ATI PROCTORED CAPSTONE COMPREHENSIVE TEST B 2023 FINAL EXAM VERIFIED SOLUTION

ATI PROCTORED CAPSTONE COMPREHENSIVE TEST B 2023 FINAL EXAM VERIFIED SOLUTION A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of the following actions is the priority? A. Assessfluid intake every 24 hours B. Ambulate three times a day C. Assist with deep breathing and coughing D. Monitorthe incision site forfindings of infection C The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia. A nurse is talking with a client who hasstage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? A. I have experienced physical discomfort when intimate with my partnersince my diagnosis B. I wish other women would stop socializing with my partner C. I told my doctor that I would like to start a support group for other women who are sick in my community D. I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness C Thisstatement indicatesthat the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept. A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the clients IV site every 8 hours B. Check the clients WBC count every 48 hours C. Monitor the clients mouth every 8 hours D. Change the clients IV tubing every 48 hours C A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? A. Eyes area B. Chest area C. Lower abdominal area C Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems with passing stool. Thisis present at birth (congenital) as a result of missing nerve cellsin the muscle of the baby's colon A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgetsto buy their partner a birthday gift after a disagreement B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorterthan average is verbally assertive with coworkers D. A client states that they did not get a job promotion because the boss did not like them B 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? A. irritability B. increased urination C. vomiting D. facial flushing A 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. A client who transfers their anger about their job onto their family and then apologizes B. A client who misses provider appointments because they say they are too busy C. A client who channels their energy into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place for him at dinner each night C The nurse should identify that this client is using the defense mechanism ofsublimation by channeling negative feelings over the loss of their job into a new hobby. 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? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. A hospice nurse will come to the house each time our mother needs pain medication C. Now that my mother is receiving hospice services, we will not be able to get respite care D. Hospice care focuses on arranging treatment that will prolong our mother'slife A Hospice care includes bereavementservices after a family member's death. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors maintain a distance of 1.8m (6 feet) from the client C. Restrict fresh flowersfrom the clients room D. Assign the client to a private room with negative air pressure D A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? A. Limit your fat intake for 72 hours before the test B. You will need to fast the night before the test C. We will collect a urine sample the day after testing D. A blood sample will be collected every 15 minutes during the test B A nurse on a pediatric unit hasreceived change-of-shift report for four children. Which of the following children should the nurse assess first? A. A 6month old infant who has croup and an O2 saturation of 92% on room air B. A 15 year old adolescent who is 2 hour postop following an open reduction and internal fixation of the left ankle and is requesting pain medication C. A 3 year old toddler who has gastroenteritis, moderate dehydration, and had 2 loose bowel movements over the past 24 hours D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain. D A nurse in a community center is providing an educationalsession to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? A. Diarrhea B. Urinary retention C. Purulent discharge D. Abdominal bloating D A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reportsfeeling lightheaded. Which of the following actionsshould the nurse take? A. Check the clientstemperature B. Prepare to administer acetylcysteine to the client C. Place the client in the Trendelenburg position D. Check the client's oxygen saturation level D Restlessness and lightheadedness are indications of hypoxia. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A. An older adult client who reports constipation of 4 days B. A preschooler who has a skin rash C. An adolescent who has a closed fracture D. