ATI PN EXIT EXAM GRADED A 2025

A nurse is caring for a client who is today's postoperative which of the following findings should the nurse identify as an indication of postoperative infection? Serous drainage in the clothes section collection device A nurse is caring for a client who was admitted for observation following a head injury, which of the following findings by the nurse indicates the client is experiencing increased ICP? Decreased BP A nurse is reviewing the medical record of a client who has hepatic cirrhosis which of the following lab values should the nurse report to the provider? Potassium 3.1 mEq/L A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives, which of the following findings is a contraindication for this client? HTN A nurse is reinforcing discharge teaching with a client who is stable angina pectoris, which of the following statements by the client indicates an understanding of what to do when chest pain occurs? Stop what I am doing and lie down A nurse is receiving a telephone prescription from a client's provider which of the following actions should the nurse take? SATA - Ask the provider to spell out the name of the medication - Request that the provider confirm the read back of the prescription - Record the date and time of the telephone prescription A nurse is reinforcing teaching about passive ROM exercises with the family of a client who has had a stroke, which of the following instructions should the nurse include in the teaching? Support the extremity above and below each joint during the exercises A nurse is reinforcing teaching with a client who has a prescription for an antibiotic therapy the client tells the nurse that he always experiences diarrhea when he takes antibiotics which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? Yogurt A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization which of the following findings in the clients record should the nurse recognize as a contraindication? Chemotherapy treatments A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift which of the following tasks the nurse delegate to an AP? SATA - Measure VS for a client who requires contact precaution - Record urine output for a client who has a super pubic catheter - Transfer a client who is receiving radiation therapy to radiology A nurse in an inpatient medical health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy, which of the following statements about a client indicates an understanding of the procedure? I might have short term memory loss after the procedure A nurse is assisting with discharge planning for a group of clients during a mass casualty incident which of the following client should the nurse recommend for discharge? A client who had DKA and has a blood glucose level of 120 mg/dL A nurse is caring for a client who is postoperative following a subtotal thyroidectomy the nurse should place the client in which of the following positions? Semi Fowler's A nurse is discussing the plan of care of a client who is four hours postoperative and has a urostomy with an AP which of the following statements should the nurse include in the discussion? We need to check the clients urine output every hour A nurse is collecting data from a client who has heart failure the nurse notices the client has crackles in the bases of the lungs, SOB and a RR of 24 bpm, which of the following actions should the nurse take? Maintain the client in high Fowlers position A nurse is preparing to administer 0.9% sodium chloride 250 mL IV to infuse over 30 minutes to a client the nurse just set the IV pump to deliver how many milliliters per hour? 500 mL/hr A nurse is collecting data from a client who has a UTI and is taking Ciprofloxacin. The client reports pain in her calf muscle ,which of the following statements should the nurse make? Discontinue the medication I will ask your provider for another antibiotic A home health nurse is conducting a home inspection for a client who is at risk for falls, which of the following instruction should the nurse provide for the client? Move the clients bed to the main floor on the house A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior which of the following actions should the nurse take after applying physical restraints to the client? Plan to remove the restraints as soon as the client is calm A nurse is caring in the client's respirations and notes they are of average heart rate is 24 bpm and the rhythm is regular which of the following alterations in the clients breathing pattern should the nurse continue to monitor? Tachypnea A nurse manager is a system with the negotiation between to charge nurses were having a conflict over staff not completing assignments which of the following actions should the nurse manager take? Establish ground rules before beginning discussion between the charge nurses A nurse is caring for a client who is receiving intermittent external feeding and he has diarrhea which of the following actions should the nurse take? Deliver a smaller amount of formula more frequently A nurse is feeding a client who had a stroke resulting in left side of weakness which of the following actions should the nurse take? Encourage the client to drink a small amount of liquids to clear his mouth of food A nurse is caring for a client who is taking furosemide which of the following affects should the nurse monitor? Hypokalemia A nurse is reinforcing teaching with a client who has a UTI which of the following instruction should the nurse include in the teaching? Wear cotton underwear A nurse is reinforcing dietary teaching with a client who's pre-pregnancy BMI was 30.5 the nurse should recognize that the client understands the teaching when she states she should expect to gain how many pounds during her pregnancy? 