ATI comprehensive EXIT EXAM Latest Update 2024 With Verified And 100%Correct Answers Graded A+

ATI comprehensive EXIT EXAM Latest Update 2024 With Verified And 100%Correct Answers Graded A+   A nurse, an emergency department complete an assessment on an adolescent client that has conduct disorder. The client threaten suicide to a teacher at school which of the following statements should the nurse include in the assessment. - VERIFIED ANSWER -Tell me how often do you drink alcohol? A nurse is observing bonding to the client, her newborn, which of the following actions by the client requires the nurse to intervene - VERIFIED ANSWER -Viewing the newborn's actions to be uncooperative A nurse is caring for a client who is taking levothyroxine, which of the following finding should indicate that the medication was effective - VERIFIED ANSWER -Weight loss A nurse is planning, discharge teaching for cord care for a parent of a newborn which instructions would you include in the teaching - VERIFIED ANSWER -Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection) A nurse is assessing a client in PACU, which of the following findings indicates decreased cardiac output - VERIFIED ANSWER -oliguria A nurse is assisting with mass, casualty triage explosion at a local factory which of the following client. Should the nurse identify as a priority. - VERIFIED ANSWER -A client with indications of hypovolemic shock A nurse is receiving report on for clients which of the following client should the nurse assess first - VERIFIED ANSWER -A client who is chronic kidney disease with cloudy, diasylate outflow A nurse is caring for a client just received the first dose of lisinopril. The following is appropriate nursing intervention. - VERIFIED ANSWER -Provide standby assist with the client from bed A nurse is caring for a client who is in labor, and is receiving electronics fetal monitoring. The nurse is reviewing the monitor tracing in notes early decelerations, which of the following should the nurse expect - VERIFIED ANSWER -Head compression A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication of hemodialysis. - VERIFIED ANSWER -Glomerular filtration rate of 14 ML/minute A nurse is caring for an infant who has prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take. - VERIFIED ANSWER -Heat the skin one minute prior to placing the program A nurse in a mental health facility receives a change of shift report on four clients which of the following client. Should the nurse plan to assess first. - VERIFIED ANSWER -Client placed in restraints to the aggressive behavior A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management, which of the following statement by the nurse is an appropriate description of the use of hypnosis during labor - VERIFIED ANSWER -Hypnosis promotes increase control of her pain perception during contractions A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? - VERIFIED ANSWER -I think that people just you're just lazy and should earn money honestly A nurse is obtaining a medical history of a client who has a new prescription for Isosorbide monotitrate which of the following should the nurse identify as a contraindication to medication - VERIFIED ANSWER -glaucoma 16 - VERIFIED ANSWER -No questions The nurse is caring for a client recovering from an acute myocardial infraction, which of the following intervention should the nurse include in the point of care - VERIFIED ANSWER -Obtain a cardiac rehabilitation consult A nurse is caring for a client who has breast cancer and has been covering receiving chemotherapy, which of the following laboratory value should nurse report to the provider - VERIFIED ANSWER -WBC 3,000/mm3 Home health nurse is carefully planned for Alzheimer's disease to the following action. Should the nurse include in the plan of care - VERIFIED ANSWER -Place a daily calendar in the kitchen A nurse is performing change of shift assessments on four clients which of the following findings. Should the nurse report to the provider first. - VERIFIED ANSWER -Client who has gastroenteritis and his lethargic and confused A nurse is caring for a client who is in the second trimester of pregnancy and ask how to treat constipation which of the following statements by the nurse is appropriate - VERIFIED ANSWER -Drink hot water with lemon juice each morning when you wake up 22 - VERIFIED ANSWER -No question A nurse is caring for a client who is preparing his advance directives, which of the following statements by the client indicates an understanding of advance directives SATA - VERIFIED ANSWER -I have the right to refuse treatment My health care proxy can make medical decisions for me A nurse is caring for a client who is 32 weeks gestation and has a history of cardiac