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? D 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? A. Adjust the crutches for comfort as needed B. Use a three-point gait. C. Wear leather soled shoes D. Advance the affected leg first when walking upstairs B 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? A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand A A nurse is planning to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP? A. Perform gastrostomy feedingsthrough a clients established gastrostomy tube B. Administer glycerin suppository to a client who is constipated C. Provide instructions about client care to a family member over the telephone D. Teach a client how to measure their own blood pressure A A nurse is caring for a newborn immediately after delivery. Which of the following interventionsshould the nurse implement to prevent heat loss by conduction? A. Dry the newborn immediately after birth B. Maintain an ambient room temp of 24 celcius C. Use a protective cover on the scale when weighing the infant D. Place the newborns bassinet away from outside windows C Conduction is the process of losing heat through physical contact with another object or body. For example, if you were to sit on a metal chair, the heat from your body would transfer to the cold metal chair. Convection is the process of losing heat through the movement of air or water molecules acrossthe skin A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client's heparin? A. aPTT B. PT C. INR D. WBC count A A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following factsrelated to the incident should the nurse document in the client's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist B 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? A. "I will administer aspirin to my child to treat pain or fever" B. "I will record an average ofthree readings from my child's peak expiratory flow meter" C. "I will place carpet in my child's bedroom to control allergens" D. "I will make sure my child receives a yearly influenza immunization." D -- Children who have asthma should be immunized and protected from infections. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? A. Obtain capillary blood glucose level every 2 hours B. Check the neurovascular status of the client'slower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour. D. Maintain the affected ankle elevated and immobilized C A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision D The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. Other adverse effects include constipation, urinary retention, and dry mouth. 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? A. "Perhaps you think the ECT is dangerous, but I've seen it have good results" B. "You have the right to change your mind about this procedure at any time." C. "Everyone gets a little nervous about this procedure as the time for it approaches" D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you" B A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who hassevere oliguria. The client weighs 198 lbs. What is the amount in gramsthe nurse should administer? 18g A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? A. Select a 1 inch needle B. Use a 45 degree angle when inserting the needle C. Use the ventroglutealsite D. Pinch the skin up during injection C 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 A. Check the functioning of oxygen equipment once each week B. Wear clothing made with cotton fabrics while oxygen is in use C. Apply petroleum-based lubricant to the nares as needed D. Store full oxygen tanks on theirside B A nurse is providing teaching to the guardians of a newborn about measures to prevent SIDS. Which of the following guardian statements indicates an understanding of the teaching? A. "I will not allow anyone to smoke near my baby." B. "I will place bumper pads in my baby's crib" C. "My baby's head should be placed on a pillow for sleeping" D. "My baby should sleep in a side-lying position" A -- Thisstatement by the guardian indicates an understanding of the nurse'sinstructions. Research indicates a strong correlation between exposure to cigarettes smoke and the occurrence of SIDS. 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? A. Nalbuphine B. Terbutaline C. Oxytocin D. Magnesium sulfate C A nurse on a medical-surgical unit is caring for a client who 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. Contact the facility chaplain to visit with the client B. Explain the process of leaving the facility against medical advice C. Make a referral forsocialservices D. Encourage the client to continue with inpatient care C 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? A. Obtain a prescription for the client to receive an enzyme product B. Aspirate the client'stube C. Flush the client's tube with 30 mL of water D. Change the position of the client D 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? A. Administer a bowel preparation the night before the procedure B. Place the client on bed rest for 24 hours after the procedure C. Perform pulmonary function testsfollowing the procedure D. Instruct the client to avoid coughing during the procedure D A charge nurse is providing an educationalsession about infection control for a group ofstaff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? A. "Droplet precautionsshould be initiated for client who tests positive for measles" B. "A client who requires airborne precautionsshould be placed in a negative pressure airflow room" C. "Airborne precautionsshould be initiated for a client who has Clostridium Difficile" D. "A client who isimmunocompromised should be placed in a negative pressure airflow room" B 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? (Select all that apply.) A.Broccoli B. Yogurt C. Pepperoni pizza D. Cream cheese E. Bologna sandwich A, B, D A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect? A. Paradoxical chest movement B. Subcutaneous emphysema C. Acute confusion D. Distended neck veins C 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? A. Maintain a flexible daily schedule for the client B. Use a reward system to modify the child's behavior C. Provide a variety of family membersto care for the child D. Administer alprazolam as needed to reduce the child's anxiety B A nurse is preparing to administer lactated Ringer's 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? 