ATI Comprehensive Predictor: Nursing Practice Questions and Answers, Exams of Nursing

Download ATI Comprehensive Predictor: Nursing Practice Questions and Answers and more Exams Nursing in PDF only on Docsity!

ATI Comprehensive Predictor

What can be delegated to Assistive personnel (AP)?  ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? C. Reapplying a condom catheter for a client who has urinary incontinence A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? D. Replacing the cartridge and tubing on a PCA pump A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: B. Right supervision/evaluation C. Right direction/communication E. Right circumstances A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client? B. RN What is the study of conduct and character? Ethics What are the values and beliefs that guide behavior and decision making?- Morals What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest- Autonomy What are positive actions to help others- Beneficience What is an agreement to keep promises- Fidelity What is fairness in care delivery and use of resources- Justice What is avoidance of harm or injury- Non-maleficence

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? D. Beneficience-D A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle C. Justice A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle D. Nonmalificence Which of the following situations can be identified as an ethical dilemma? C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill Most managers can be categorized as- authoritative, democratic, and laissez faire Authoritative  makes decisions of the group  motivates by coercion  communication occurs down the chain of command  Work output by the staff is usually high- good for crisis situations and bureaucratic settings - Democratic  includes the group when decisions are made  Motivates by supporting star achievements  Communication occurs up and down the chain of command  Work output by staff is usually of good quality- good when cooperation and collaboration is necessary - Laissez faire  makes very few decisions and does little planning  motivation is largely the responsibility of individuals staff members  Communication occurs up and down the chain of command and between group members  Work output is low unless an informal leader evolves from the group

A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure?

2. High-pitched cry. A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 4. Urine output of at least 30 cc per hour.- The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 2. decreased temperature. A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 3. Instruct client to push a button when she feels fetal movement. Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 4. Assist her with heat application and ROM exercises.- The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient 1. with his neck in a midline position and the head of the bed elevated 30°. The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 4. avoid abrupt changes in posture.- A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client

3. verbalizes that s/he is not responsible for the sexual abuse. An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 2. "Wear sunscreen and a hat when outdoors." After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan?

2. Alteration in skin integrity related to decrease in tissue oxygenation. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse? 3. The dialysate outflow is cloudy. The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of 1. red meat and shellfish. A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 3. Restlessness and increased heart rate.

The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for

1. a client with Alzheimer's requiring assistance with feeding. An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 4. cough and deep breathe.- Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 4. Fluid volume deficit related to bleeding.- An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence? 1. Steadily increasing vital signs. The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 4. The client will be required to take prescribed medication for a duration of 6- months.- The nurse's INITIAL priority when managing a physically assaultive client is to 3. restore the client's self-control and prevent further loss of control. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be 1. confused with cold, clammy skin and a pulse of 110. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room.

When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

3. The patient's voluntary/involuntary status. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 2. Maintain optimal function within the client's limitations. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 4. Avoid eating large meals that are high in simple sugars and liquids.- A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 3. The patient's albumin level is 4.0mg/dL. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 2. Aspirate the gastric contents with a syringe. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 2. There is clear fluid draining from the client's right ear. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 4. Serve the meal to the client in the seclusion room.- A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 3. Administer naloxone (Narcan).

A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? c) "I flushed what I urinated at 7 am and have saved the rest since" A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? c) 0.9% sodium chloride A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? c) maintain two points of support on the floor Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? c) cleanse the wound from the center outwards A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? d) orange sherbet A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? d) pour warm water over the clients perineum When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

3. Prescription drug intoxication. Which of the following is essential when caring for a client who is experiencing delirium? 2. Identifying the underlying causative condition or illness. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

3. Regain orientation to time and place. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
4. Assess the client's gait for steadiness.

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.

2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.
4. Promote relaxation before bedtime with a warm bath or relaxing music. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?
   3. Agitation and assaultiveness. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider?
5. Paradoxical excitement. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?
6. Maintain consistency in environment, routine, and caregivers- What are some ways to identify a patient before giving a medication? The Joint Commission requires 2 client identifiers be used when administering medications.

