ATI - Comprehensive Practice 2019 A

1. a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of the left lower leg. which of the following interventions should the nurse include in the plan of care? - elevate the affected leg -ambulation should be encouraged -warm compresses -encourage the client to drink 2 to 3 L decrease platelet aggregation 2. a nurse is teaching a group of guardians about child safety measures. which of the following statements by a guardian indicates an understanding of the teaching? - I should have my child avoid sun exposure between 10 am and 2 pm 3. a home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? - I will walk for short distances throughout the day 4. a nurse is providing dietary teaching to the parents of a 6-month-old infant. which of the following instructions should the nurse include? - Introduce new foods one at a time over 5 to 7 days The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies. -The parents should not offer the infant whole milk, because the majority of the infant's calories should come from human milk or commercial, iron-fortified formula. 5. a charge nurse is planning care for a client who has mechanical restraints in place. which of the following interventions should the nurse include in the plan? - Provide a staff member to stay with the client continuously can be physically or using an audiovisual device need to document every 15-30 minutes, a new prescription should be in every 4 hrs for adults, every 3 hrs for 9-17 years and every hour for those younger 6. need to document every 15-30 minutes, a new prescription should be in every 4 hrs for adults, every 3 hrs for 9-17 years and every hour for those younger 7. a community health nurse is assisting with the development of a disaster management plan. the nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? - performing a rapid needs assessment -Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage. 8. a nurse manager is assisting with the orientation of a newly licensed nurse. which of the following actions by the nurse requires the nurse manager to intervene? - tells the hospital chaplain a clients diagnosis 9. a nurse is caring for a client who is in labor at 39 weeks of gestation. during the second stage of labor, the nurse observes early deceleration on the monitor tracing. which of the following actions should the nurse take? - continue observing the fetal heart rate these are an expected finding 10. a nurse manager is planning to make changes to the current scheduling system on the unit. to facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? - provide information about scheduling issues to the staff unfreezing stage - increase understanding of why change is needed 11. a nurse is planning teaching about allowable foods for a client who has a history of uric acid based urinary calculi formation. which of the following foods should the nurse include in the teaching? - oranges can eat citrus fruits no chicken, no organ meats like liver, no red wine (avoiding purine) 12. a charge nurse is teaching a newly licensed nurse how to identify true labor. which of the following should the nurse include in the teaching? - the cervix transitions to an anterior position contractions will be felt in the lower abdomen and back, intensity increases with ambulation, cervix shortens and thins 13. a nurse on a medical surgical unit is caring for a client prior to a surgical procedure. which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? - the client is able to accurately describe the upcoming procedure 14. a charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. which of the following actions should the charge nurse take first to provide teaching about chest tubes? - ask the nurse about their knowledge of the procedure 15. a nurse is teaching a client who has a new prescription for estradiol. for which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? - headaches - can be indicative of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. 16. a nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand maul seizure. available is diazepam solution for injection 5mg/mL. how many mL should the nurse administer? 0 - 0.6 mL 17. a nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. which of the following staff members should the nurse assign to collect the information? - An assistive personnel (AP) who is assisting a client to return to bed 18. a nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm^3. which of the following interventions should the nurse include in the plan? - withhold administering the varicella vaccine to the child - severe immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed. 19. a nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. which of the following instructions should the nurse include? select all - A speech pathologist will be performing a swallowing study for you you should rest before eating meal thicken your beverage before drinking "A speech pathologist will be performing a swallowing study for you." is correct. The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. “You should rest before eating a meal." is correct. The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued. “You should restrict foods that are high in vitamin D." is incorrect. The nurse should instruct the client to maintain adequate vitamin D levels, because vitamin D deficiency is a risk factor for multiple sclerosis. “Reduce your intake of dietary fiber." is incorrect. The nurse should instruct the client to increase dietary fiber and fluids to decrease the risk of constipation, which is a manifestation of multiple sclerosis. “Thicken your beverages before drinking." is correct. The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. 20. a nurse is assessing a client who has schizophrenia and is taking chlorpromazine. which of the following findings is the priority for the nurse to report to the provider? - temperature 39.4 (102.9) 21. a client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? - flumazenil 22. a nurse is caring for an older adult client in the PACU following general anesthesia. which of the following findings should the nurse report to the provider? - audible stridor 23. a nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. which of the following techniques should the nurse use to maintain surgical aseptic technique? - set the catheter tray on the overbed table at waist height -open the top outer flap away from the body to prevent contamination of the sterile field by reaching over it when opening the remaining flaps. -clean with the dominant hand -don sterile gloves before touching an item 24. a nurse is planning care for a client who has a deficit with cranial nerve II. which of the following actions should the nurse plan