12.5 gtt/min (or 13 if rounding to nearest whole number) A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta C A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? A. Weight gain B. Decrease in anteroposterior diameter ofthe chest C. HCO3- 24 mEq/L D. pH 7.31 D COPD causes hypoventilation, which leadsto retained CO2. High amounts of CO2 lead to acidosis(pH below 7.35) A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructionsshould the nurse include in the teaching? (select all that apply) A. "You will give the medication every 4 hours" B. "Shake the medication bottle feel before each dose is given." C. "Store themedication in the refrigerator." D. "Report diarrhea to the provider immediately." E. "Discard the unused portion of medication after 21 days" B, C, D A nurse is preparing a client for a paracentesis. Which of the following actionsshould the nurse take? A. Instruct the client to void B. Position the client on their left side C. Insert an IV catheter D. Prepare the client for moderate (conscious)sedation A A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A. Initiate contract precautions forthe client upon admission B. Restrict visitorsfrom entering the client'sroom during hospitalization C. Wear a surgical mask while providing care for the client D. Have the client wear a surgical mask while being transported outside the room D A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take? A. Teach the client to massage the affected extremity B. Instruct the client to elevate the affected extremity when sitting C. Assess pulses proximal to the affected area D. Apply a cold compressto the affected extremity B A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? A. Drainage system located above the clients chest wall B. Continuous bubbling in the waterseal chamber C. Occlusive dressing on the insertion site D. Drainage of 125 mL/hr C All chest tube dressings should be an occlusive, air tight dressing to prevent air leaks. In order to keep the dressing occlusive and to avoid an air leak, tape all the connections from the insertion site of the patient to the chest drainage unit. If the water seal is continuously bubbling, you should suspect an air leak. Think of the lungs as wrapped in plastic. An air leak occurs when there is a hole in the plastic wrap allowing air to escape from the lung tissue into to the pleural cavity. A nurse on an inpatient mental health unit is monitoring a visit 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? A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here isso controlling" C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting D Hyperactivity and pacing indicatesthatthis 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 clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Evaluate dietary intake for a client who has anorexia B. Measure the vitalsigns of a client who just returned from the PACU C. Arrange the lunch tray for a client who has a hip fracture D. Assess I&O for a client who is relieving dialysis C A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux B The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia. A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. Palpatation Inspection Percussion Auscultation 1. Inspection 2. Auscultation 3. Percussion 4. Palpitation Go from least invasive to most invasive. Touch the abdomen last, you do not want to move around any organs A nurse is updating the plan of 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? A. Determine the client'sreading skills B. Instruct the client on the technique for esophagealspeech C. Provide the client with an alphabet board D. Show the client how to use artificial larynx A The first action the nurse should take when using the nursing process is to assess the client. By determining the client'slevel of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost. A nurse is planning care for a client who hasrheumatoid arthritis. Which of the following interventions should the nurse include in the plan? A. Encourage the client to take a coolsponge bath each morning B. Administer opioid analgesia C. Increase the client's dietary iron intake D. Restrict the client's intake of foods high in purines C A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actionsshould the nurse take first? A. Document the client'srefusal in the medication record B. Honor the client's decision to refuse the blood transfusion C. Explore the client'sreasonsfor refusing the treatment D. Discussthe client'srefusal with the provider C A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? A. An older adult client who is anxious and attempting to pull out an IV line B. A middle adult client who isreporting nausea after receiving pain medication C. An older adult client who has