ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using
which of the following instruments? - ansCup
a nurse is caring for a 4m old infant who is immediately postop following cleft palate repair, what intervention should the nurse take -
ansapply elbow restraints to the infant
A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse
anticipate for the infant 6 hr after the procedure? - ansSmall, frequent bottle feedings of electrolyte solution
a nurse is caring for a child who has a congenital heart defect, the nurse should recognize which of the following defects is
associated with increased pulmonary blood flow - ansPDA
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made.
Which of the following responses should the nurse make? - ansAn abdominal ultrasound will confirm the pocket in the intestine
a nurse is caring for a child who has acute glomerulonephritis without edema, what action should the nurse take to obtain - ansdaily
weight
a nurse is caring for a child who has bacterial meningitis, what action should the nurse take - ansinitiate seizure precautions
a nurse is caring for a child who has cancer and is receiving chemo, the parent tells the nurse that she wants to d/c treatment and
take the child home, what responses should the nurse make - anstell me more about your reasons for making this decision today
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? - ansEncourage the child
to use an incentive spirometer
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? -
ansFrequent swallowing
a nurse is caring for a school-age child who has hemophilia and reports increased bruising, what lab values explain the finding -
ansplt count 120,000
a nurse is caring for a school-age child who has metastatic osteosarcoma, the child asks the nurse "am I going to die?", what should
the nurse respond - ans"It sounds like you are worried. tell me what you have been told"
a nurse is caring for a toddler who drinks 950mL (32oz) of milk per day and has a poor appetite, the nurse should identify that the
toddler is at risk for - ansiron deficiency anemia
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- ansPeriorbital edema
A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take?
- ansSuction the infant gently with a bulb syringe PRN
a nurse is caring for an infant who has GERD, what action should the nurse take to avoid regurgitation - ansthicken the pt's formula
and avoid giving the pt citrus juices position the child with the head elevated after meals
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions
should the nurse include in the plan? - ansMonitor the child for increased temperature
a nurse is developing a plan of care for a 4yr old who has hemophilia and is experiencing acute hemarthrosis, what interventions
should the nurse include in the plan - ansplace ice packs on the affected joints
a nurse is instilling otic drops into a toddler's ears, what method is used - anspull the pinna down and back
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the
following interventions should the nurse include in the plan? - ansMaintain the child on bed rest
a nurse is preparing a teaching plan for the parent of a school-age child who has asthma, the nurse should include what
manifestation as an "exacerbation" of asthma - anshacking, non-productive cough
,ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent
asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? - ans"The test shows us
if your child had a recent strep infection."
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations
should the nurse make? - ansIncrease the child's protein intake.
a nurse is providing discharge teaching to the parent of a school-age child who has an infection of the throat caused by group A
beta-hemolytic streptococci, what instructions should the nurse give to the parent - anscontinue to administer the prescribed
antibiotic for 10d give your child acetaminophen or children ibuprofen for fever
A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which
of the following statements by the parent indicates an understanding of the teaching? - ansI will inspect my child's mouth every day
for sores
a nurse is providing discharge teaching to the parents of a 6-month-old infant following a surgical procedure to repair hypospadias,
what instructions should the nurse include in the teaching - ansavoid giving the infant a tub bath until the stent is removed
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions
should the nurse include in the teaching? - ansKeep the child away from people who have an infection
a nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing
a Vaso occlusive crisis. what instructions should the nurse include in the teaching - ansincrease your child's intake of oral fluids
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods
should the nurse recommend? - ansScrambled eggs
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human
immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? - ansThe pneumococcal
and influenza vaccines are recommended for your child
a nurse is providing teaching to a mother who plans to breastfeed her 3-day-old infant, what info should the nurse include in the
teaching - ansyour baby will need a follow-up evaluation by her provider within the next 3 days
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse
include in the teaching? - ansPlace a plastic bag over the cast when showering
a nurse is providing teaching to an adolescent who has a new prescription for cefazolin, what adverse effect should the nurse
monitor for and report to the physician - ansurticaria
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following
responses by the adolescent indicates an understanding of the teaching? - ansI can take my brace off for about an hour daily to
shower
a nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin, what
instruction should the nurse include - anstake the medication at the same time each day
a nurse is providing teaching to parents of a school-age child who has ADHD and a new prescription for methylphenidate ER
capsules, what responses by the parent indicate an understanding of the nurse's instruction - ansI will inform my child's teacher that
he is taking this medication
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent
indicates an understanding of the teaching? - ans"My child should consume 1,000 calories per day."