16 pounds A nurse is caring for a client who is taking acetaminophen overdose which of the following findings should the nurse expect? Diarrhea A nurse is reinforcing teaching with a newly licensed nurse about performing a 12 lead ECG which of the following statements about a newly licensed nurse indicates an understanding of the teaching The test will show conduction patterns and different paths of cardiac electrical activity A nurse is reinforcing teaching with a parent of a newborn about home safety precaution, which of the following statements by the parent indicates an understanding of the teaching? I will make sure that I can fit one finger between the mattress and the side of my newborns crib A nurse is collecting data from a client who is receiving IV therapy the nurse suspects fluid infiltration which of the following findings should the nurse expect at the insertion site? Edema A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus which of the following instruction should the nurse include in the teaching? Cut your toenails straight across A nurse is caring for four clients which of the following situations require a signed consent form? Giving a Haemophilus influenza B vaccine to a infant A nurse is collecting data from a middle adult client who reports experiencing sexual dysfunction the nurse should identify that which of the following medications the client states can cause sexual dysfunction? FLUOXETINE A nurse is reinforcing teaching with a client who has Gerd and a prescription for ranitidine which of the following statements by the client indicates an understanding of the teaching I should take this medication in the morning and at bedtime A nurse manager in a long-term care facility is discussing evidence-based practice with a group of staff nurses which of the following activities should the nurse manager identify as an example of evidence-based practice? Staffing the unit based on client acuity and needs A nurse is preparing to give change of shift report on a client who is today's postoperative following total knee arthroscopy which of the following information about the client should the nurse include in the report? Time of last pain medication A nurse is assisting with the plan of care for an order of the client who has dementia and is experiencing nocturnal confusion which of the following actions should the nurse take to decrease the clients risk for injury? Activate bed alarm A nurse is reinforcing teaching with a client who has a new diagnosis of COPD which of the following statements by the client indicates an understanding of the teaching? I should practice pursed lip breathing exercises A nurse is reinforcing teaching with a group of adolescent male clients about testicular examination which of the following statements by a client indicates an understanding of the teaching I should expect one testicle to be larger than the other A nurse is reinforcing teaching with a client who is in 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron deficiency anemia which of the following recommendations should the nurse week to improve the absorption of the medication? Avoid drinking milk with the iron supplement A nurse answers the room of a school age child and find some on the floor experiencing a tonic clonic seizures which of the following actions should the nurse take? Place a pillow under the child's head A nurse is implementing a bladder training program for a client who had a stroke which of the following intervention should the nurse take? Check for residual urine after voiding A nurse is collecting data from a client who is it risk for a pulmonary embolism following surgery which of the following findings should the nurse monitor? Dyspnea A nurse is contributing to the plan of care for a client who has bulimia nervosa, which of the following intervention should the nurse recommend? Schedule the client for a dental examination A nurse is assisting with the plan of care for a group of clients which of the following client should the most recommend for an interprofessional conference A client who has a spinal cord injury A nurse is reinforcing teaching with a parent of a 4 month old infant during a home visit which of the following statements by the parent indicates an understanding of the teaching? I will use a cool mist vaporizer in my babys room A nurse is receiving change of shift report on 4 clients which of the following clients should the nurse plan to see first? A client who has a femur fracture and reports numbness of the toes A nurse is reinforcing teaching with the parents of a school aged child who has oppositional defiant disorder which of the following recommendations should the nurse include in the teaching? Establish consequences for disruptive behavior A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak which of the following intervention should the nurse recommend Place disposable thermometers in the clients room A nurse is reinforcing teaching about albuterol with a client who has asthma which of the following affects of medication shut the nurse include in the teaching? Decreased bronchospasms A nurse is caring for a client who has schizophrenia which of the following behaviors of the client should the nurse identify as a negative symptom Initiates speech rarely A nurse is caring for a client who reports diarrhea for the past 48 hours which of the following finding's indicates the client is experiencing dehydration Temperature 37.2 (99.1) A nurse in an adult daycare facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss which of the following strategies should the