kidney failure and returned from dialysis 4 hr ago D. A middle adult client who has a terminal illness and is requesting a visit from the chaplain A A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrientsshould the nurse instruct the client to decrease in their diet? A. Calories B. Protein C. Potassium D. Fiber D The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation. A nurse manager is preparing an educationalsession for nursing staff about how to provide cost-effective care. Which of the following method should the nurse include in the teaching? A. Delegate non-nursing tasksto ancillary staff B. Stock client rooms with extra supplies C. Assign dedicated equipment to each client'sroom D. Change continuousIV infusion tubing every 24 hours A A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? A. Heart rate 136/min B. Nasal flaring C. Transientstrabismus D. Overlapping ofsutures B --A newborn heart rate is normally 120-160bpm --Nasal flaring indicates respiratory distressin a newborn. --Transient misalignment/ strabismus of a baby's eyes is very common up to the age of four months. The eyes may be intermittently esodeviated or exodeviated, but by three months of age, the eyes should be straight. Any strabismus that is apparent after that time is a source of concern --In an infant only a few minutes old, the pressure from delivery compresses the head. This makes the bony plates overlap at the sutures and creates a small ridge. In the next few days, the head expands and the overlapping disappears A nurse is assessing a client who has a decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? A. An increase in the intra-ocular pressure B. Deterioration of the macula C. Increased opacity of the lens D. Vitreous hemorrhage C A nurse must recommend clients for discharge in order to make room forseveral critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? A. A client who has cellulitis and is receiving oral antibiotics every 8 hr B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C. A mother and their newborn 12 hr postdelivery D. A client who haslower extremity weakness and is newly admitted for observation A Oral antibiotics may be taken at home, IV antibiotics would require admission. A patient without a gag reflex is at risk for aspiration and should not go home. A patient with weaknessis a fall risk and requires observation in a hospital A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client'sfamily to obtain consent. Which of the following actions should the nurse take? A. Contact the facility's ethics committee B. Obtain consent from the client's employer C. Limit care to comfort measures D. Proceed with provision of medical care D A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include the plan? (see exhibit) History and physical: 8 year old male admitted with cystic fibrosis Reports shortness of breath Wheezing throughout lung fields Productive cough with thick sputum Graphic Record: Heart rate 108/min Respiratory rate 26/min Temperature 37.2 (98.9) Blood pressure 100/62 Oxygen saturation 92% Diagnostic results: Sputum culture: Burkholderia cepacia A. Initiate droplet isolation precautions B. Keep the child on NPO status for 12 hours C. Maintain the child on bed rest for 24 hours D. Administer high-dose antibiotic therapy D This bacteria is spread through contact, not droplet A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "Expect to have blurred vision while taking this medication" B. "Notify your provider if you experience increased thirst" C. "You might be unable to have an orgasm while taking this medication" D. "You should take this medication on an empty stomach" B A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mmHg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory Alkalosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Metabolic Acidosis C pH 7.2= low PaCO2 60= high Opposites= respiratory Low pH= acidosis A nurse is providing teaching about advance directivesto a middle adult client. Which of the following client responses indicates an understanding of the teaching? A. "I can designate my partner as my health care surrogate" B. "I am only 40 years old, so I don't need to worry about this yet" C. "I will need a lawyer's help to draw up the documents" D. "I understand that my family can alter my advance directives if I become incapacitated" A A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? A. "I would like to talk to you about the unit policies regarding break time." B. "If you continue to take a long lunch break, I will have to report thisto the nurse manager" C. "Have you thought about how your extended lunch breaks affect the other members of our team?" D. "Did you inform the other members of your team about when you left and returned from break?" A -- The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront. A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? A. Organizing the work environment B. Delegating assigned tasks appropriately C. Making a list of activities to complete D. Rewarding yourself for accomplishing goals C A nurse is teaching about adverse effects with a client who isstarting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? A. Tinnitus B. Cough C. Polyuria D. Blurred vision B The client can develop a cough due to a buildup of bradykinin in