disease which of the following positions to the nurse place the client to best promote optimal, cardiac output - VERIFIED ANSWER -Left lateral A nurse is caring for a group of clients which of the following client. Should the nurse assigned to an AP. - VERIFIED ANSWER -Client who had a cerebral vascular accident two days ago, and needs help toileting A nurse is providing discharge, teaching to a client who has schizophrenia, isn't starting therapy with clozapine which of the following is the Fever highest priority for the client to report to the provider - VERIFIED ANSWER -Fever A nurse observes an AP providing care to a child, who is in a skeletal traction, which of the following action requires intervention - VERIFIED ANSWER -Placing weights as a child's bed A nurse is planning to delegate twin a piece of fasting blood glucose testing for a client who has diabetes which of the following action should the nurse take - VERIFIED ANSWER -Determine if the AP is qualified to perform the test A nurse is assessing a client brought to the hospital psychiatric emergency service by law-enforcement officer. The client has just organized incoherent speech with loose associations and religious contact. You should recognize the signs and symptoms as being consistent with which of the following. - VERIFIED ANSWER -Schizophrenia A nurse is caring for a child who has infectious mononucleosis which of the following findings are associated with this diagnosis SATA - VERIFIED ANSWER -Splenomegaly Malaise Sore throat A nurse is performing dressing change for a client with a sacral wound using negative pressure wound therapy which of the following action should the nurse take first - VERIFIED ANSWER -Determine pain level A nurse is caring for a client recovery from a bowel surgery has a nasogastric tube connected to load intermittent section which of the following assessment findings should indicate to the nurse at the NG tube may not be functioning properly - VERIFIED ANSWER -Abdominal rigidity A nurse is preparing to administer TPN with added fat supplements to client who has malnutrition which of the following action should the nurse take - VERIFIED ANSWER -Check for an allergy to eggs A charge nurse is discussing the use of applying ice to the clients injured knee with a newly licensed nurse, which of the following should the nurse identify as a benefit - VERIFIED ANSWER -decreased capillary permeability A nurse is developing discharge care plans for a client who has osteoporosis to prevent injury. The nurse should instruct the client to. - VERIFIED ANSWER -Perform weight-bearing exercises A nurse on a cute meds. Surgical unit is performing assessments on a group of clients which is highest priority. - VERIFIED ANSWER -A client has surgical hypoparathyroidism, and positive trousseau sign A nurse is caring for a client with congestive heart failure, which of the following prescriptions for the provider should the nurse anticipate - VERIFIED ANSWER -Give the client enalapril 2.5 MGPO twice daily. A nurse is caring for a client who has a prescription for sertraline to treat depression, which of the following statements by the client indicates an understanding of the medication treatment plan - VERIFIED ANSWER -I understand I may experience difficulty sleeping on this medication A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states I do not know how much longer I can take this, but I'm afraid he'll really hurt me if I leave which of the following is an appropriate nursing intervention - VERIFIED ANSWER -Help the client to recognize the signs of escalation of the best behavior A client was having suicidal thoughts tells a nurse it just does not seem worth it anymore. Why not and my misery which of the following responses for the nurses appropriate - VERIFIED ANSWER -Do you have a plan to end your life? A nurse is caring for a client who has schizophrenia which of the following assessment findings should the nurse expect - VERIFIED ANSWER -Poor problem solving ability A nurse is caring for a client who has deep vein, thrombosis of the left lower extremity which of the following action. Should the nurse take "possible NGN" - VERIFIED ANSWER -Withhold heparin IV infusion A nurse is caring for a client with a new prescription of enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse. - VERIFIED ANSWER -Inject a medication into lateral abdominal wall A nurse is caring for four clients which of the following client data. Should the nurse report to the provider. - VERIFIED ANSWER -A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 A nurse is caring for a client with end stage osteoporosis and is reporting severe pain clans. Respiratory rate is 14 permanent which of the following medication should the nurse expect to