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Nursing Procedures and Decisions, Exams of Health sciences

Harvard UniversityHealth sciences

A series of scenarios where a nurse must make decisions or take specific actions based on various client conditions and situations. Topics include patient care, medication administration, client education, and more. It serves as a valuable resource for nursing students and professionals to review and reinforce their knowledge.

Typology: Exams

2023/2024

Available from 06/16/2024

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ATI Comprehensive Practice B
A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the
following findings should indicate to the nurse that the therapy has been effective? -
hemoglobin 14.9 g/dL
a nurse working in an emergency department is triaging four clients. which of the following
clients should the nurse recommend for treatment first? - a middle adult client who has
unstable vital signs
a nurse is caring for a client who has fluid volume overload. which of the following tasks
should the nurse delegate to an assistive personnel? - measure the client's daily weight
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
a nurse is conducting a physical examination for an adolescent and is assessing the rang of
motion of the legs, which of the following images indicates the adolescent is abducting the
hip joint? - Moving the leg away from the midline of the body (off to the side, not to the
front)
a nurse is caring for a client who has hyperthyroidism. which of the following findings
should the nurse expect? - tremors
tachycardia, diaphoresis, weight loss, insomnia, exopthalmia
hypothyroidism has dry corase hair, bradycardia, and periorbital edema
a nurse is assessing a school age child who has bacterial meningitis. which of the following
findings should the nurse expect? - nuchal rigidity
also weight loss
a nurse is assessing a newborn's heart rate. which of the following actions should the nurse
take? - auscultate the apical pulse at least 1 min
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
a nurse is 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? - the child exhibits discomfort while walking
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Download Nursing Procedures and Decisions and more Exams Health sciences in PDF only on Docsity!

ATI Comprehensive Practice B

A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? - hemoglobin 14.9 g/dL a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first? - a middle adult client who has unstable vital signs a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse delegate to an assistive personnel? - measure the client's daily weight 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 a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint? - Moving the leg away from the midline of the body (off to the side, not to the front) a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect? - tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect? - nuchal rigidity also weight loss a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? - auscultate the apical pulse at least 1 min 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 a nurse is 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? - the child exhibits discomfort while walking

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 nutrients should the nurse instruct the client to decrease in their diet? - fiber - reduce diarrhea and inflammation a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following a total knee arthroplasty. which of the following actions should the nurse take? - Turn off the CPM machine during mealtime promote client comfort and dietary intake 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 developing a client education program about osteoporosis for older adult clients. the nurse should include which of the following variables as a risk factor for osteoporosis? - sedentary lifestyle also, small framed body with a thin build, estrogen deficiency 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 as the priority? - initiate transmission based precautions 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 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? - empty the appliance when it is one third to one half full a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? - sodium 148 mEq/L a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive personnel? - Arrange the lunch tray for a client who has a hip fracture a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take? - instruct the client to void a nurse has received change of shift report on four assigned clients. for which of the following clients should the nurse intervene to prevent a potential food and medication interaction? - a client who is receiving an MAOI and is requesting a cheeseburger for dinner

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? - seeks input from the other nurses 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? - noting the progress of the group toward assigned goals a nurse is creating a plan of care for a newly admitted child. which of the following actions should the nurse include in the plan? - Administer high dose antibiotic therapy cystic fibrosis kid with lung infection a nurse is caring for a newborn immediately after delivery. which of the following interventions should the nurse implement to prevent heat loss by conduction? - use a protective cover on the scale when weighing the infant a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the nurse's priority? - assist with deep breathing and coughing 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 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? - aspirate contents from the tube and verify the pH level an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions? - a client who is at 33 weeks of gestation and has severe gestational hypertension 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 use water soluble lubricant not petroleum based lubricant a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place 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 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? - The time of the client's last dose of pain medication a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal VP shunt. Which of the following findings should the nurse report to the provider? - irritability when being held - increased intracranial pressure 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? - decreased hallucinations 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? - "Notify your provider if you experience increased thirst" 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? - insert a lubricated gloved finger and advance along the rectal wall a nurse is planning to delegate client care tasks to an assistive personnel 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 a nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. which of the following methods should the nurse include in the teaching? - delegate non nursing tasks to ancillary staff 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? - The client is pacing around the chair in which their partner is sitting a nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy. 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 this procedure at any time" 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? - Agency for healthcare research and quality a nurse is assessing a newborn following a vaginal delivery. which of the following findings should the nurse report to the provider? - Nasal flaring

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 feedings? - albumin 2.8g/dL should be 3.5 to

A nurse is conducting group therapy with clients who have breast cancer. the nurse should recognize which of the following statements by a client as an example of altruism? - "I told my doctor that I would like to start a support group for other women who are sick in my community" - reaching out and helping others 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 - broccoli yogurt cream cheese a nurse is assessing a client for compartment syndrome. which of the following findings should the nurse expect? - edema 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? - ensure that the client understands the medication regimen a nurse at an urgent care clinic 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? - floating dark spots a nurse on a medical surgical unit is assessing a client who has had a stroke. for which of the following findings should the nurse initiate a referral for occupational therapy? - difficulty performing ADL's a nurse is assessing a client following a colonoscopy. which of the following findings should indicate to the nurse that the client is hemorrhaging? - rapid decrease in blood pressure 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? - "You're afraid that your other kidney will fail at some point after the organ donation" a nurse is assessing a client who has pulmonary edema. which of the following findings should the nurse expect? - pink frothy sputum 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 facts related to the incident should the nurse document in the client's medical record? - time the medication was given