the lungs. A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A. A client whose family requests hospital based hospice care B. A client who requirestransfer to a skilled care facility C. A client who qualifiesfor telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services D A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? A. Fever B. Shortened femoral neck C. Edema D. Dark brown urine C A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify asthe priority? A. Encourage oral fluids B. Apply topical calamine lotion C. Administer acetaminophen as an antipyretic D. Initiate transmission based precautions D A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? A. Strict adherence to routines B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents A A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make? A. "I understand your hesitation, but I'm very proud of you for making the right decision" B. "Organ donation from a first degree relative is your brother's best chance ofsurvival" C. "You're afraid that your other kidney will fail at some point after the organ donation" D. "I know this process won't be easy, but you should focus on saving your brother'slife" C A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? A. Check the client's blood type and crossmatch it against the providers orders B. Ask the client to state their blood type prior to beginning blood administration C. Compare information on the blood product to the informed consent form D. Verify the client and blood product information with another licensed nurse. D A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? A. The last time the provider evaluated the client B. The client's most recent ventilatorsettings C. The time of the client's last dose of pain medication D. The frequency in which the client pressesthe call buttom C A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following lab values should the nurse report to the provider? A. Platelets 268,000/mm3 B. Calcium 9.2 mg/dL C. WBC 5,200/mm3 D. Sodium 148 mEq/L D Sodium is elevated and could indicate issues with renal A nurse is caring for a client who hasfluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Palpate the degree of edema B. Regulate IV pump fluid rate C. Measure the client's daily weight D. Assess the client's vitalsigns C A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? A. Creatinine 1.1 mg/dL B. Albumin 2.8 g/dL C. Triglycerides 100 mg/dL D. Alkaline phosphatase 118 units/L B A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sitstill for nebulizer treatments" B. "I think that my child has been running a fever over the last couple of days" C. "My child has only a small amount of mucus after percussion therapy" D. "I am concerned about my child's future participation in team sports" C A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? A. Insert air in the tube and listen for gurgling sounds in the epigastric area B. Aspirate contents from the tube and verify the pH level C. Review the medicalrecord for previous x-ray verification of placement D. Auscultate the lungsfor adventitious breath sounds B A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect? A. 11 seconds B. 22 seconds C. 30 seconds D. 45 seconds D A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A. "It's natural for you to feel this way now, but things will get better with time" B. "You seem to be having a difficult time right now" C. "Why do you feel like your life isn't worth living?" D. "You'd be surprised how many people experience these feelings" B An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? A. The LPN and AP lower the side rails before lifting the client up in bed B. Prior to lifting the client, the LPN and AP raise the bed to waist level C. The LPN and the AP grasp the client under this arms to life him up in bed D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift C A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect? A. Decreased hematocrit B. Hypokalemia C. Hyponatremia D. Increased albumin C the initial resuscitation period (between 0 and 36 h). characterized by hyponatremia and hyperkalemia d/t sodium loss in burn tissue and tissue necrosis. Hyponatremia is due to extracellularsodium depletion following changesin cellular permeability. A nurse on a mental health unit is conducting a mentalstatus examination (MSE) on a new admitted client. Which of the following components of the MSE is the priority for the nurse to assess? A. Mood B. Speech C. Ideas of self harm D. Memory loss C A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? A. Avoidsinitiating change B. Seeks input from the other nurses C. Makes decisions quickly D. Limits the amount of feedback to the staff B A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include? A. Limit intake of fluids to 1,000 mL daily B. Take a laxative if no stool has passed after 12 hr C. Empty the appliance when it is one-third to one-half full D. Change the entire pouch system every 1-2 days C A nurse manager is preparing an educationalsession about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching? A. Advocacy is a leadership role that helps others to self- actualize B. Subordinates are advocatesfor the nurse manager C. Advocacy encourages clients to rely on health care staff for decision making D. Nurse