ATI RN CONCEPT BASED ASSESSMENT LEVEL 1 ONLINE PRACTICE A 2023 100

ATI RN CONCEPT BASED ASSESSMENT LEVEL 1 ONLINE PRACTICE A 2023 100% VERIFIED SOLUTION Clinical manifestations of heart failure - cool extremities 6 month infant has bacterial pneumonia. clinical manifestations of b. pneumonia - nasal flaring Acute asthma exacerbation what actions should the nurse take first - apply humidified oxygen with a simple mask Diabetes foot care - ill wash my feet everyday with soap and lukewarm water Decreased urinary output. what findings should be identified as a risk factor for the development of pyelonephritis? - diabetes mellitus Acute cholecystitis (select all) - fever, dyspepsia, and eructation Client has appendicitis. what actions should the nurse take - place the client in semifowler's position Caring for a client following collection of admission data. what should the nurse identify as a priority? - client reports coughing and a change of voice whenever he eats Client has respiratory acidosis due to opioid oversedation - ensure the patient airway using a chin-lift maneuver Which client is at risk for developing respiratory acidosis? - client who has abdominal ascites? Teaching about newborns and crib use - dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or sheet Findings that indicate a therapeutic response to anti hyperlipidemia medication - HDL 50 mg/dL Teaching to parents about epinephrine auto-injector - "give a second injection if the first fails to reverse your child's symptoms" Client is experiencing a panic attack - stay with the client until manifestations subside Mix NPH insulin and insulin steps - cloudy, clear, clear, cloudy Gastroenteritis with dehydration. which med should the nurse administer? - ondansetron Adverse effect of acetaminophen - elevated aspartate aminotransferase levels Potassium level of 6 mEq/L would cause ECG to look like what? - Tall T waves 6 month old infant with mild dehydration - capillary refill greater than 2 seconds Acute pyelonephritis findings - urinary burning A client has COPD and a resp. rate of 22 and reports SOB. what would the nurse do - place the client in high-fowlers position A client has metabolic acidosis due to salicylate overdose. what findings should the nurse expect? - flushed, dry skin Hypermagnesemia clinical manifestation - bradycardia Client has external fixator to the right lower arm, what would indicate that the client has compartment syndrome? - numbness of the fingers on the right arm A client has AIDS, what lab data would determine if the client is at risk for malnutrition - albumin level Client is 1 hour post op from open carpal tunnel release to treat injury - elevate the client's arm above the heart Discharge teaching for the parent of a newborn - "do not bathe your new born immediately after she eats" A client is at 13 weeks gestation with hyperemesis gravidarum - "drink fluids between, rather than with, meals" Client has calcium oxalate renal calculi. what would u teach them - "limit the amount of spinach in your diet" A school age child has asthma and SOB. what findings would be priority? - inaudible lung sounds An adolescent client has a skin infection caused by MRSA - "I will soak in a bathtub filled one-fourth full of water and one-half cup of bleach" An adolescent has infectious mononucleosis. what would be a manifestation of this - onset of abdominal pain A client is experiencing an asthma attack. what would the nurse use to assess the client's respiratory status - peak expiratory flow meter testing A nurse is teaching a client about foot care with peripheral neuropathy - "file your toenails straight across to prevent ingrown toenails" Clinical manifestations of heat stroke - oliguria A client has a sodium level of 124 mEq/L, what manifestations should the nurse expect? - orthostatic hypotension A client's parent recently died. what would place the client at risk for maladaptive grieving? - the client lost his house in a fire one month ago The parent has a child with pediculosis capitis. what would the nurse tell the parent? - to comb the child's hair daily with an extra fine tooth comb A parent has a child with scabies. what would the parent say to indicate understanding of teaching? - "i should wash my child's bed linens and clothing in hot water and detergent" A client has peripheral arterial disease. what would be a finding of this? - dependent rubor A nurse is providing teaching to a client with MRSA. what would be an understanding of this disease for the client to say? - "I will wash all uninfected skin areas with a fresh washcloth" What would be a manifestation that the nurse should expect for an infant who might have otitis media? - enlarged postauricular lymph nodes A client has hyperthyroidism and has been taking methimazole for 6 months. what indicates a therapeutic response? - the client reports sleeping longer during the night Metabolic alkalosis would give u what lab value? - potassium 3 mEq/L A client is going in for a laproscopic appendectomy. which of the findings would the nurse report? - report of urinating small amounts twice daily a client has severe hypothermia. which actions should the nurse take - contact a