nurse include in the plan Use symbols in the communal room signage ... Hep C A nurse is reviewing the medical record for a client who is at 30 weeks of gestation and has anemia which of the following laboratory values should the nurse expect Hgb 9.9 g/dL A nurse is reinforcing teaching with a female client about contraception which of the following statements by the client indicates an understanding of the teaching My partner will use condoms with spermicides A nurse in a providers office is reinforcing teaching about skin care with a client who has a new diagnosis of lupus which of the following statements about a client indicates an understanding of the teaching I will dry my skin by patting it with a towel A nurse is contribution to the plan of care for a client who had prolonged exposure to the cold weather And has a core body temperature of 32.5 c (90.5 f)which of the following data is the priority for the nurse to monitor Heart rhythm A nurse is assisting with the plan of care for a client who is 72 hr postoperative following a above the knee amputation which of the following interventions should the nurse include Assist the client to perform range of motion of the hips A nurse is reinforcing teaching with the parent of a preschooler who has atopic dermatitis which of the following instruction should the nurse include in the teaching Dress the child in soft Cotton clothing A home health nurse is preparing to set up a continuous passive motion machine for a client who is postoperative following total knee replacement which of the following actions should the nurse plan to take first Inspect the cpm machine electrical cord for damage A nurse is caring for a client who is 2 days postoperative following an above the knee amputation which of the following actions should the nurse tske to promote progression toward independence and mobility for the client Encourage the clieny to use overbed trapeze A nurse is collecting data from a client who has macular degenration which of the following findings should the nurse expect Loss of central vision A nurse is collecting data from a client who is jn bucks traction which of the following findings indicates the functioning correctly The weights apply a pulling force continiously A nurse is caring for a 3 yr old at a well child visit the parent reports they are concerned that their son has begun playing with an imaginary friend. Which of the following responses should the nurse make This is a common behavior for children this age A nurse is participating in a performance improvement program which of the following actions should the nurse take to evaluate the effectiveness of the program Review the facilitys policy and procedure manual BUN levels 10-20 WBC levels 5,000-10,000 Serum creatinine levels males 0.6-1.2; females 0.5-1.1 Therapeutic digoxin levels 0.8-2.0 HbA1c levels 4%-6% Fasting glucose levels 70-105 HDL levels males 35-65; females 35-85 Total serum cholesterol levels less than 200 LDL levels less than 130 ABG values [pH, PCO2, HCO3] pH 7.35-7.45 PCO2 35-45 HCO3 21-28 Phosphorus levels 3-4.5 Platelet levels 150,000-400,000 aPTT levels; therapeutic level? 30-40 seconds; therapeutic is 1.5 to 2 times the normal INR levels 0.7-1.8 Therapeutic level for INR with anticoagulant therapy 2-3 PT levels; therapeutic level? 11-12.5 seconds; therapeutic is 1.5 to 2 times the normal Chloride levels 98-106 Calcium levels 9-10.5 Diseases that require airborne precautions measles, TB, herpes zoster and varicella Heparin antidote protamine sulfate Coumadin antidote vitamin k Digoxin antidote digibind Alcohol withdrawal antidote librium (chlordiazepoxide) Potassium levels 3.5-5 Sodium levels 136-145 Magnesium sulfate antidote calcium gluconate Magnesium levels 1.3-2.1 Diseases for droplet precautions [SPIDERMAN] S - scarlet fever; sepsis P - pneumonia; pertussis I - influenza D - diphtheria E - epiglottitis R - rubella M - mumps; meningitis AN - adenovirus Risk factors of metabolic alkalosis ingestion of antacids; GI suction; hypokalemia; blood transfusion; prolonged vomiting; total parenteral nutrition A cause of metabolic acidosis diarrhea [acidosis - from the ass]; fever; hypoxia; starvation; seizure; kidney failure; diabetic ketoacidosis; dehydration Position of cane walking cane opposite affected leg [COAL] Don't give Metformin when ... someone is having procedures with contrast dye; can cause acute renal failures Diseases for contact precautions [Mrs. Wee] M - multidrug resistant organism R - respiratory infections S - skin infections W -wound infections E - E - eye infection; conjuctivitis Do not delegate to AP assessment, teaching, medication, evaluation, and unstable patients Immediate treatment for MI [MONA] M - morphine O - oxygen N - nitroglycerin A - aspirin Bleeding precautions [RANDI] R - razor (electric) A - aspirin (NO!) N - needles (small gauge) D - decrease needle sticks I - injury (protect from) Stomach pain in upper right quadret gallstones, stomach ulcers, pancreatitis Stomach pain in upper left quadret stomach ulcer, duodenal ulcer, biliary colic, pancreatitis Stomach pain in lower right quadret appendicitis, constipation, pelvic pain, groin pain (inguinal hernia) Stomach pain in lower left quadret diverticular disease, pelvic pain, groin pain Stomach pain in upper middle quadret stomach ulcer, heartburn/indigestion, pancreatitis gallstones, epigastric hernia Lab values for renal failure low magnesium and high creatine Vaccinations contraindicated in pregnant women smallpox, measles, mumps, rubella, varicella Don't give what food with MAOIs tyramine (chocolate, alcohol, and fermented foods like cheese) NEVER give _ in IV push potassium Do not give _ at bedtime