be highest priority to minister to the client. - VERIFIED ANSWER -Hydromorphone A nurse is caring for a client who has DVT, which of the following instructions should the nurse include in the plan of care - VERIFIED ANSWER -Elevate the client's affected extremity when in bed A nurse is caring for a client who is receiving Oxytocin IV for argumentation of labor. The clients contractions are hurting every 45 seconds within nine second generation the fetal heart rate is 170 to 180 for a minute which of the following action should the nurse take - VERIFIED ANSWER -Discontinue Oxytocin infusion A nurse is admitting a client who is in labor and at 38 weeks gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 which of the following questions is most appropriate for the nurse to ask the client. - VERIFIED ANSWER -Do you have any active lesions? A nurse is providing teaching for a child prescribed Ferris sulfate, which of the following instruction should the nurse include - VERIFIED ANSWER -Take with a glass of orange juice Four clients present to the emergency department, the nurse should plan to see which of the following clients first - VERIFIED ANSWER -a 50-year old client who has slurred speech, is disoriented and reports a headache A nurse is completing a dietary assessment for a client who is Jewish and observes, kosher dietary practices which of the following behaviors should the nurse expect to find - VERIFIED ANSWER -meat and dairy products are eaten separately 52 - VERIFIED ANSWER -No question A nurse in the ER caring for a client or multiple wins, do to motor vehicle crash, which of the following interventions are appropriate SATA - VERIFIED ANSWER -Apply direct pressure to bleeding wounds Cover wounds with a sterile dressing Determine date of last tetanus toxoid vaccination The nurse reviewing clients in Mission laboratory results, which of the findings require further evaluation - VERIFIED ANSWER -Creatinine 1.8 A nurse is providing teaching for a client who has a new prescription for methadone, which of the following client statements indicates need for further teaching - VERIFIED ANSWER -I understand the methadone may cause me to have difficulty sleeping Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation - VERIFIED ANSWER -An older adults who has difficulty taking in fluids A nurse is caring for a group of clients which of the following client should the nurse assess first - VERIFIED ANSWER -A client whose abdominal pain and is vomiting coffee ground emesis And our sister gay medication history from a client with type two diabetes is scheduled for an arterial gram which of the following medication's to the nurse instruct the client to discontinue 48 hours prior to the procedure - VERIFIED ANSWER -Metformin The nurse is assessing a client with post traumatic stress disorder, which of the following findings should the nurse expect to find - VERIFIED ANSWER -Loss of interest in usual activities A nurse working in a long-term care facility is caring for an older adult client with dementia the clients, often agitated and frequently wandering the halls which of the following intervention should the nurse include in the plan of care - VERIFIED ANSWER -Maintain nutritional requirements by offering finger foods A nurse on a mental health unit receives report on for clients which of the following client. Should the nurse attend first - VERIFIED ANSWER -Client was having auditory hallucinations is becoming agitated A nurse is caring for a full term newborn immediately following birth, which of the following action, should the nurse take first - VERIFIED ANSWER -Dry the newborn A nurse receives report on a group of clients which of the following client should the nurse attend first - VERIFIED ANSWER -A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10 A client at 38 weeks of gestation interest emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor. - VERIFIED ANSWER -The cervix is dilated 2 cm The charge nurse for medical surgical units, discovers client care assignments that should be reassigned, which of the following delegated to should be reassigned - VERIFIED ANSWER -A license practical nurse to provide internal feeding for a client who had a cerebral vascular accident A nurse is caring for a client who has a cast due to a compound fracture to the right ankle, which of the following findings requires immediate intervention - VERIFIED ANSWER -Paresthesia of the distal extremity The nurse is providing care for preschoolers with acute gastroenteritis spacing information below which of the following is an appropriate nursing action "possible NGN" - VERIFIED ANSWER -Administer oral rehydration solution The nurse caring for a client who is taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the