specialized team to place the client on cardiopulmonary bypass a client has cellulitis in a lower extremity. what action should the nurse take? - elevate the extremity above heart level a client has frostbite to the fingers and toes, what would the nurse include in the teaching about frostbite? - place the affected areas of frostbite in a warm water bath a young female client has GAD and is taking clonazepam. what would the nurse include in the teaching? - "this medication could cause you to have thoughts of self-harm" what is a manifestation of respiratory acidosis? - confusion a client has a subdermal implant placed for contraception. what are the adverse effects of this? - irregular bleeding which of the following is a risk factor for peptic ulcers? - long term use of NSAIDs a client has been practicing adaptive use of coping mechanisms. which one indicates the client's use of suppression? - "I avoid thinking about my problems that worry me until I have time to focus on a solution" a client has osteoporosis. what should be included in the teaching? - perform exercises to strengthen the abdominal core a client has hyperventilation. the client's ABG results are "7.5 pH, 29 mm Hg PaCO2, and 25 mEq/L HCO3-" what can be interpreted? - Respiratory alkalosis a client has hyperglycemic-hyperosmolar state related to complications of diabetes - hypotension a client has recently lost his partner to a terminal illness. the client asks how his 4 year old son should react to this death. - A preschooler often believes that death is reversible which of the communicable diseases diseases require reporting? - gonorrhea a client has osteoarthritis. what would the nurse include in teaching about exercise? - perform exercise even on d ays when joints are painful which area should the nurse assess on a patient with cholelithiasis? - A -- RUQ Which would suggest that a client's nutritional status is improving? - 1 kg weight gain over the past 2 days a client has AIDS and is experiencing anorexia. which would the provider prescribe to the client? - megestrol (increases appetite) a client has renal calculi. what would cause the nurse to notify the provider immediately? - oliguria with bladder distention a client is taking atorvastatin. which would suggest the medication is having an adverse effect? - aspartate aminotransferase (AST) 45 units/L a client's partner died 1 month ago. the client doesn't believe she can ever be happy again. what would the nurse say? - "What are some of the best times with your partner that you remember?" age-related macular degeneration has a risk factor of what? - hypertension a client is about to have an induction of labor due to fetal demise. what would the nurse do? - bathe, diaper, and dress the child before bringing the newborn to the client a client has hypokalemia. what fruits should the nurse recommend? - one small orange a client has renal calculi and is taking oxybutynin for pain. what would the nurse identify as an adverse effect of this medication? - distended bladder a client has gestational diabetes and ketoacidosis. what manifestation would be expected? - increased urination a client is being taught about how to prevent hearing loss from trauma. what would be included in the teaching? - "keep your mouth open when sneezing" a client has partial obstruciton of the large bowel. what would be a manifestation? - ribbon-like stools what lab results would be identified as na adverse effect of sulfasalazine? - WBC count 4,000/mm3 what should the nurse instruct to avoid in a patient who has gerd? - caffeinated coffee emergency department for someone who has been out of the country? (exhibit) - surgical mask which of the following medications should the nurse expect the provider to prescribe in C. difficile? - vancomycin A nurse in a providers office is reviewing the medical record of a client who has COPD. which of the following findings should the nurse report to the provider? - sputum culture shows gram positive bacteria nurse providing discharge teaching to a client with diverticulitis. what should she include? - consume a clear liquid diet nurse teaching about ezetimibe with a client who has hyperlipidemia. What client statements is correct? - i will return to have my cholesterol checked in two weeks a nurse is assessing a client who has musculoskeletal trauma following a motor vehicle crash two days ago. what finding should she report? - pain report discharge teaching for a client who has a new diagnosis of COPD. which of the following statements shows PT understanding? - breathe out slowly through pursed lips if i feel short of breath which of the following menu choices shows patient understanding of hyperlipidemia? - black bean burger on a whole grain bun a nurse is participating screenings for osetoporosis. which of the following is a risk factor for the disease? - hip fracture 6 months ago client who has an intense fear of heights - acrophobia which of the following actions should the nurse take for a client who has possible appendicitis? - start IV fluid replacement a nurse is assessing a preschool-age child who has chickenpox. how should the parent treat it - avoid giving aspirin a nurse is preparing