters the room of an adolescent client and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take when the seizure subsides? ANSWER ANS: Keep the client in a side-lying position RAT: The nurse should keep the client in a side-lying position to facilitate drainage of any secretions and prevent aspiration QUESTION A nurse is contributing to the plan of care for a client who has a prescription for rangeof- motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension? ANSWER ANS: Move the arm behind the body with the elbow straight RAT: Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight QUESTION A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which of the following client statements should the nurse use as an example of rationalization? ANSWER ANS: I didn't get a good grade because my teacher does not like me. RAT: The nurse should recognize this statement as the use of rationalization by a client. Rationalization is used as a means of justifying unreasonable feelings, thoughts, or actions QUESTION A nurse is caring for an older adult client who is experiencing difficulty sleeping. Which of the following actions should the nurse take? ANSWER 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 QUESTION A nurse is preparing a client for an enternal feeding and notices that the pump at the client's bedside is warm to the touch. Which of the following actions should the nurse take?