tetracycline; don't let them lie down b/c it might cause gastric reflux S/S of LSHF cyanosis, tachycardia, orthopnea, pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea) restlessness, paroxysmal nocturnal dyspnea S/S of RSHF edema, weight gain, ascites, distended jugular veins, fatigue, anorexia Risk factors of respiratory acidosis respiratory depression; pneumothorax; airway obstruction; inadequate ventilation Risk factors of repiratory alkalosis hyperventilation; hypoxemia; altitude sickeness; asphyxiation; asthma; pneumonia Response for fire [RACE] R - rescue A - alarm C - contain E - extinguish How often to remove restraints and check on client every 2 hours Characteristics that increase risk for falls older age, cognitive/sensory impairment, impaired mobility, bowel and bladder dysfunction, side effects of medications, and history of falls Equipment at client's bedside for seizure precautions oxygen, oral airway, and suction equipment Description of semi-fowlers head of bed elevated at 30 degrees Description of fowlers head of bed elevated to 45 degrees Description of high-fowlers head of bed elevated to 90 degrees Description of supine lying on back, head, and shoulders Description of prone lying on abdomen, legs extended, and head turned to side Description of lithotomy lying on the back with hips and knees flexed at righ angles and feet in stirrups Description of sims lying on left side with most of the body weight borne by the anterior aspect of the ilium, humerus, and clavicle (client is unconscious or receiving enema) If patient isn't voiding, don't give ... potassium Manifestations of hypokalemia (low potassium) muscle weakness, cramping, nausea, vomiting, decreased bowel motility, dysrhythmias, irritability Manifestations of hyperkalemia (high potassium) peaked T waves, ventricular dysrhythmias, increased bowel motility Addison's disease need to add ... cortisol Newborn vital signs HR 100-160 R 40-60 BP 60-80 systolic; 40-50 diastolic APGAR categories HR, respiratory effort, muscle tone, reflex irritability, color Motor skills of 1 month old demonstrates head lag; strong palmar grasp reflux Motor skills of 2 month old lifts head off matress; holds hands Motor skills of 3month old raises head and shoulders off mattress; voluntary grasp present Motor skills of 4 month old rolls from back to side; places objects in mouth Motor skills of 5 month old rolls from front to back; strong palmar grasp Motor skills of 6 month old rolls from back to front; holds bottle Motor skills of 7 month old bears full weight on feet; moves objects from hand to hand Motor skills of 8 month old sits unsupported; begins using pincer grasp Motor skills of 9 month old pulls to a standing position; pincer grasp is more precises Motor skills of 10 month old changes from a prone to a sitting position; grasp rattle by its handle and picks up finger foods Motor skills of 11 month old walks while holding onto something; places objects into a container Motor skills of 12 month old sits down from a standing position without assistance; tries to build a two-block tower without success Prevention of SIDS place babies on their backs to sleep, breastfeeding may provide some protection, and use of a pacifier when sleeping Newborn's first BM dark green and viscous Contraction of hep A contaminated water or food Contraction of hep B blood or bodily fluids of an infected person Contraction of hep C exposure to tainted blood; can transfer from mother to child during birth; tattooing, body piercing, and cocaine snorting are associated Contraction of hep D produces when hep B is present; can be prevented with hep B vaccine Contraction of hep E contaminated water supplies or in travelers returning from abroad Type 2 diabetes and the flu drink sugar-free liquids to prevent dehydration Orthopnea position ..... lung expansion increase Duration of precautions for varicella until lesions crust over S/S of meningitis fever, headache, irritability, altered LOC, nuchal rigidity, increased ICP Latex allergy manifestation rhinorrhea (thin, watery discharge from the nose) Foods to avoid when taking aldactone salt substitutes and foods with high levels of potassium Foods rich in thiamine lean meats, whole grain cereals, leguems Foods rich in riboflavin milk, organ meats, enriched grains, green leafy veggies Foods rich in niacin meat, beans, peas, peanuts, enriches grains Foods rich in folic acid leafy green veggies, eggs, liver Diet management for Diverticulosis high-fiber diet Diet management for Diverticulitis begin with clear liquids, then advance to low-fiber diet; low residue Positioning for hip arthroplasy keep abductor pillow in place while in bed; don't flex hip more than 90 degrees Positioning for knee arthroplasty maintain continue passive motion machine to promote joint mobility Nursing intervention for Addison's Disease monitor and treat hypoglycemia Nursing intervention for Cushing's Disease monitor and treat hyperglycemia Contributing factors to type 2 diabetes family history, obesity, race/ethnicity, hypertension, history of gestational diabetes, and sedentary lifestyle Position for spinal cord injuries high-fowlers Nursing interventions for radiation treatment monitor condition of skin; clients should wear soft, loose clothing, and avoid exposure to sun Foods rich in iron fish, organ meats, green leafy veggies, enriched breads/cereal/macaroni, whole grain products, dried fruit like raisins and apricots, and egg yolk Calculating delivery date subtract 3 months and add 7 days to the first day of the last menstraul period Five rights of delegation right person, task, circumstances, direction and communication, and supervision and evaluation