to administer medication to a client who has a history of hypertension. what should the nurse administer for antihypertension therapy? - hydrochlorothiazide exercise induced asthma and has new prescriptions for cromolyn. what should the nurse include in the teaching? - use albuterol prior to planned exercise? a nurse is admitting an infant who has pertussis. what following action should the nurse take? - droplet precautions warfarin to treat atrial fibrillation. what should nurse identify as adverse effect? - black, tarry stools a nurse is preparing an in-service for coworkers about failure to thrive in infants. What should she include? - congenital heart disease assessing a client for manifestations of GERD. which of the following findings is indicitive of GERD? - globus providing teaching for a client who has cataract surgery. which of the following shows that the client understands the teaching - avoid using the vacuum cleaner for several weeks a nurse is assessing a client who has DVT in the right lower leg. which of the following findings on the affected extremity should the nurse expect? - swelling a nurse in the emergency department is assessing a client who displays manifestations of a small bowel obstruction. which of the following findings should the nurse expect? - abdominal distention, vomiting, hyperactive bowel sounds a client has peptic ulcer disease and an upper gastrointestinal bleed. what manifestations should the nurse expect? - dark, tarry stools, bright red emesis, increased heart rate a client receiving gentamicin for the treatment of an infection related to renal calculi which lab finding would the nurse report immediately? - creatinine 2.5 a client has pneumonia. what is priority for the nurse? - observe the client perform incentive spirometry a client has GAD and is experiencing a moderate level of anxiety. what manifestations should the nurse expect? - focuses on the source of the anxiety a client has DVT and is receiving heparin via continuous IV. the client has a positive fecal occult blood test and abdominal tenderness upon palpation. what would the nurse expect the provider to prescribe? - protamine sulfate a client has COPD and is learning about preventing pneumonia. which statement shows an understanding? - "I will wash my hands whenever i come home from the grocery store" what are manifestations of right-sided heart failure? - jugular vein distention a client had a cardiac catheterization. what instructors would the nurse include in the teaching to the child's guardian? - monitor the site daily for drainage a client's medication list to manage osteoarthritis? - lidocaine 5% patches, celecoxib, cyclobenzaprine, glucosamine a client recently lost her partner in a motor-vehicle crash. which reaction is a secondary stage of grieving? - feeling anger toward family members a client has GAD. which medications would the nurse administer? - escitalopram a client is at risk for developing glaucoma. which is a risk factor? - heredity a client has hypothyroidism. which is a manifestation? - cold intolerance a client has peripheral neuropathy of the lower extremities. which statement indicates understanding of teaching? - "i should limit wearing the same shoes 2 days in a row" ileostomy priority - purple stoma meter-dose inhaler understanding - deep breath, blow it out before inhale female obese - bmi 40 Starting epoetin - hypertension foot care - trim toenails straight discharge planning for gestational diabetes - determine knowledge manifestations fo hypoglycemia - fruit juice Rifampin - no alcohol amputation trauma - call 911, apply pressure, elevate extremity, find toe, place toe in bag Discharge teaching for hearing impairment - encourage the client to repeat left lower dvt - legs elevated in bed atherosclerosis self-care - increase fiber 30g/day Cholecystectomy - adhesive bandages fall off receiving potassium by IV, level back to normal - stronger hand grasp mild anxiety - follows directions mild hypothermia - slurred speech risk factor for cholecystitis - taking atorvastatin Preschooler with heart failure - offer small, frequent meals panic level anxiety - protect client from harm COPD disease management - use pursed-lip breathing toddler left lower leg fracture - toe movement limited morphine PCA - naloxone newborn hypothermia - hypoglycemia pertussis - droplet precautions Heparin antidote - protamine sulfate acute bacterial wound infection - set temp @ 72 left sided heart failure - nocturia, dyspnea, hacking cough Use a cover sheet when sending a fax from the health care unit. - A nurse manager is developing a faculty policy about using a fax machine to communicate information from a client's electronic medical record (EMR). Which of the following actions should the nurse include in the policy Administer a beta-blocking medication to the client - A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experience in a dull, burning pain in the leg that was amputated. Which of the following should the nurse take to treat the client's neuropathic pain. Pregabalin PO twice daily - A nurse is assessing a client who has fibromyalgia. Which of the following treatment modality prescriptions should