affectedness of the medication. - VERIFIED ANSWER -Uric acid level A nurse is caring for a client on the cardiac unit who is hemodynamically unstable, which of the following dysrhythmias should the nurse plan for cardioversion - VERIFIED ANSWER -Arterial fibrillation A nurse manager preparing an educational program on infection control measures which of the following should the nurse include when discussing contact precautions - VERIFIED ANSWER -Herpes simplex A nurse is assessing an older adult client with the decrease caloric, intake, and weight loss which of the following findings should the nurse report to the provider immediately - VERIFIED ANSWER -The client experiences, coughing, and wheezing after eating A nurse and an AP came for a group of clients which of the following task is appropriate for the nurse to delegate to an AP - VERIFIED ANSWER -Administrative oral fluids to a client with dysphasia A nurse from the state health department is instructing a group of nurses regarding reportable infections, which of the following instructions. Should the nurse report to the CDC. - VERIFIED ANSWER -Lyme disease The nurse is assessing an adolescent client for sickle cell anemia which of the following is a priority, finding by the nurse - VERIFIED ANSWER -shortness of breath A nurse is caring for a client who is one day postop follwoing hypophysectomy for the removal of the pituitary tumor, which of the following findings requires further assessment by the nurse - VERIFIED ANSWER -Urinary output greater than fluid intake A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction when - VERIFIED ANSWER -Maintains 3 to 4 finger with between a crutch pad and axilla A nurse is caring for a toddler who has respiratory syncytial virus which of the following action should the nurse plan to take - VERIFIED ANSWER -Use a designated stethoscope, when caring for the toddler A nurse is admitting to a client to emergency department in initiates, continuous, cardiac monitoring, which of the following ECG strips, indicate sinus tachycardia - VERIFIED ANSWER -B A nurse is planning care for a client to prevent complications of immobility, which of the following action should the nurse include in the plan of care - VERIFIED ANSWER -Remove antiembolism stockings for three hours each day to decrease skin breakdown A nurse discovers at the wrong dose of medication is given to the client with determining what action to take. You should recognize that which of the following ethical principle should be applied. - VERIFIED ANSWER -Veracity 81 - VERIFIED ANSWER -No question A nurse is reviewing the prescription for doxazosin a client which of the following should be included in the teaching - VERIFIED ANSWER -Rise slowly, when setting up from bed A nurse, addressing planning to provide teaching too young adult client with insomnia, which of the following should the nurse include in the teaching - VERIFIED ANSWER -Consume a high carbohydrate, snack at bedtime A nurse is caring for a client who has a store culture that is positive for clostridium difficile which of the following infection control precautions is appropriate - VERIFIED ANSWER -Place the client in private room A nurse is planning care for a child who has increased intercranial pressure with a decreased level of consciousness, which of the following intervention should the nurse include in the plan of care - VERIFIED ANSWER -Maintain ahead at a midline position The nurse is assessing a client who is receiving radiation therapy which of the following findings should the nurse expect - VERIFIED ANSWER -Platelets 95,000/mm3 A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medication is contraindicated. - VERIFIED ANSWER -Methylergonovine A nurse is caring for a client with GERD which of the following assessment findings. Should the nurse expect to find - VERIFIED ANSWER -Atypical chest pain A nurse is caring for a newborn who is under phototherapy light switch of the following is an appropriate nursing action - VERIFIED ANSWER -Ensure Eyeshield is covering the eyes The nurse is assessing clients, who had a long arm cast, which of the following findings of the dress moderate and when assessing for acute compartment syndrome "question written bad" - VERIFIED ANSWER -Edema I just came from client is receiving IV moderate (conscious) sedation with midazolam The client has a respiratory rate of 9/min and is not responding to come out, which is the following is an appropriate action by the nurse.. - VERIFIED ANSWER -Administer flumazenil A nurse in a hospital cafeteria overhears to APs discussing a client. They are using the clients name of discuss the details of his diagnosis which of the following action should the nurse take first. - VERIFIED ANSWER -Tell