a nurse is providing teaching to the parent of a child who has a new prescription for methylphenidate, what instruction should the
nurse include to administer - ansthe second dose of the medication at lunchtime
a nurse is providing teaching to the parent of a preschooler about health promotion, what response by the parent indicates an
understanding of the teaching I should encourage my child to have - ans1 hour of physical activity each day
a nurse is providing teaching to the parent of an infant about care seat safety, what statement by the parent indicates an
understanding of the teaching - ansI should place the car seat rear facing until my child is 2
,ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
a nurse is providing teaching to the parents of a school-age child who has pediculosis capitis, what instruction should be included -
anssoak her brushes in boiling water for 10min
A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of
hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? - ansI will make sure
my child drinks 240 mL (8 oz) of milk as soon as possible
A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops.
Which of the following instructions should the nurse include? - ansMassage the anterior area of the infant's ear following
administration
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the
following findings should the nurse report to the provider? - ansPotassium 2.5 mEq/L
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory
values should the nurse report to the provider? - ansHg 6g/dL
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values
for urine specific gravity should the nurse expect? - ans1.035
a nurse is reviewing the medical record of a 16 yr old brought in by his parents to receive a physical, the record indicates he
received his last immunization 10 years ago, what immunizations should the nurse expect to administer to the adolescent - ansTdap
a nurse is suctioning the tracheostomy of a child, what assessment findings indicate the effectiveness of the procedure - ansclear
breath sounds
A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The
nurse should teach the newly hired nurse to monitor the infant for which of the following complications - ansHydrocephalus
a nurse is teaching a school-age child and her parents about managing diabetes mellitus during illness, the nurse determines
teaching has been effective when they indicate they will provide which of the following when the child is ill - ansincrease fluids
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse
take first? - ansDemonstrate the injection technique on an orange.
A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair
as a newborn. Which of the following findings should the nurse include in the teaching? - ansBarking cough
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following
responses by the adolescent indicates an understanding of the teaching? - ansI will record the highest reading of three attempts.
A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the
parent indicates an understanding of the teaching? - ansI will give my child a dose of albendazole today and again in 2 weeks
a nurse is teaching the parent of an infant about preventing SIDS, what following statement should the nurse make - ansyou should
put your infant in bed with a pacifier
a nurse is teaching the parents of a toddler about strategies to manage temper tantrums, what instructions should the nurse include
in the teaching to establish - ansa structured daily routine for the child
a nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following the placement
of tympanoplasty tubes. the parent asks, what should I do if the tubes fall out. What should the nurse instruct? - ansnotify the
provider that the tubes have fallen out
a school nurse is assessing a child who fell from playground equipment and landed headfirst, what clinical manifestations should the
nurse recognize as indicating increased intracranial pressure - ansreport of diplopia
a school nurse is assessing the visual acuity of a school-age child, what finding indicates that the child should be evaluated for
strabismus - ansmovement of the uncovered eye during a cover test
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of
the following assessment findings are indicative of increased ICP? (Select all that apply)
A. Headache
, ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
B. Dilated pupils
C. Tachycardia
D. Decorticate posturing
E. Hypotension - ansA, B, D
A nurse in the ED is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and
slumped to the ground." Which of the following techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - ansA
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing
slowly. Which of the following actions should the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - ansA, C, D, E
A nurse is assessing a client for changes in the level of consciousness using the GCS. The client opens his eyes when spoken to,
speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse
document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ansB
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings?
(Select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - ansB, C
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the
following actions should the nurse implement? (Select all that apply)
A. Provide privacy
B. Ease the client to the floor if standing
C. Move furniture away from the client
D. Loosen the client's clothing
E. Protect the client's head with padding
F. Restrain the client - ansA, B, C, D, E
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception - ansC
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and
Brudzinski's signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
ALREADY GRADED A+
A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using
which of the following instruments? - ansCup
a nurse is caring for a 4m old infant who is immediately postop following cleft palate repair, what intervention should the nurse take -
ansapply elbow restraints to the infant
A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse
anticipate for the infant 6 hr after the procedure? - ansSmall, frequent bottle feedings of electrolyte solution
a nurse is caring for a child who has a congenital heart defect, the nurse should recognize which of the following defects is
associated with increased pulmonary blood flow - ansPDA
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made.