• clients name
• assigned identification number
• telephone number
• birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients What are some things to teach about home safety with elderly patients?
• Removing items that could cause the client to trip, such as throw rugs and loose carpets
• Placing electrical cords and extension cords that against a wall behind furniture
• Making sure that steps and sidewalks are in good repair
• Placing grab bars near the toilet and in the tub or shower and installing a stool riser
• Using a non-skid mat in the tub or shower
• Placing a shower chair in the shower
• Ensuring that lighting is adequate both inside and outside of the home

health promotion (injury prevention-suffocation): infant (birth-1 yr)--avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing hypotension is classified with a reading below normal; -systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation What temperature should pork be cooked at -160 degrees What is the safest way to thaw out frozen foods -In the refrigerator What are the precautions for vancomycin resistant enterococcus -Standard precautions including hand washing and gloving should be followed What does a newborns poop look like -If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency What is appropriate for an adolescent in the hospital? -Puzzles and books What is the proper nutrition during pregnancy-

• Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida
• green leafy vegetables and brown rice What should be avoided during pregnancy -Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby What is the most appropriate method for contraception for an adolescent -IUD or implant If a patient has anorexia nervosa and works out constantly -Allow them to workout and continue their regimen

What medications can be taken to help with smoking cessation  -Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix) What are the five stages of grief  denial  anger  bargaining  depression  acceptance discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss  anticipatory grief involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time  dysfunctional grief Signs for meningococcemia-  Vomiting, febrile, petechial rash (unstable) Levothyroxine effects-  Used to restore client's metabolic rate  Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension Multiple Sclerosis Patient -Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug)

• Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone)
• Vomiting = causes dehydration
• Hair Loss = emotional distress
• Amenorrhea = emotional distress Malnourished COPD patients-(1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair"-Anger stage

a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals.-B A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake-C A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant-D Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.-A Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Warm moist skin d) Polyuria-A The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool-B After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver-C A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth

c) Regular diet d) Clear liquids-B Bladder retraining for the treatment of urge incontinence:-• Use timed voidings to increase intervals between voidings/decrease voiding frequency.

• Perform pelvic floor (Kegel) exercises.
• Perform relaxation techniques.
• Offer undergarments while the client is retraining.
• Teach the client not to ignore the urge to void.
• Provide positive reinforcement as client maintains continence.
• Eliminate or decrease caffeine drinks.
• Take diuretics in the morning. what are normal creatinine levels? what are normal BUN levels?-0.8-1.4 mg/dL 8-25 mg/dL What are total serum protein values (normals)-6-8 g/dL Describe pre-albumin-this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half- life is 2-3 weeks) what is normal pre-albumin values? what are normal serum levels of magnesium? what is a normal potassium serum level?-17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia) what are good sources of folic acid?-Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils. Sources of potassium-beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas what is important about the diet of someone taking ACE inhibitors?-can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas) Taking Coumadin. Which foods should the client limit?-Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs?-37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL what foods should you avoid if you have diverticulitis?-avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) When taking MAOI's, limit your consumption of-thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats

a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV). for what adverse effect should the nurse monitor this client-the nurse should monitor the client respiratory depression a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider-serum potassium 5. a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix). the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk-Toxic level of digoxin a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching-i should decrease the amount of calcium in my diet while taking the medication A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity?-* Verapamil (Calan) Adverse effect of Verapamil-Avoid grapefruit juice Interaction of diuretics and ACE inhibitors-excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia What can prevent MI, stroke, or death in high-risk patients-Ramipril What to monitor for when taking enoxaparin (lovenox)-Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported What are the therapeutic effects of protamine-Antidote to severe heparin overdose + Reversal of heparin administered during procedures How to prevent adverse effects of oxycodone-can cause respiratory depression. What is the nursing intervention and/or client education? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol). opioid agonists can cause Constipation What is the nursing intervention and/or client education ?-Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation. Adverse effects of ferrous sulfate-constipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth. Baclofen (Lioresal) therapeutic outcome:-Decrease the frequency and severity of muscle spasms (MS).

What is the difference between respiratory acidosis and respiratory alkalosis?-Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45. Bowel elimination how to get a specimen collection-Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine. Identifying manifestations of transient ischemic attacks-symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke. Musculoskeletal congenital disorders-Monitor skin for breakdown areas and prevent pressure sores. The nurse caring for a child in Buck's skin traction will keep the:-Child pulled up in bed Where should the cath bag be placed when urinary catheterization-Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux. What are the signs and symptoms of fluid volume deficit-loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. What is the nursing action for dehiscence-Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's.