managersshould distrust people who advocate against inappropriate professional practices A A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect? A. Dry, coarse hair B. Bradycardia C. Tremors D. Periorbital edema C Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss despite increased hunger, insomnia, and exophthalmia. A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Hypotension B. Report of tinnitus C. Report of chest pain D. Ecchymosis C A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? A. Autonomy B. Nonmaleficience C. Justice D. Fidelity A A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect? A. Nuchal rigidity B. Weight gain C. Tinnitus D. Positive Trendelenburg sign A A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client showsthe nurse multiple superficialself-inflicted lacerations on their forearm The nurse should identify these behaviors as characteristics of which of the following personality disorders? A. Borderline B. Antisocial C. Histrionic D. Paranoid A A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? A. Place the client in the lithotomy position B. Elicit a vagal response by performing gentle rectalstimulation C. Administer oral bisacodyl 30 min prior to the procedure D. Insert a lubricated gloved finger and advance along the rectal wall D Lithotomy position: a supine position of the body with the legs separated, flexed, and supported in raised stirrups, originally used for lithotomy and later also for childbirth. For fecal impaction, place pt in sims position (having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. It is also called lateral recumbent position.) A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asksthe nurse for assistance in making the decision. Which of the following responses should the nurse make? A. "I understand this is a difficult decision" B. "Tell me more about your understanding of the options" C. "You will make the right choice" D. "I will ask your provider to talk with you further" B A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? A. Measuring the group's work against the assigned objectives B. Noting the progress of the group toward assigned goals C. Sharing experiences as an authority figure D. Offering new and fresh ideas on an issue B A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuousIV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory valuesfor the client are aPTT 98 seconds and INR 1.8. Which of the following actionsshould the nurse take? A. Prepare to administer vitamin K1 B. Prepare to administer alteplase C. Withhold the heparin infusion D. Withhold the next dose of warfarin C A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? A. Implement fall precautionsfor the client B. Monitorthe client'sthyroid function C. Place the client on a fluid restriction D. Discontinue the medication if hallucinations occur A A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responsesshould the nurse make? A. "I'm sure your family does not want you to die" B. "Why would you believe such things" C. "How does this make you feel" D. "You should talk to your family about your feelings" C A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? A. Discussthe suspicion of physical abuse with the provider B. Confront the parents with the suspicion of physical abuse C. Ask the hospitalsecurity to detain and question the parents D. Contact Child Protective Services D A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication? A. Diarrhea B. Dry mouth C. Photophobia D. Brusiing B A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? A. Initiate continuous cardiac monitoring B. Administer 40 mEq/L potassium chloride PO with orange juice C. Provide a diet rich in legumes, nuts, and green vegetables D. Monitorthe client for tetany A normal mg level is 1.5-2.5. Elevated magnesium can cause cardiac arrhythmias A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? A. Agency for Healthcare Research and Quality B. National Institutes of Health C. Department of Agriculture D. World Health Organization A. A nurse is planning care for a client who hasrheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? A. Perform ADLsfor the client to promote rest B. Allow for frequent rest periodsthroughout the day C. Use heat to reduce joint inflammation D. Develop a daily schedule for acetaminophen up to 6g/day that covers peak periods of pain B The nurse should encourage clients who have rheumatoid arthritisto balance rest with exercise to maintain muscle strength, joint function, and range of motion. A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? A. Form a committee ofstaffmembersto investigate currentstaffing issues. B. Provide support to staff members who are resistantto staffing changes C. Schedule a staff meeting to present the different options to staff members D. Give the staff members advance written notice ofstaffing changes A A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? A. Sudden drop in heart rate B. Rapid decrease in blood pressure C. Client reports a feeling of abdominal fullness D. Client reports pain as an 8 on a scale of 0 to 10 B A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuousIV infusion. Which of the following assessments is the nurse's priority? A. Amount of vaginal bleeding B. Amount of urinary output C. Pain