the nurse expect for the client's mixed pain. Scrambled eggs - A nurse is planning the menu for a client who practices Seventhday Adventist. Which of the following food selections should the nurse make? Take NSAIDs for body aches and pains - A nurse Is providing teaching to a client who has chronic fatigue syndrome. Which of the following statements should the nurse make. Tell me what is causing your anger at this moment - A nurse is using therapeutic communication to attempt deescalation with a client who is yelling at staff members. Which of the following statements should the nurse make Recommend a single coding system for each department to use. - A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. Which of the following actions should the nurse manager take to promote interoperability? Administer ondansetron to the client prior to chemotherapy administration - A nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemothaerapy-induced nausea and vomiting (CINV) during her previous round of treatment. Which of the following interventions should the nurse include in the clients plan of care? Perform moderate exercise daily Add more whole grains to your diet Increase your fluid intake - A nurse is teaching a client about strategies to prevent recurrent constipation. Which of the following instruction should the nurse include? Request the AP use another computer to enter the data. - A nurse is documenting an assessment in a clients electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take. Can you describe what the pain feels like? - A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to assess the quality of the client's pain? Remove the mask by securely holding the ties and moving it away from the face - A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask? rapid breathing - A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. Which of the following fundings should the nurse identify as a need for administration of a PRN pain medication? Have the client lie supine. - A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. Which of the following actions should the nurse take "You have the right to refuse this and any other procedure, even after you have signed the consent form." - A nurse is preparing a client for an elective vaginal hysterectomy when the client states, "My doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already signed that consent form." Which of the following responses should the nurse make? An adult client may be in a mechanical restraint for up to 4 hr. - A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse include? 1. Assist the client to an upright position 2. Aspirate 5 mL of gastric contents. 3. Test the pH of gastric aspirate 4. Measure the gastric residual volume 5. Flush the NG tube with 30 mL of water - A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all steps) A healthy woman of any age should consume no more than seven drinks in a week - A nurse is planning a community health program about substance use disorders. Which of the following information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? Document the client's status every 15 min. - A nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion. Which of the following actions should the nurse take? 1.2 mL - A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Using a leading zero if it applies. Do not use a trailing zero.) Inform the parent that anger is a natural response when dealing with loss. - A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support tot he parent? Client medicated with morphine 5 mg IM for pain - A nurse is preparing to document care in a client's medical record. In adherence with the Joint Commission National Patient Safety Goals regarding communication errors, which of the following eateries should the nurse make. Stop the continuous IV infusion - A nurse is preparing to administer a medication via intermittent IV bonus to a client who is receiving a continuous infusion via an infusion pump. The client's IV fluid solution is incompatible with the bonus. Which fo the following actions should the nurse plan to take first Spinal nerve pain Postherpetic neuralgia pain Phantom limb pain - A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following types of pain are classified as neuropathic? (Select all that apply) Droplet - A nurse on a media trip unit is admitting an infant who has pertussis. Which of the follow isolation precautions should the nurse initiate? Ciprofloxacin - A nurse is preparing to collect a stool specimen from a client who has had diarrhea for 3 days, with fever and abdominal cramping. When reviewing the client's recent medication administration record, the nurse should recognize that treatment which which of the following medications increases the client's risk for developing a Clostridium difficile infection Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies - A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. Which of the following statements should the nurse include in the teaching? Wear a gown when providing care for the client - A nurse is caring for a client who has a Clostridium difficile infection that is incontinent of stool