ATI RN Comprehensive Practice B

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? Assist with deep breathing and coughing A nurse is talking with a client "I told my doctor that I would like to start a support who has stage IV breast group for other women who are sick in my cancer. The nurse should community" recognize which of the following statements by the client as a constructive use of a defense mechanism? A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Monitor the client's mouth every 8 hr A nurse is caring for a 2 month C old infant who has The nurse should assess the infant's abdomen for Hirschsprung disease (HD). distention and visible peristalsis, which are Which of the following areas manifestations of HD should the nurse assess for manifestations of HD? 2/37 A nurse at a mental health clinic A client who was abused as a child describes the is caring for four clients. The abuse as if it happened to someone else nurse should recognize the following clients is using dissociation as a defense mechanism? A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? irritability A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? A client who channels their energy into a new hobby following the loss of their job A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? "We can expect the hospice nurse to provide support for us after our mother's death" 3/37 A nurse is caring for a client Assign the client to a private room with negative air who has active tuberculosis. pressure Which of the following actions should the nurse take? A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3 hour oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? "You will need to fast the night before the test" A nurse on a pediatric unit has received change of shift report for four children. Which of the following children should the nurse assess first? A 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain A nurse in a community center is providing an education session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Abdominal bloating A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? Check the client's oxygen saturation level 4/37 A nurse is working in an A middle adult client who has unstable vital signs emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? Use a three-point gait A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? Radial vein of the inner arm A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse plan to delegate to the AP? Perform gastrostomy feedings through a client's established gastrostomy tube 5/37 A nurse is caring for a newborn Use a protective cover on the scale when weighing immediately after delivery. the infant Which of the following interventions should the nurse implement to prevent heat loss by conduction? A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? aPTT A nurse administers an incorrect dose of medication to a client. The nurse recognized the error immediately and completes and incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? Time the medication was given A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? "I will make sure my child receives a yearly influenza immunization" 6/37 A nurse is caring for a client Apply a cold pack to the client's ankle for 30 min who has type 1 diabetes every hour RN Comprehensive Practice B mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? Blurred vision A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? "You have the right to change your mind about the procedure at any time" A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? 18 g 7/37 A nurse is preparing to Use the ventrogluteal site administer an IM injection to a RN Comprehensive Practice B client who is obese. Which of the following actions should the nurse plan to take? A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? Wear clothing made with cotton fabrics while oxygen is in use A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? "I will not allow anyone to smoke near my baby" A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer? Oxytocin 8/37 A nurse on a medical-surgical Make a referral for social services unit is caring for a client who RN Comprehensive Practice B has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first? Change the position of the client A nurse is creating a plan of care for a client who has leftsided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Support the client's left arm on a pillow while sitting A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions? Instruct the client to avoid coughing during the procedure 9/37 A charge nurse is providing an "A client who requires airborne precautions should educational session about be placed in a negative pressure airflow room" RN Comprehensive Practice B infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicated an understanding of isolation precautions? A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? Broccoli Yogurt Cream cheese Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli, yogurt, and cream cheese do not contain tyramine. A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect? Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia. A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? Use a reward system to modify the child's behavior 10/37 A nurse is preparing to 13 gtt/min administer lactated ringer's RN Comprehensive Practice B 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? A nurse is caring for a client Cervical laceration following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? pH 7.31 Respiratory acidosis is an expected finding for a A nurse is assessing a client client who has COPD. The expected reference who has COPD. Which of the range of pH is 7.35 to 7.45. A pH level less than 7.35 following findings should the indicated acidosis. For a client who has COPD a nurse expect? decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45, indicating respiratory acidosis. 11/37 A nurse is providing discharge "Shake the medication bottle well before each dose teaching for the parents of a is given RN Comprehensive Practice B preschool age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? SATA "Store the medication in the refrigerator" "Report diarrhea to the provider immediately" A nurse is preparing a client for Instruct the client to void a paracentesis. Which of the following actions should the nurse take? A nurse is caring for a client Have the client wear a surgical mask while being who has active tuberculosis transported outside the room (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A nurse is caring for a client Instruct the client to elevate the affected extremity who has a deep-vein when sitting thrombosis. Which of the The nurse should instruct the client to elevate the following actions should the affected extremity to reduce edema and facilitate nurse take? venous return A nurse is assessing a client Occlusive dressing on the insertion site who has a chest tube. Which of the following findings should Occlusive dressing on the insertion site prevents air the nurse expect? from leaking and is an expected finding 12/37 A nurse on an impatient mental The client is pacing around the chair in which their health unit is monitoring a visit partner is sitting RN Comprehensive Practice B between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences. A nurse is caring for four Arrange the lunch tray for a client who has a hip clients. Which of the following fracture tasks should the nurse delegate to an AP? A nurse is caring for a client Decreased hallucinations who has a prescription for chlorpromazine. Which of the Chlorpromazine is an antipsychotic medication following findings should the administered to decrease hallucinations and other nurse identify as an indication manifestations of schizophrenia that the medication is effective? A nurse is performing an Inspection abdominal assessment on a Auscultation client. Identify the sequence of Percussion actions the nurse should take. Palpitation A nurse is updating the plan of Determine the client's reading skills care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?