the AP to discontinue their conversation A community health nurse is teaching a group of adults about the importance of health screenings the nurse should include African-American males, almost twice as likely as Caucasian males to experience which of the following - VERIFIED ANSWER -stroke A nurse is caring for a client who sprained his left ankle 12 hours ago which of the following prescription is given by the provider should the nurse clarify - VERIFIED ANSWER -Apply heat to affected extremity for 45 minutes on the 45 is off A nurse is providing dietary teaching for the client who has hepatic and cephalopathy, which of the following foods elections indicates that the client understands teaching - VERIFIED ANSWER -Rice with black beans A nurse is planning care for a client with a sailed, radiation implant, and is to remain in the hospital for one week which of the following should the nurse include in the plan of care - VERIFIED ANSWER -Where a dosimeter film badge while in the clients room A nurse is caring for four clients which of the following client should the nurse care for first - VERIFIED ANSWER -A client with hypothyroidism and has stuporous The nurse is planning care for a newly admitted adolescent who has bacterial meningitis, which of the following instructions is appropriate for the nurse to include in the plan of care - VERIFIED ANSWER -Initiate droplet precautions for the client A nurse is giving discharge instructions to a client with a new ileostomy. The nurse should recognize that the teaching has been affected when a client states. - VERIFIED ANSWER -My stoma will drain liquid fluid continuously A nurse in the providers office is interviewing a client who is requesting an oral contraceptive, which of the following findings in the clients history is a contraindication to use in combination oral contraceptives - VERIFIED ANSWER -impaired liver function The nurse is providing teaching to a client who has mild, persistent asthma, has been prescribed montelukast, which of the following statements to the nurse or in teaching - VERIFIED ANSWER -This medication helps decrease swelling, and mucus production A nurse on the medical surgical unit is receiving reports on four clients which of the following client should the nurse assess first - VERIFIED ANSWER -A client who has acute kidney injury Creatinine 4 MG/DL and a BUN 52 A nurse is assessing a client who has pericarditis, which of the following findings is priority - VERIFIED ANSWER -paradoxical pulse A charge nurse is providing teaching to a new license nurse on how to clean up surfaces contaminated with blood which of the following agents should the nurse include in the teaching - VERIFIED ANSWER -Chlorine bleach A nurse is preparing to feed a newly admitted patient with dysphasia, which of the following actions should the nurse take - VERIFIED ANSWER -Sit at or below the clients are level during feedings A nurse is caring for a client who repeatedly refuses Mills. The nurse over here is an AP telling the client. If you don't eat, I'll put restraints on your wrist and feed you. The nurse should intervene and explain to the AP that this statement constitutes which of the following torts - VERIFIED ANSWER -Assault A charge nurse is evaluating the time management skills for a new license nurse. The charge nurse should interview when a newly licensed nurse does which of the following - VERIFIED ANSWER -Works on several test simultaneously A nurse is monitoring the client during IV urography procedure which of the following client reports is Priority finding - VERIFIED ANSWER -Swollen lips A nurse is planning to delegate client assignments to an AP which of the following task is appropriate for the nurse to delegate - VERIFIED ANSWER -Collecting urine sample A nurse is assessing a client with the following vital signs oral temperature: 37.2 (99F) apical pulse rate: 80/min, radial pulse rate: 62/min, respiratory rate: 16/min and BP: 132/40mmhg What is the clients pulse pressure? - VERIFIED ANSWER -Systolic pressure subtracted by diastolic pressure (132-40=92) A nurse is caring for a group of clans in a medical surgical unit which of the following situation requires completion of an incident report - VERIFIED ANSWER -A client who is IV pump has malfunctioned A nurse is caring for a client who has diabetes, insipidus and is receiving desmopressin which of the following should the nurse monitor - VERIFIED ANSWER -weight The nurse is providing discharge instructions about engorgement for a client has decided not to breast-feed, which of the following statements by the client indicates a need for further instruction by the nurse - VERIFIED ANSWER -I will manually expressed breastmilk A nurse is caring for a client in preterm labor, who is receiving