level D. Fundal height A Oxytocin increases uterine contractions, which increases the risk of hemorrhaging A nurse is caring for a school-age child who has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective? A. Hematocrit 45% B. Urine specific gravity 1.035 C. Serum sodium 138 mEq/L D. BUN 19 mg/dL C Serum of 138 is within normal range (135-145), which indicates a balanced hydration status A nurse is assessing a newborn's heart rate. Which of the following actionsshould the nurse take? A. Assessthe apical pulse while the newborn is crying B. Palpate the radial pulse for 30 seconds C. Listen to the apical pulse while palpating the radial pulse D. Auscultate the apical pulse at least 1 min D We assess a brachial pulse and not a radial pulse for a newborn, too A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? A. Weight loss B. Jaundice C. Bradycardia D. Polyuria B Valproic acid can cause valproate hepatotoxicity A nurse is providing information to a client immediately before hisscheduled Romberg test. Which of the following statements should the nurse make? A. "You will be standing with your feet 1 foot apart" B. "You will place and hold your hands on your hips" C. "I will be standing acrossthe room from you to evaluate yoursense of balance" D. "I will be checking you once with your eyes open and once with them closed" D The Romberg test is a test of the body's sense of positioning (proprioception), which requires healthy functioning of the dorsal columns of the spinal cord. The Romberg test is used to investigate the cause of loss of motor coordination (ataxia) The test is performed as follows: The patient is asked to remove hisshoes and stand with histwo feet together. ... The clinician asksthe patient to first stand quietly with eyes open, and subsequently with eyes closed. ... The Romberg test is scored by counting the secondsthe patient is able to stand with eyes closed. A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective? A. The client reports a decrease in episodes of nausea B. The client reports a decrease in breast tenderness C. The client reports a decrease in headaches D. The client reports a decrease in urinary frequency A A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placenta of a VP shunt. Which of the following findings should the nurse report to the provider? A. Heart rate 122/min B. Irritability when being held C. Hypoactive bowelsounds D. Urine specific gravity 1.018 B A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicatesthat the client is experiencing fluid overload? A. Oliguria B. Bradycardia C. Dyspnea D. Poorskin turgor C Fluid overload would present as increased urinary output (oliguria= small urine output), dyspnea/ shortness of breath caused by extra fluid entering your lungs and reducing your ability to breathe normally, we could see a high or low HR (usually a bounding pulse), and edema (poor skin turgor isseen with dehydration/ hypovolemia) A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect? A. Hgb 15 g/dL B. Urine specific gravity 1.052 C. Urine osmolarity 300 mOsm/ kg D. Hct 44% B The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting. A nurse is developing a client education program about osteoporosisfor older adult clients. The nurse should include which of the following variables as a risk factor for osteroporosis? A. Obesity B. Acromegaly C. Estrogen replacement therapy D. Sedentary lifestyle D When women lose estrogen during menopause, that puts them at greater risk for osteoporosis. A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse? A. The child exhibits discomfort while walking B. The child hasthin extremities C. The child has bruises on the upper back D. The child is wearing a stained shirt A A nurse in a providers office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of his medication A. "have you experienced muscle stiffness?" B. "have you had any stomach pain or bloody stools?" C. "have you experienced a dry cough?" D. "have you noticed an increase in urine output?" B A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will decrease my intake of high fiber foods" B. "I will apply hydrocortisone cream if I develop a rash on my face" C. "I willsleep flat on my stomach if I develop back pain" D. "I will wear a supportive bra overnight" D This helpsto decrease pain associated with engorgement orswelling A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina? A. Halos around lights B. Floating dark spots C. Pain in the affected eye D. Blurred vision B A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique? A. Hold handsfolded below the waist after donning sterile gloves B. Pick up and pour solutions with the palm of the hand covering bottle labels C. Keep sterile items within a 1.3cm (0.5 in) boarder of the sterile drape D. Maintain sterile objects within the line of vision D A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client? A. Droplet B. Airborne C. Contact D. Protective environment A A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority A. Instruct the client about the importance of regular medical appointments B. Encourage the client to participate in daily exercise C. Explain proper foot care techniques to the client D. Ensure that the client understands the medication regimen D Key to preventing hyper/hypoglycemic episodes