following long-term antibiotic therapy. Which of the following actions should the nurse take? Use a new blood administration tubing set for each blood bag infused - A charge ruse is teaching a group of newly licensed nurses hot to prevent errors during administration of blood transfusions. Which of the following actions should the nurse include Determine the need for an interpreter - A nurse is preparing to admit a client tot he hospital. Which of the following actions should the nurse take first I will increase her intake of foods high in fiber - A nurse is providing teaching to the parent of a 6-year old girl about preventing urinary tract infections. Which of the following statement by the parent indicates understanding of the teaching. Gradually lengthen the time between the client's scheduled voids. - A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plant to take? Witness consent obtained from the infant's mother - A nurse in an emergency room is caring for an infant who required emergency surgery. The infant is accompanies by his 16 year old mother and his sternal grandfather. Which of the following should the nurse take when assisting with informed consent Sleep in the location of your home where you feel you rest bast - A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the client's preferences into a sleep promotion plan Increase your intake of potassium-rich foods while you are experiencing diarrhea - A nurse is providing dietary teaching to a client who has diarrhea. Which of the following instructions should the nurse include Exercise in the morning after arising - A nurse is teaching sleep hygiene to a client who has insomnia. Which fo the following statements should the nurse make? Elastin fibers separate and thicken - A nurse is caring for an older adult client who has a leg wound following a fall on the stairs. The nurse should identify which of the following factors as an expected, age-related change in older adults that can impair wound healing Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water - A nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, and ibuprofen gel cap, and a delayed release omeprazole capsule. Which of the following actions should the nurse take Have a second nurse witness and initial the disposal of the remaining medication. - A nurse is preparing to administer morphine 5 mg IM from a 10 mg/mL vial to help manage a client's acute pain. Which fo the following actions should the nurse plant take after administering a controlled substance? Lock or log off computers whenever he leaves the areas - A nurse in an orthopedic clinic is documenting data about several clients. Which of the following actions should the nurse take to comply with the regulations of the Health Insurance Portability and Accountability Act (HIPAA) FLACC scale - A nurse is caring for a 2 year old toddler who is immediately postoperative. Which of the following pain scales should the nurse use to assess the toddler's pain level? Obtain a specimen from the client for culture - A nurse is caring for a 47-year- old female client who has urinary incontinence. Which of the following actions should the nurse take first? Enoxaparin 40 mg SQ QD - A nurse is reviewing a client's new prescription that were just documented in the client's medical record by the provider. Which of the following abbreviations should the nurse clarify with the provider? I should use a warm paraffin dip for my hands and feet - A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the following statements by the client indicates an understanding of the teaching. Have a high-calorie protein drink between meals - A nurse is providing discharge teaching about nutrition management to a client who has COPD. Which of the following instructions should the nurse include the teaching? Research facilities for the client that best meet her specific needs. - A nurse is caring for an older adult client who has osteoarthritis and plans to go to an assistive living facility due to decreased mobility. Which of the following actions should the nurse take when acting in the role of client advocate? A client who has a T12 spinal cord injury - A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflux urinary incontinence Install the car seat so that it is facing the rear of the vehicle - A nurse is teaching a client who is postpartum about preventing injury when using a car seat for her newborn. Which of the following instructions should the nurse include? Cumulative Index to Nursing and Allied Health Literature (CINAHL) - A nurse is searching electronic databases for clinical research about behavior indications of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue Wash your child's exposed clothing with hot water and detergent - A nurse is caring for a child who has contact dermatitis due to poison ivy. The patient asks the nurse how to prevent further reactions. Which of the following responses should the nurse make? The client is in audible distress and rates her pain as an 8 on a scale from 0 to 10 - A nurse is preparing to contact a client's provider regarding the need for a prescription for pain medication. When using the