magnesium sulfate by continuous IV infusion, which of the following client findings indicates medication toxicity - VERIFIED ANSWER -Urine output of 20 ML per hour The nurse is completing an assessment for newborn who is two hours old which of the following findings is indicative of cold stress - VERIFIED ANSWER -Jitteriness of the hands A nurse is planning care for four clients which of the following clients is the highest priority - VERIFIED ANSWER -A client who is wearing an arm cast and reports numb fingers A nurse is caring for a male adolescent client who has heart failure based on the clients chart findings which of the following action should the nurse plan to take "possible NGN" - VERIFIED ANSWER -Withhold the digoxin (0.8-2.0) The nurse is assessing a clients blood glucose level of 250 MGDL which of the following clinical manifestations are associated with this finding - VERIFIED ANSWER -Thirst A nurse is assessing for allergies before administering propofol to a client place on a mechanical ventilator, which of the following allergies is a contraindication for this medication - VERIFIED ANSWER -Eggs A nurse is assessing a client diagnosed with schizophrenia. The nurse asked the client to interpret the following statement. When the cats away the mice will play the client response was the mice come out when the cat is not around the nurse should document this finding which of the following in the clients chart - VERIFIED ANSWER -Concrete thinking A nurse is caring for a client who is receiving total parenteral nutrition, which of the following assessment findings required immediate intervention by the nurse - VERIFIED ANSWER -Weight increase of 2 KG/day A nurse in the telemetry unit is receiving the laboratory findings for adult male client who's been treated for myocardial infraction the following is an expected finding for the client - VERIFIED ANSWER -Troponin 1 (TNI) 8mg/dl A nurse is reviewing the results of an ABG performed on a client with chronic emphysema, which of the following results suggest the need for further treatment - VERIFIED ANSWER -PaCO2 level of 55mmhg A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching. - VERIFIED ANSWER -Carbohydrates should be at least 45% of your caloric intake. A nurse is caring for a client who has a prescription for a Vancomyosin 1g IV every 12 hours. The client is scheduled to have the morning dose at oh 0700. The nurse should schedule the trough level to be drawn out which of the following time - VERIFIED ANSWER -1800 A nurse is planning an education session for a client who has type one diabetes which of the following should the nurse plan to include when teaching a client to monitor for hypoglycemia - VERIFIED ANSWER -Diaphoresis A nurse in urgent care clinic is collecting omission history from my client who is 16 weeks of gestation and has bacterial vaginosis to the nurse should recognize that which of the following clinical findings are associated with this infection - VERIFIED ANSWER -Profuse, milky, white discharge A nurse is planning care for a client who has a new diagnosis of dysphasia, which of the following foods to the nurse include when initiating feeding - VERIFIED ANSWER -Oatmeal A nurse is receiving a change of shift report which of the following client should the nurse attend to 1st - VERIFIED ANSWER -A client who reports tingling in the fingers following a thyroidectomy A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods. - VERIFIED ANSWER -Spinach A client who is eight hours postpartum ask the nurse if she will need to receive Rh immune globulin in the client is gravida 2 para 2 in her blood type is AB negative. The newborn blood type is be positive which of the following statements is appropriate. - VERIFIED ANSWER -You should receive Rh immune globulin within 72 hours of delivery A nurse is caring for the mother of an adolescent who was killed in a motor vehicle crash after a school event from other states I should never have let him take the car. It's all my fault which of the following responses by the nurse is appropriate. - VERIFIED ANSWER -You appear to be feeling overwhelmed A nurse is educating a client about caloric intake and weight reduction, which of the following client statements, indicates an understanding of the teaching - VERIFIED ANSWER -If I eat 500 fewer calories per day I should lose 1 pound per week A nurse is teaching postoperative care with the parents of a toddler, following cleft palate repair which of the following should the nurse include in the teaching - VERIFIED ANSWER -Remove elbow splints periodically to perform range of motion A nurse is caring for four clients, which of the following task and the nurse delegate to an AP - VERIFIED ANSWER -Perform chest compressions during