Which of the following responses should the nurse make? - ansAn abdominal ultrasound will confirm the pocket in the intestine
a nurse is caring for a child who has acute glomerulonephritis without edema, what action should the nurse take to obtain - ansdaily
weight
a nurse is caring for a child who has bacterial meningitis, what action should the nurse take - ansinitiate seizure precautions
a nurse is caring for a child who has cancer and is receiving chemo, the parent tells the nurse that she wants to d/c treatment and
take the child home, what responses should the nurse make - anstell me more about your reasons for making this decision today
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? - ansEncourage the child
to use an incentive spirometer
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? -
ansFrequent swallowing
a nurse is caring for a school-age child who has hemophilia and reports increased bruising, what lab values explain the finding -
ansplt count 120,000
a nurse is caring for a school-age child who has metastatic osteosarcoma, the child asks the nurse "am I going to die?", what should
the nurse respond - ans"It sounds like you are worried. tell me what you have been told"
a nurse is caring for a toddler who drinks 950mL (32oz) of milk per day and has a poor appetite, the nurse should identify that the
toddler is at risk for - ansiron deficiency anemia
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- ansPeriorbital edema
A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take?
- ansSuction the infant gently with a bulb syringe PRN
a nurse is caring for an infant who has GERD, what action should the nurse take to avoid regurgitation - ansthicken the pt's formula
and avoid giving the pt citrus juices position the child with the head elevated after meals
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions
should the nurse include in the plan? - ansMonitor the child for increased temperature
a nurse is developing a plan of care for a 4yr old who has hemophilia and is experiencing acute hemarthrosis, what interventions
should the nurse include in the plan - ansplace ice packs on the affected joints
a nurse is instilling otic drops into a toddler's ears, what method is used - anspull the pinna down and back
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the
following interventions should the nurse include in the plan? - ansMaintain the child on bed rest
a nurse is preparing a teaching plan for the parent of a school-age child who has asthma, the nurse should include what
manifestation as an "exacerbation" of asthma - anshacking, non-productive cough
,ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent
asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? - ans"The test shows us
if your child had a recent strep infection."
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations
should the nurse make? - ansIncrease the child's protein intake.
a nurse is providing discharge teaching to the parent of a school-age child who has an infection of the throat caused by group A
beta-hemolytic streptococci, what instructions should the nurse give to the parent - anscontinue to administer the prescribed
antibiotic for 10d give your child acetaminophen or children ibuprofen for fever
A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which
of the following statements by the parent indicates an understanding of the teaching? - ansI will inspect my child's mouth every day
for sores
a nurse is providing discharge teaching to the parents of a 6-month-old infant following a surgical procedure to repair hypospadias,
what instructions should the nurse include in the teaching - ansavoid giving the infant a tub bath until the stent is removed
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions
should the nurse include in the teaching? - ansKeep the child away from people who have an infection
a nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing
a Vaso occlusive crisis. what instructions should the nurse include in the teaching - ansincrease your child's intake of oral fluids
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods
should the nurse recommend? - ansScrambled eggs
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human
immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? - ansThe pneumococcal
and influenza vaccines are recommended for your child
a nurse is providing teaching to a mother who plans to breastfeed her 3-day-old infant, what info should the nurse include in the
teaching - ansyour baby will need a follow-up evaluation by her provider within the next 3 days
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse
include in the teaching? - ansPlace a plastic bag over the cast when showering
a nurse is providing teaching to an adolescent who has a new prescription for cefazolin, what adverse effect should the nurse
monitor for and report to the physician - ansurticaria
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following
responses by the adolescent indicates an understanding of the teaching? - ansI can take my brace off for about an hour daily to
shower
a nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin, what
instruction should the nurse include - anstake the medication at the same time each day
a nurse is providing teaching to parents of a school-age child who has ADHD and a new prescription for methylphenidate ER
capsules, what responses by the parent indicate an understanding of the nurse's instruction - ansI will inform my child's teacher that
he is taking this medication
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent
indicates an understanding of the teaching? - ans"My child should consume 1,000 calories per day."