Situation, Background, Assessment, Recommendation (SBAR) communication tool, the nurse should provide which of the following information in the assessment portion of the tool Check the state's nurse practice act before performing the procedure - A nurse is asked by a provider to preform an invasive procedure for which he has nor received training. Which of the following actions should the nurse take to ensure that it is within his legal scope of practice to perform this procedure Delay the client's meal time if he is fatigued - A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? The state board of nursing can provide this information - A newly licensed nurse asks a change nurse where to find information about scope of practice for registered nurse. Which fo the following responses should the charge nurse make Have your child rest with his head elevated after meals - A home health nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. Which of the following statements should the nurse make Airborne - A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission- based precautions should the nurse initiate Fruit - A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent gastrointestinal (GI) cancers. Which of the following images indicated a food or beverage the nurse should encourage the client to include liberally in his diet? Place grab bars by the toilet - A nurse is developing a plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty. Which of the following should the nurse include? It's wrong because my dad said I cant kick her - A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the nurse expect Abdominal Pain - A nurse is assessing a preschooler who has a urinary tract infection. Which of the following should the nurse expect? Start a needle-exchange program - A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. Which of the following plans should the nurse recommend as part of tertiary prevention Allow time for a family member to perform a ritual bath after the client dies - A hospice nurse is planning care for a client who has terminal cancer. The client tells the nurse that she practices the Hindu religion. Which of the following interventions should the nurse include in the plan of care to support the client's religious beliefs. African Americans - A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk for hypertension Compare a list of the client's current medications with the ones he will take in long-term care - A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? 125 - A nurse is preparing to administer 0.9% sodium chloride 1000mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round you answer to the nearest whole number I wish God had not allowed this cancer to invade my body - A nurse is caring for a client who has cancer and is planning discharge to home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress? Prednisone - A nurse is reviewing the medication administration record of a client who is 2 days postoperative following abdominal surgery. The nurse should identify that which of the following medications can result in delayed wound healing? Bend forward at the waist and let your arms hang down - A nurse in a community health clinic is screening a 10 year-old-girl for scoliosis. Which of the following instructions should the nurse five the child for this examination The body of a client who practices Islam is washed and wrapped in a cloth following death - A charge nurse is educating unit staff about the cultural aspect of client care following death. Which of the following statements by an assistive personnel indicates an understanding of the teaching Are you ready to make a lifelong commitment to a healthier lifestyle? - A nurse is beginning nutrition counseling with a client who has a BMI of 34.2. Which of the following questions should the nurse ask first to address the client's excessive nutrition and obesity? Slide the pin on top of the fire extinguisher straight out - A nurse is preparing to extinguish a small fire in a client's room. Which of the following action should the nurse take when using the fire extinguisher? Baked potato - A nurse is providing teaching about nutrition management to the parent of an 18- month-old toddler who has phenylketonuria. Which of the following foods should the nurse recommend? Verify the client and blood component using a two-person process - A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals Regarding blood administration, which of the following actions should the nurse plan to take? Offer the client a glass of water every 2 hours when repositioning - A nurse is creating a plan of care for a client who is non ambulatory and his bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown Place a mask on the client during transport out of the room - A nurse is planning care for a client who has bacterial meningitis caused by Haemophilus influenza. Which of the following infection control interventions should the nurse include in the plan It sounds as though you're feeling hopeless - A nurse is talking with a client who has major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse make? Observe the client ambulation go a distance of 3 m (10 