Nursing Care Planning and Assessment: A Shift Guide, Exams of Nursing

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ATI PN Comprehensive Exit Review

Nuchal rigidity (neck stiffness), photophobia (intolerance of bright light) and headache. correct answer- 180. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis. Which of the following findings should the nurse expect?

179. A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel? correct answer- d. Ambulating a client receiving patient-controlled analgesia.
180. A nurse is reinforcing teaching to an adult client who is prescribe Lipitor. The nurse should advise the client that which of the following is an adverse effect of this medication and should be reported to the provider? correct answer- b. Unexplained muscle pain
181. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? correct answer- a. Dependent edema A pregnant client presents with bright red painless vaginal bleeding at 30 weeks. What should the nurse plan to assess for? a. Placenta previa b. Placental abruption c. Cervical dilation d. Cervical tears correct answer- a. Placenta previa The new graduate nurse on a surgical oncology floor is reviewing osteosarcoma signs and symptoms. Which of the following findings does the nurse review that can be seen in a client with osteosarcoma? Select all that apply a. Localized acute pain b. increased range of motion c. gait disturbance d. increased appetite e. palpable mass correct answer- a. Localized acute pain-e. palpable mass-. c. gait disturbance A client with COPD is receiving care at the primary provider's clinic with worsening of symptoms of emphysema. The provider orders an outpatient chest xray to determine if there have been any changes in lung structure. Which best describes what would show on a chest x-ray in the later stages of emphysema? a. increase size of heart

b. flattened diaphragm c. plaque formation scattered throughout the lung d. mediastinal shift to the right correct answer- b. flattened diaphragm A client presents for the care of a primary care facility. The client is coughing and has a fever of 102. Which statement from the nurse regarding protective equipment is most appropriate in preventing the potential spread of this client's infection? a. please wait while I put on a mask before taking your vital signs b. I'm sorry, but you cannot come in here with your symptoms c. you will need to wear a mask, gown, and gloves while you wait to see the doctor d. you will need to wear a mask while you wait to see the provider correct answer- you will need to wear a mask while you wait to see the provider The nurse speaking to parents about treating head lice advises that any children with allergies to which of the following should avoid using permethrin 1%? a. ragweed b. strawberries c. grass and hay d. peanut butter correct answer- a. ragweed A client has developed a reaction after receiving a blood transfusion. The nurse suspects that it is a bacterial reaction due to a contaminated blood product. Which of the following signs or symptoms would the nurse see with this type of reaction? Select all that apply a. hypertension b. distended neck veins c. vomiting d. nausea e. fever and chills correct answer- c. vomiting d. nausea e. fever and chills A nurse assessing a four-year-old's language development knows to be concerned by which one of the following assessment findings? a. speech that is unintelligible b. repeating the same question many times until the child gets an answer c. frequent imitation of words that the child is unfamiliar with d. the ability to form sentences of about three to four words correct answer- a. speech that is unintelligible Which best describes the difference between a do-no-resuscitate (DNR) order and an advanced directive? a. an advance directive is a medical order, while a DNR is not

b. A DNR is a medical order, while an advance directive is not c. An advance directive needs to be removed, but a DNR does not d. An advance directive cannot be revoked, while a DNR can be revoked correct answer- b. A DNR is a medical order, while an advance directive is not A 58 year old client has been admitted to the hospital for treatment of septic arthritis. Which of the following is NOT a risk factor for this condition? a. poorly controlled diabetes b. an artificial joint implant c. taking medications for rheumatoid arthritis d. a history of femur fracture correct answer- d. a history of femur fracture A nurse is admitting a 70-year-old client for the treatment of pneumonia. The nurse notes the client is in distress about being in the hospital. Which of the following areas are common psychosocial concerns for older adults? Select all that apply a. adjustment to deteriorating physical health b. fear of loss of independence c. dependence on government programs d. adjusting to retirement e. coping with the loss of loved ones correct answer- a. adjustment to deteriorating physical health b. fear of loss of independence c. dependence on government programs d. adjusting to retirement e. coping with the loss of loved ones A nurse is giving education on completing a breast self-exam to a client who appears uneasy. Which of the following is the most appropriate action for the nurse to do next? a. discuss the purpose of self-exam b. acknowledge the uneasiness and address it c. tell the client there is nothing to worry about d. continue giving the education correct answer- b. acknowledge the uneasiness and address it which best describes the order in which the nurse should assess a client's abdomen? a. inspection, auscultation, percussion, palpation b. inspection, palpation, percussion, auscultation c. percussion, inspection, palpation, auscultation d. auscultation, palpation, percussion, inspection correct answer- a. inspection, auscultation, percussion, palpation A nurse must move the medication cart on the unit from one end of the hallway to the other. Which principles would the nurse utilize in order to best stay protected from being injured while pushing this cart? Select all that apply a. keep the elbows close to the body