to take? - clear objects from the clients walking area 25. a nurse is providing discharge instructions to a client following a total hip arthroplasty. which of the following instructions should the nurse include? - install a raised toilet seat at home 26. a nurse is assessing a client who is receiving a blood transfusion. which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? - low back pain other signs include hypotension, tachycardia 27. a nurse is caring for a child who is experiencing a tonic clinic seizure. which of the following actions should the nurse take? - place the child in a side lying position 28. a nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. which of the following actions should the nurse take to prevent clogging of the tube? - flush the client's gastrostomy tube with 30 mL of water before administering the medication 29. a nurse is assessing a client who has macular degeneration. which of the following findings should the nurse expect? - decreased central vision - The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina. 30. a nurse is assessing a client who has schizophrenia. the nurse should identify the following alteration in speech as which of the following? - clang association - uses words based on their sound rather than their meaning (this one had a lot of b words) 31. a nurse in a clinic receives a call form a guardian whose child has varicella. the guardian asks when the child can return to school. which of the following responses should the nurse make? - when the crusts have formed on every lesion 32. a nurse is providing discharge instructions to a client who has a new prescription for warfarin. which of the following client statements should the nurse identify as an indication that the client understands the teaching? - I should report a change in the color of my stools - red, black, tarry, etc. 33. a nurse is assessing a school age child who has cystic fibrosis. which of the following findings is the priority for the nurse to report to the provider? - hemoptysis 275 mL/24 hr 34. when caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? - blowing bubbles with liquid soap to blow the hurt away 35. an assistive personnel and a nurse are turning a client onto the right side. which of the following actions by the AP requires the nurse to intervene? - Places a pillow under the client's right arm the AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder the AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder 36. a nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. which of the following actions should the nurse take? - document the client's refusal of the medication 37. a nurse is caring for four clients., which of the following clients should the nurse assign to an assistive personnel to assist with meals - a client who has Alzheimer's disease and is demonstrating aphasia 38. a mental health nurse is conducting the first of several meetings with a client whose partner recently died. the nurse should perform which of the following actions to establish trust during the orientation phase of the nurse client relationship - establish the termination date of therapy 39. a nurse is caring for a client who is at 28 weeks of gestation. the client asks the nurse to explain what causes her to have constipation. which of the following responses should the nurse make? - the enlarged uterus compresses the intestines and causes constipation -During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation. 40. a nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0540 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis - investigate environmental factors that might be contributing to client injury during these hours 41. a nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. which of the following actions should the nurse take first? - measure the clients vital signs (every 15 minutes until stable) and then every 4 hr for the next 48 hr.) 42. a charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. which of the following information should the nurse plan to include? - the family can have the child in an open casket without fearing that the organ donation might disfigure the child's body 43. a nurse is teaching about total parenteral nutrition TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? - you will receive fingersticks for blood glucose testing MY ANSWER-A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPM solution 44. a nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hours. which of the following assessment findings should the nurse identify as the priority? - the client's heel is reddened and tender (possible pressure injury) Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel. 45. a home health nurse is providing teaching to a client who has hepatitis A. which of the following instructions should the nurse include? - use hydrogen peroxide to clean kitchen surfaces 46. a nurse is preparing to perform an intermittent urinary catheterization for a client who has unrainy retention. which of the following images indicates the catheter the nurse should use? - It's a picture of a catheter that is pink in color with no bulbs or anything just one single tube 47. a community health nurse is preparing a health education program for a local rural community. which of the following actions should the nurse plan to take first? - identify health related issues within the community 48. a nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. which of the following actions should the nurse take? - initiate fall precautions for the client (common adverse effects are orthostatic hypotension, dizziness, confusion, and lethargy) 49. a nurse in the delivery room is caring for a newborn immediately after birth. which of the following actions should the nurse take first? - dry the newborn 50. a nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. which of the following interventions should the nurse include in the clients plan of care? - supervise the client during and after eating. The nurse should monitor the client during and for 1 hr after meals to prevent the client from hiding food or purging. everything to do with food should be structured, the client has minimal choices 51. a nurse is talking with the partner of a client who attempted suicide. which of the following statements by the client's partner should the nurse identify as the priority? - "my husband doesn't know that I've already moved out of the house and filed for a divorce" (lack of social and emotional support) 52. a nurse is assessing a client who has multiple sclerosis. which of the following manifestations should the nurse expect? - nystagmus (involuntary eye movement) abdominal striae is found in Cushing’s disease masklike face is found in Parkinson’s disease