a nurse is providing teaching to the parent of a child who has a new prescription for methylphenidate, what instruction should the
nurse include to administer - ansthe second dose of the medication at lunchtime
a nurse is providing teaching to the parent of a preschooler about health promotion, what response by the parent indicates an
understanding of the teaching I should encourage my child to have - ans1 hour of physical activity each day
a nurse is providing teaching to the parent of an infant about care seat safety, what statement by the parent indicates an
understanding of the teaching - ansI should place the car seat rear facing until my child is 2
,ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
a nurse is providing teaching to the parents of a school-age child who has pediculosis capitis, what instruction should be included -
anssoak her brushes in boiling water for 10min
A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of
hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? - ansI will make sure
my child drinks 240 mL (8 oz) of milk as soon as possible
A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops.
Which of the following instructions should the nurse include? - ansMassage the anterior area of the infant's ear following
administration
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the
following findings should the nurse report to the provider? - ansPotassium 2.5 mEq/L
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory
values should the nurse report to the provider? - ansHg 6g/dL
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values
for urine specific gravity should the nurse expect? - ans1.035
a nurse is reviewing the medical record of a 16 yr old brought in by his parents to receive a physical, the record indicates he
received his last immunization 10 years ago, what immunizations should the nurse expect to administer to the adolescent - ansTdap
a nurse is suctioning the tracheostomy of a child, what assessment findings indicate the effectiveness of the procedure - ansclear
breath sounds
A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The
nurse should teach the newly hired nurse to monitor the infant for which of the following complications - ansHydrocephalus
a nurse is teaching a school-age child and her parents about managing diabetes mellitus during illness, the nurse determines
teaching has been effective when they indicate they will provide which of the following when the child is ill - ansincrease fluids
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse
take first? - ansDemonstrate the injection technique on an orange.
A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair
as a newborn. Which of the following findings should the nurse include in the teaching? - ansBarking cough
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following
responses by the adolescent indicates an understanding of the teaching? - ansI will record the highest reading of three attempts.
A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the
parent indicates an understanding of the teaching? - ansI will give my child a dose of albendazole today and again in 2 weeks
a nurse is teaching the parent of an infant about preventing SIDS, what following statement should the nurse make - ansyou should
put your infant in bed with a pacifier
a nurse is teaching the parents of a toddler about strategies to manage temper tantrums, what instructions should the nurse include
in the teaching to establish - ansa structured daily routine for the child
a nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following the placement
of tympanoplasty tubes. the parent asks, what should I do if the tubes fall out. What should the nurse instruct? - ansnotify the
provider that the tubes have fallen out
a school nurse is assessing a child who fell from playground equipment and landed headfirst, what clinical manifestations should the
nurse recognize as indicating increased intracranial pressure - ansreport of diplopia
a school nurse is assessing the visual acuity of a school-age child, what finding indicates that the child should be evaluated for
strabismus - ansmovement of the uncovered eye during a cover test
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of
the following assessment findings are indicative of increased ICP? (Select all that apply)
A. Headache
, ATI CAPSTONE FUNDAMENTALS PRE-ASSESSMENT
ALREADY GRADED A+
B. Dilated pupils
C. Tachycardia
D. Decorticate posturing
E. Hypotension - ansA, B, D
A nurse in the ED is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and
slumped to the ground." Which of the following techniques should the nurse use to open the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - ansA
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing
slowly. Which of the following actions should the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - ansA, C, D, E
A nurse is assessing a client for changes in the level of consciousness using the GCS. The client opens his eyes when spoken to,
speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse
document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ansB
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings?
(Select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - ansB, C
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the
following actions should the nurse implement? (Select all that apply)
A. Provide privacy
B. Ease the client to the floor if standing
C. Move furniture away from the client
D. Loosen the client's clothing
E. Protect the client's head with padding
F. Restrain the client - ansA, B, C, D, E
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception - ansC
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and
Brudzinski's signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