b. keep an eye out for obstacles in the way of the cart c. push with the shoulders and upper back instead of the arms and legs d. assess the weight of the cart before pushing it e. if possible, pull the cart instead of pushing it correct answer- d. assess the weight of the cart before pushing it Which of the following medications lower blood pressure by decreasing the volume of blood in the body? a. beta-adrenoreceptors b. ACE inhibitors c. Calcium channel blockers d. diuretics correct answer- d. diuretics A nurse is caring for a postpartum client with a suspected DVT in one leg, what symptoms would be indicative of this? Select all that apply a. left calf 3 cm larger than right b. bilateral leg edema c. discoloration of the leg d. cold foot on affected leg e. pedal pulses 1+ bilaterally correct answer- b. bilateral leg edema A client has been diagnosed with stress incontinence and has frequent episodes of leaking urine. Which of the following nursing interventions are most appropriate in this situation? Select all that apply a. examine the client for signs of pelvic muscle weakness b. teach the client how to perform intermittent catheterization c. help the client to use an anti-incontinence device d. collect a urine sample to test for infection e. teach the client to perform Kegal exercises correct answer- a. examine the client for signs of pelvic muscle weakness c. help the client to use an anti-incontinence device d. collect a urine sample to test for infection e. teach the client to perform Kegal exercises A nurse is caring for a client who recently had an NG tube placed. Before starting the first enteral feeding, the nurse wants to check for proper placement. Which of the following techniques is most appropriate to confirm placement? a. ask the client to open his mouth and check the back of the throat b. drawback a small amount of gastric fluid and test the pH c. inject 10 ml of air into the tube while auscultating over the abdomen d. inject 10 ml of normal saline into the tube and listen over the chest correct answer- b. drawback a small amount of gastric fluid and test the pH

A nurse is preparing to give blood products to a client who is experiencing excess bleeding after surgery. Prior to administration, which action should the nurse perform first? a. ensure that there is an order for the transfusion b. gather appropriate equipment for blood product administration c. document the client's vital signs d. prime the IV tubing with NS correct answer- ensure that there is an order for the transfusion A nurse is taking care of a client with chronic controlled atrial flutter and knows that which of the following medications is the priority? a. antihypertensives b. anticonvulsants c. diuretics d. anticoagulants correct answer- d. anticoagulants Which of the following is an advantage of using a peripherally inserted central catheter (PICC)? Select all that apply? a. it carries a lower risk of infection compared to peripheral IV's b. it can be used for hemodialysis c. it is cost effective d. it can be inserted at the bedside by a trained PICC RN e. it is less painful with insertion correct answer- c. it is cost effective d. it can be inserted at the bedside by a trained PICC RN Which best describes how elevated stress levels in a client can worsen symptoms of acute coronary syndrome? a. stress causes poor perfusion of the distal extremities b. too much stress leads to platelet activation and endothelial dysfunction c. stress causes blood clots in the microvasculature of internal organs d. too much stress leads to poor muscle tone and decreased activity tolerance. correct answer- b. too much stress leads to platelet activation and endothelial dysfunction A client with a lung infection must undergo a bronchoalveolar lavage. The nurse assists the physician during the procedure in the endoscopy suite. Which of the following considerations regarding this type of bronchoscopy are true. Select all that apply a. a tube is inserted into the lung tissue to visualize lesions associated with cancer b. a bronchoscope is passed into the lung tissue and a small amount of tissue is taken out using forceps c. medication is instilled into the lung tissue and a small amount of fluid is inserted d. a bronchoscopy is passed into the lung tissue and a small amount fo fluid is inserted e. fluid is inserted the lung tissue, some of it is suctioned into a trap and then analysed d, e