feet) during the TUG test - A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? Pull up a small amount of skin using the thumb and forefinger of the non dominant hand - A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk for thromboembolic events. Which of the following actions should the nurse take? Secure the catheter tubing to the client's leg - A nurse is planning care for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse include in the plan to prevent the development of a Cather associated urinary tract infection Pull the alarm to notify emergency services - A nurse in a long term care facility discovers a small fairy in a client's trash can. After moving the client to safety, which of the following actions should the ruse take next Ensure the client and the interpreter are compatible - A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take Your advance directives can designate a friend to make your health care decisions - A nurse is teaching about advance directives with an older adult client who has a terminal illness. Which fo the following statements should the nurse make? Oatmeal with raisins - A nurse is caring for a child who has celiac disease. Which of the following items should the nurse remove from the child's meal? Check the client for injuries - A nurse enters a client's room to find the client lying on the floor. The client states that on the way to the bathroom her "knee locked" causing her to fall. Which of the following actions should the nurse take first Apply a moisture barrier cream to the client's skin - A nurse is developing a care for a client who has urinary incontinence. Which of the following actions should the nurse include? I can give her watermelon pieces after I remove the seeds - A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the rolling statements by the parent indicates an understanding of the teaching? The client is permitted to eat fish that have scales - A nurse is planning meals for a client who practices Judaism and reports that he strictly adheres to orthodox dietary laws. The nurse should recognize that which of the fallowing dietary practices applies to the client's beliefs Initial screening colonoscopy Digital rectal examination Monthly testicular self-examination Annual skin examination - A nurse in a provider's office is caring for a male client who just turned 50 years old. The client has no significant health problems or family history of health problems. Which of the following preventative health screenings should the nurse recommend? The client has been very tearful since finding out he has diabetes mellitus - A nurse is providing change of shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include? Smokeless tobacco provides a higher dose of nicotine than cigarettes - A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include? Select a 1-inch needle for the injection - A nurse is preparing to administer an immunization via MI injection into an adult client's deltoid muscle. Which of the following actions should the nurse take? Eat foods that are high in protein - A nurse is caring for a client who is morbidly obese and is 3 days postoperative following variations surgery. Which of the following dietary recommendations should the nurse make I should expect to feel a firm ridge along the bottom curve of each breast - A nurse is teaching a young adult female client about health screening for breast cancer. Which of the following statements by the client indicates an understanding of breast selfexamination (BSE) Determine the level of health equality in groups in the community - A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. Which of the following actions should the nurse plant to take first What do you think would help you cope with your loss? - A nurse is talking with a client who reports difficulty adjusting tot he death of her partner. Which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting Perform hand hygiene before touching the IV tubing - A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan B - A nurse is preparing to administer enoxaparin subcutaneously to a client who is postoperative following orthopedic surgery. The nurse should plan to administer this medication in which of the following locations (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer Ask the client to demonstrate how to use the call light. - A nurse is developing a Plan of care for an older adult who is at risk of falling. Which of the following fall prevention measures should the nurse include in the plan Airborne - A nurse is planning care for a newly admitted school age child who has rubeola. Which of the following isolation precautions should the nurse plan to initiate The nurse compares the medication level with the client's medication administration record. - A charge nurse is observing a newly licensed nurse prepare medications for a client. Which of the following actions by the newly licensed nurse adheres to safe medications administration practices - A nurse is caring for a client who is morbidly obese and is 3 days postoperative following variations surgery. Which of the following dietary recommendations should the nurse make