Ati Rn Predictor Exam

1. A nurse is assessing a client who has left-sided heart failure. Which of the following symptoms should the nurse identify as the highest priority? Jugular distention Frothy pink sputum Hepatomegaly Weight gain 2. A nurse in the emergency department is assisting with the suturing of a laceration to the client’s face. Which of the following actions should the nurse take? Pour the sterile cleansing solution holding the bottle 10 cm (4 in.) above the sterile field Pull the top flap of the suture tray towards the body when opening. Place the bottle of local anesthetic 5 cm (2 in) inside the sterile field border. Drop the suture package on to the sterile field from a distance of 30 cm (12 in). 3. A nurse is assessing a client 1 hr following delivery and notes that her uterus is boggy and….to the umbilicus. Which of the following actions should the nurse take first? Massage the fundus. Assess lochia Take vital signs Give oxytocin (Pitocin) IV bolus. 4. (missing) 5.. A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse? Urinary output greater than fluid intake Report of dry mouth Glasgow Coma Scale score of 15 Bloody drainage on the nasal dressing measuring 3 cm 6. A nurse in an emergency department is caring for a client who has multiple wounds due to a crash. Which of the following interventions are appropriate? (Select all that apply). Apply direct pressure to bleeding wounds. Clean lacerations and abrasions with hydrogen peroxide. Administer 650 mg aspirin PO as needed for pain. Cover wounds with a sterile dressing Determine date of last tetanus toxoid vaccination. 7. A nurse is planning care for four clients. Which of the following clients is the highest priority? A client who has frequent incontinence A client who has dry, black eschar on the heel A client who has a reddened skin area with blanching around the coccyx A client who is wearing an arm cast and reports numb fingers 8. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the clients should the nurse identify as the priority? A client who has massive head trauma A client who has an open fracture of the lower extremity A client who has full-thickness burns to the face and trunk A client who has indication of hypovolemic shock 9. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care? Assist the client to a supine position. Recommend prophylactic acyclovir (Zovirax) for the client's family. Initiate droplet precautions for the client. Perform a Glasgow Coma Scale every 24 hr. 10. A nurse is caring for a client who is unconscious and has an advanced directive indicating no extraordinary measures. The client's son wants everything possible done for his father. Which of the following is an appropriate statement by the nurse? "I will notify the health care provider of your wishes." "Have you talked about this with your family?" _X_ "We have to honor your father's wishes." "Have you discussed this with your minister?" 11. A nurse is assessing a client brought to the hospital's psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. The nurse recognizes these signs and symptoms as being consistent with which of the following? Alzheimer's disease Depression Substance intoxication X Schizophrenia 12. A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile (C. difficile) of the following infection control precautions is appropriate? Place the client in a negative pressure room. _X Place the client in a private room Wear a face shield prior to entering the room. Use an alcohol-based hand rub following client care. 13. A nurse is caring for a client who sprained his left ankle 12 hr. ago. Which of the following orders given by the provider should the nurse clarify? Elevate the affected extremity using two pillows. Apply heat to the affected extremity for 45 min. on and then 45 min off. Assess the affected extremity for sensation, movements and pulse every 4 hr. Wrap the affected extremity with a compression dressing. 14. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? Remove the disposable gown after leaving the toddler's room. Place the toddler in a room with negative air pressure. Use a designated stethoscope when caring for the toddler. Wear an N95 respiratory mask while caring for the toddler. 15. A nurse is developing a discharge care plan for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to avoid sitting in one position for prolonged periods. avoid crossing the legs beyond the midline. splint the affected area. X_ perform weightbearing exercises. 16. A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess first? A client who had a barium enema 2 days ago and reports constipation A client who has anorexia and peripheral edema. A client who has Addison's disease with a blood glucose level of 75 mg/dL A client who had a hip arthroplasty reports and erythema in his calf. 17. A nurse working in a long-term care facility is caring for an older adult client who has dementia. The client is often agitated and frequently wanders the halls. which of the following interventions should the nurse include in the plan of care? Maintain nutritional requirements by offering finger foods Confront the client regarding unacceptable behavior. Stimulate the client by leaving the television on throughout the day. Give the client several choices when scheduling activities. 18. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the foods should be included when initiating feeding? ---- Toast -----Oatmeal ------Beef Broth ------Apple juice 19. A Nurse is performing a skin assessment on a client with risk factors for Development of skin cancer. The nurse should understand that a suspicious lesion is ?