correct answer- d. a bronchoscopy is passed into the lung tissue and a small amount fo fluid is inserted e. fluid is inserted the lung tissue, some of it is suctioned into a trap and then analysed A mind-body technique that patients may use for complementary therapy and that involves focusing the mind on a relaxed and calming subject is best known as which of the following? a. moxibustion b. guided imagery c. iridology d. apitherapy correct answer- b. guided imagery A nurse is taking care of a client who has just returned from a session of hemodialysis. The physician has ordered percutaneous nephrolithotomy for the client and the nurse does not schedule the procedure until 8 hours later. What is the rationale for this? a. the client most likely has an infection that needs treatment first b. the client should receive fluids for several hours after hemodialysis c. the client is at risk of bleeding because of heparin administered with dialysis d. the client is in too much pain after having dialysis correct answer- c. the client is at risk of bleeding because of heparin administered with dialysis The nurse is going to administer midazolam to a client for moderate sedation. Which of the following vital signs does this drug affect? Select all that apply a. temperature e. oxygen saturation c. pain d. blood pressure e. oxygen saturation correct answer- oxygen saturationd-d. blood pressure- e. oxygen saturation. A pregnant client with a Bishop's score of 8 means which? a. spontaneous labor is likely b, preterm labor is likely c. the use of carvidil is necessary d. the client should be admitted correct answer- a.spontaneous labor is likely A nurse is caring for a client who is seeking care for symptoms of serotonin syndrome. The client has a prescription for citalopram. Which of the following substances, when combined with this medication, would most likely lead to serotonin syndrome? Select all that apply a. oxycodone b. esomeprazole c. bupropion

d. naproxen correct answer- a. oxycodone c. bupropion The nurse is caring for a client who has not had a bowel movement for the past 6 days. Which of the following medications pulls water into the colon to soften the stool? a. lactulose b. levofloxacin c. levothyrozine d. lamotrigine correct answer- a. lactulose While a nurse is educating students at a middle school health fair, the nurse is approached by a student who shares there are some bumps that look like the pictures of herpes simplex. Which of the following responses by the nurse is most appropriate? a. requesting the student call her parents to take her to the doctor b. asking the client if the sexual parent has ever mentioned having genital herpes c. telling the student that abstinence would have prevented her infection d. asking the student if she would be comfortable speaking in a more private place about her concerns correct answer- d. asking the student if she would be comfortable speaking in a more private place about her concerns A nurse is caring for a diabetic client who uses an insulin pump. The client is in the hospital for diagnostic testing of kidney disease and the provider has ordered an MRI. Which action of the nurse is most appropriate? a. removes the insulin pump four hours before the MRI and check the client's glucose before the test b. leave the insulin pump in place with the continued settings and check the client's glucose just before the MRI c. leave the insulin pump in place but power it down and check the clients glucose levels just before the MRI d. check the client blood glucose and remove the insulin pump just before the MRI correct answer- d. check the client blood glucose and remove the insulin pump just before the MRI The nurse assesses a client adn notices that the lungs have coarse crackles and the client is struggling to breath, and the client's legs are edematous. The nurse should implement which of the following orders first? a. give PRN hydralazine 25mg IV b. Palpate the client's pulses in the legs c. call the healthcare provider d. check vital signs correct answer- d. check vital signs

The nurse is studying to renew basic life support certifications. The nurse knows that which of the following is the most important aspect of basic life support? a. giving epinephrine per ET tube b. cardiopulmonary resuscitation c. intubation d. IO access for emergency rugs correct answer- b. cardiopulmonary resuscitation A client present to the emergency department with abdominal pain. The client states she has not had a bowel movement for one week. An x-ray confirms constipation, and the provider is concerned about a blockage if the client doesn't have a bowel movement soon. Which of the following medications pulls water into the colon to soften the stool? a. metformin b. mannitol c. meperidine d. methylprednisone correct answer- b. mannitol A client with major depressive disorder is receiving care for suicidal ideation. THe nurse is talking to the client about treatment options. Which of the following is a feature of shared decision making used to meet this client's needs for care? a. shared decision making checks the physical feature of the client and his healthcare problems and appoints a guardian to share in the assessment b.shared decision making considers multiple alternatives to the client's provisions to determine the best choice of care c. shared decision making occurs when a person is able to make a decision on behalf of, or in a way that impacts another person d. shared decision making involves selecting a treatment choice that is based on both clinical evidence and the clien'ts preferences correct answer- d. shared decision making involves selecting a treatment choice that is based on both clinical evidence and the clien'ts preferences A nurse is performing chart checks and reviewing medication orders. Which of the following information described a medication order? a. it is a written list of medications that is signed by a practitioner b. it is a written order from a prescribing provider c. it is a verbal order given to a nurse or UAP d. it may be an electronically signed prescription document e. it may be a copy of handwritten medication directions from a provider correct answer- a. it is a written list of medications that is signed by a practitioner b. it is a written order from a prescribing provider d. it may be an electronically signed prescription document e. it may be a copy of handwritten medication directions from a provider