cardiac resuscitation A nurse, an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox. - VERIFIED ANSWER -rash in mouth A nurse is preparing to perform close intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP) which of the following actions is appropriate by the nurse - VERIFIED ANSWER -Apply sterile gloves A nurse is caring for a client who has been taking haloperidol for several years which of the following assessment findings. Should the nurse recognize as a long-term side effects of this medication - VERIFIED ANSWER -Lipsmacking A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior, which of the following should the nurse include in the plan of care - VERIFIED ANSWER -Leave one side rail up on the clients bed A nurse is reviewing the laboratory date of a client who has diabetes, which of the following laboratory test is an indicator of long-term disease management - VERIFIED ANSWER -Glycosylated hemoglobin (Ha1c) A nurse on a pediatric care unit is delegating client care which of the following Task should the nurse delegate to an AP - VERIFIED ANSWER -Transport a school age child to x-ray A nurse is caring for a client who has been taking propranolol, which of the following findings indicates a need to withhold the medication - VERIFIED ANSWER -Pulse 54/min A nurse working in a mental health facility, observes a client who has bipolar disorder walk over to a table occupied by other clients and knock the game off the table which of the following is an appropriate response by the nurse - VERIFIED ANSWER -Come outside with me for a walk A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia which of the following precautions should the nurse take while caring for this client - VERIFIED ANSWER -Use a dedicated stethoscope for the client. A nurse is checking laboratory results for a client which of the following laboratory findings indicates hypervolemia - VERIFIED ANSWER -Urine specific gravity 1.001 A nurse is caring for a group of clients in a long-term care facility which of the following situation should the nurse recognize as a safety hazard - VERIFIED ANSWER -A client's rest restraints tied to the bed rails A nurse is caring for a client in mental health facility in the clients. Daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital which of the following is an appropriate response. - VERIFIED ANSWER -I'd like to know more about what's bothering you. A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions from preparing the client for discharge. - VERIFIED ANSWER -Start each meal with a protein source A nurse is assessing a client who has a chest tube following a thoracotomy, which of the following findings requires intervention by the nurse - VERIFIED ANSWER -1 cm of water present in the water seal A provider has written a do not resuscitate order for a client who is comatose and does not have advanced directives a member of the clans Family says to the nurse. I wonder when the doctor will tell us what's going on which of the following action should the nurse take first. - VERIFIED ANSWER -Ask The Family what the provider has discussed with them A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that is suspicious lesion is. - VERIFIED ANSWER -Asymmetric with variegated coloring A nurse is interviewing an older adult client in about the psychological changes he has been experiencing which of the following changes. Should the nurse recognize as normally associated with the aging process. - VERIFIED ANSWER -Decrease sense of taste A nurse in intensive care unit is planning care for a client who has alcohol withdrawal syndrome, which of the following should the nurse include in the plan of care - VERIFIED ANSWER -Provide frequent orientation to time and place A nurse is assessing a clients cardiovascular system, identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve "hot spot" - VERIFIED ANSWER - A nurse manager is planning an audit to measure the quality of care on the unit which of the following is the most appropriate size for the nurse to consult - VERIFIED ANSWER -Evidence based practice data A nurse is caring for a client who had gastric bypass surgery one week ago and has signs of early dumping syndrome which of the following findings should the nurse expect SATA - VERIFIED ANSWER -Syncope Vertigo A nurse is caring for a client who is experiencing mild anxiety which of the following findings should the nurse expect - VERIFIED ANSWER -Heightened perceptual field A nurse is delegating tasks to an AP, which of the following instructions demonstrates appropriate communication of the task - VERIFIED ANSWER -Obtain a blood pressure readings from the client in room 116 after lunch and report a systolic level less than 90 A nurse is caring for a client who has