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 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? - contact child protective services 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? - C, the abdomen for distention and visible peristalsis 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 responses should the nurse make? - "how does this make you feel" 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 instructions should the nurse include in the teaching? select all - "shake the medication bottle well before each dose is given" "store the medication in the refrigerator" "report diarrhea to the provider immediately" 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? - make a referral for social services a nurse is assessing a client who has a chest tube. which of the following findings should the nurse expect? - occlusive dressing drainage should be less than 70 ml/hr continuous bubbling in the water seal chamber indicates an air leak a nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. the clients family tells the nurse they are concerned about the level of care the client will receive. which of the following actions should the nurse take? - facilitate an interdisciplinary conference at the new facility for the family 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? - blurred vision

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? - cervical laceration a nurse is updating the plan of care for a client who is 48 hr post operative following a laryngectomy and is unable to speak. which of the following actions should the nurse plan to take first? - determine the clients reading skills 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 - serum sodium 138 mEq/L a school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. upon arrival at the playground, which of the following actions should the nurse take first? - survey the scene for potential hazards to staff and children 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 clients family to obtain consent. which of the following actions should the nurse take? - proceed with provision of medical care a nurse is caring for a school age child who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests? - serum liver enzyme levels 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? - making a list of activities to complete a nurse is caring for a client who has pulmonary embolism. the client is receiving heparin via continuous IVinfusion at 1,200 units/hr and warfarin 5 mg PO daily. the morning laboratory values for the client are aPTT 98 seconds and INR 1.8. which of the following actions should the nurse take? - withhold the heparin infusion a nurse is providing teaching to a school age child who has asthma about using albuterol metered dose inhaler. which of the following instructions should the nurse include? - take the medication 15 min before playing sports a home health nurse is evaluating a school age child who has cystic fibrosis. the nurse should initiate a request for high frequency chest compression vest in response to which of the following parent statements? - "my child has only a small amount of mucus after percussion therapy" a nurse is planning care for a client who is receiving chemotherapy and has neutropenia. which of the following interventions should the nurse include in the plan? - avoid including raw fruits in the clients diet

a nurse is caring for a client who is in the fourth stage of labor and is reviewing oxytocin via continuous IV infusion. which of the following assessments is the nurse's priority? - amount of vaginal bleeding 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? - hyponatremia hyperkalemia a nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. which of the following information should the nurse include in the teaching? - "I will need to measure your weight daily" a nurse is assessing a client who has bipolar disorder. which of the following alterations in speech is the client using? - flight of ideas - changing topics suddenly 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 client whose caregiver requests adult day care services PACE provides adult day care services along with in home assessments and supportive services 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 client who was abused as a child describes the abuse as if it happened to someone else a nurse is caring for a client who has active pulmonary tuberculosis. which of the following actions should the nurse take? - assign the client to a private room with negative air pressure a nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled 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 blood sample is collected every hour 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 vaccination" 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 - for those on heparin it should be 60-80 seconds

a nurse is performing an abdominal assessment on a client. identify the sequence of actions the nurse should take. (in order) - Inspection auscultation percussion palpation 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 preparing a sterile field to perform a sterile dressing change. which of the following interventions should the nurse use to maintain surgical aseptic technique? - maintain sterile objects within the line of vision 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? - initiate continuous cardiac monitoring - mag level is high 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? - the client reports a decrease in episodes of nausea a nurse is caring for a client who has deep vein thrombosis. which of the following actions should the nurse take? - instruct the client to elevate the affected extremity when sitting a nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. after the nurse opens the packet containing the new pouch, the client declines to accept it. which of the following actions should the nurse take? - ask another nurse to witness the disposal of the new patch a nurse is assessing an older adult client who has pneumonia. which of the following findings should the nurse expect? - acute confusion - along with fatigue, lethargy, and anorexia a nurse is providing teaching about the basal body temperature method of birth control. which of the following information should the nurse include in the teaching? - "your body temperature might decrease slightly just prior to ovulation" - decrease in body temperature of 1 degree commonly occurs immediately prior to ovulation 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? - form a committee of staff members to investigate current staffing issues

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? - use the ventrolateral site - it has a thick area of muscle and contains no large nerves or blood vessels 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" 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? - report of chest pain a nurse is caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. the nurse should monitor the client for which of the following adverse effects of PEEP? - tension pneumothorax a nurse manager is reviewing client's rights with the nurses on the unit. the nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? - autonomy a nurse preceptor is evaluating the performance of a newly licensed nurse. which of the following actions by the newly licensed nurse requires intervention by the preceptor? - starts a task then determines what supplies are needed a nurse manager is preparing an educational session about advocacy to a group of nurses. the nurse manager should indicate which of the following information in the teaching? - advocacy is a leadership role that helps others to self actualize a nurse is admitting a client who has pneumonia. the nurse should initiate which of the following isolation precautions for the client? - droplet a nurse has just received change of shift report on four clients. which of the following clients should the nurse assess first? - a client who is postoperative with abdominal distention and no bowel sounds during a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. which of the following actions should the day shift nurse take? - move the client to a room near the nurses station a nurse is reviewing the laboratory results of a toddler who has hemophilia A. which of the following aPTT values should the nurse expect? - 45 seconds a nurse is planning care for a client who has rheumatoid arthritis. which of the following interventions should the nurse include in the plan? - increase the client's dietary iron intake - promotes tissue repair