constricted pupils delayed reflexes and decrease blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following. - VERIFIED ANSWER -Heroine intoxication A nurse is assessing an older adult client, who had a stroke, which of the following findings should the nurse recognize as an indication of dysphasia - VERIFIED ANSWER -Abnormal movements of the mouth A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery which of the following information should the nurse include - VERIFIED ANSWER -The client can administer a dose of medication every 6 to 8 min. A nurse is assisting the provider with a paracentesis for a client who has ascites following collection of the specimen, which of the following action should the nurse take next - VERIFIED ANSWER -Label the specimen A nurse is caring for a client in an inpatient facility hotels a nurse that she is leaving because the facility policy prohibit smoking inside which of the following action should the nurse take - VERIFIED ANSWER -Inform the client of the risk involved if she leaves A nurse is preparing to administer a measles mumps rubella (MMR) immunization to a child, which of the following is a contra indication of administration - VERIFIED ANSWER -Recent blood transfusion A nurse is preparing to administer 2.5 ML of medication intramuscularly to older adult which of the following is the safest site for the nurse to do so. - VERIFIED ANSWER -Ventraogluteal A nurse is teaching a female client how to reduce the risk of urinary track infections, which of the following should the nurse include as a risk factor for developing a UTI - VERIFIED ANSWER -Using perfume toilet paper A nurse is providing discharge instructions for a client who has a new prescription for furosemide, which of the following client statements, indicates a need for further teaching - VERIFIED ANSWER -I will limit my intake of fish A nurse is caring for a client who has a prescription for atorvastatin, which of the following client conditions is a contraindication to this medication - VERIFIED ANSWER -Нерatitis C A nurse is planning care for an adolescent who has chronic renal failure, which of the following action should the nurse include in the plan of care - VERIFIED ANSWER -Restrict protein intake to the RDA A nurse is assessing a client one hour following birth, and outside. Her uterus is buggy and located 2CM above the umbilicus which of the following action should the nurse take first – VERIFIED ANSWER- Massage the fundus A nurse is caring for a client who is receiving intermittent internal tube feedings which of the following intervention should the nurse perform - VERIFIED ANSWER -Position the head of bed at 30° during feeding A nurse is caring for a seven month old infant, who is being treated for severe dehydration, which of the following assessment findings indicates treatment has been effective - VERIFIED ANSWER -Flat anterior fontanelle A nurse is providing teaching to a client who has a Soffa Gille cancer and is scheduled to start radiation therapy which of the following should the nurse include in the teaching - VERIFIED ANSWER -Wear clothing over the area of radiation treatment A nurse in a providers office is providing education to a client who is 16 weeks of gestation and has a new prescription for Ferrous sulfate which of the following instruction should the nurse provide - VERIFIED ANSWER -Take your iron medication with fluids, other than coffee or tea A nurse receives a change of shift report on four clients based on the shift report information which of the following client should the nurse plan to assess - VERIFIED ANSWER -A client who had a hip arthroplasty reports, pain and erythema and his calf A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment which of the following medication should the nurse administer - VERIFIED ANSWER -Diphenhydramine A client who does not speak. English arrives at the emergency department, accompanied by a child which of the following action should the nurse take - VERIFIED ANSWER -Ascertain what language, the client speaks and get an interpreter A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse just continues the magnesium sulfate after the client displays toxicity which of the following action should the nurse take - VERIFIED ANSWER -Administer calcium gluconate IV A nurse is using naegeles rule to calculate the expected delivery date for a newly pregnant Primavera the first day of the clans last period was October what is the expected delivery date? - VERIFIED ANSWER -July 7,2011 Formula: -3 months + 7 days A nurse on a medical surgical unit is receiving report on for clients which of the following client. Should the nurse assess first. - VERIFIED ANSWER -A client who is receiving a blood transfusion and reports low back pain