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ATI comprehensive predictor -with 100% verified solutions-2023 2024 What can be delegated to Assistive personnel (AP)?
Typology: Exams
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What can be delegated to Assistive personnel (AP)?
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?
✓ Autonomy 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? Beneficence 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? - 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? Non-maleficence Which of the following situations can be identified as an ethical dilemma? ✓ 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 *the use of any of these styles may be appropriate depending on the situation The nurse should consider the hierarchy of human needs when prioritizing interventions, which are? ✓ Physiological needs first (oxygen, shelter, food) ✓ Safety & security needs (physical safety) ✓ Love and belonging ✓ Self esteem ✓ Self-actualization The ABC framework identifies, in order, the three basic needs for sustaining life ✓ Airway ✓ Breathing ✓ Circulation Nurses must follow what code of standards in delegating and assigning tasks ✓ ANA codes of standards
What values would a nurse possess to be a client advocate? ✓ Caring ✓ Autonomy ✓ Respect ✓ empowerment What do the nurse need to keep in mind about the client when being their advocate? Client's religion & culture When should planning discharge process begin? at time of admission What is an interdisciplinary team? A group of health care professionals from different disciplines What is the nurse's contribution to an interdisciplinary team? ✓ knowledge of nursing care & its management ✓ a holistic understanding of the client, her/his healthcare needs & healthcare systems. 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? ✓ 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? ✓ Urine output of at least 30 cc per hour. The client is exhibiting symptoms of myxedema. The nursing assessment should reveal ✓ Decreased temperature. A non-stress 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? ✓ 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? ✓ 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- ✓ 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: ✓ 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
✓ 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? ✓ 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 ✓ 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? ✓ 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? ✓ 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? ✓ 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 ✓ 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? ✓ 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? ✓ 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 intermittentperitoneal dialysis (IPD). Which of the following would require an intervention by the nurse? ✓ 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 ✓ 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?
✓ Restlessness and increased heart rate. A 59 - year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? ✓ You are experiencing a side effect of Haldol." The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is. ✓ at hs. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe ✓ peripheral edema and anorexia. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? ✓ A 19 - year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? ✓ The client holds the cane in her left hand. A client returns to his room following a myelogram. The nursing care plan should include which of the following? ✓ Encourage oral fluid intake. The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? ✓ "Take three deep breaths, hold your incision, and then cough." A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? ✓ "I don't know who I am and I don't know where I live." A 23 - year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? ✓ Decreased level of consciousness. 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 ✓ 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 ✓ cough and deep breathe.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? ✓ 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 ✓ 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? ✓ 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? ✓ The client will be required to take prescribed medication for a duration of 6 - 9 months. The nurse's INITIAL priority when managing a physically assaultive client is to ✓ 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 ✓ 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? ✓ 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? ✓ 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? ✓ 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? ✓ 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?
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? ✓ 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? ✓ 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? ✓ 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? ✓ 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? ✓ Administer naloxone (Narcan). What type of infectious diseases are required to be reported to the health department? ✓ severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA) What is the process of taking a telephone order from a provider? Patient name, drug, dose, route, frequency read back for accuracy A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care e) Use antimicrobial sanitizer for hand hygiene A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? ✓ have family members wear a gown and gloves when visiting A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? ✓ place a warm compress over the IV site A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? ✓ use a bed exit alarm system
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? ✓ implement a regular toileting schedule Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? ✓ apply intermittent suction when withdrawing the catheter A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? ✓ instruct the client to focus on gradually resuming self-care tasks A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? ✓ serum albumin level of 3 g/dL 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? ✓ "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? ✓ 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? ✓ 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? ✓ Irritability A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? ✓ 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? ✓ 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? ✓ 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? ✓ Prescription drug intoxication.
Which of the following is essential when caring for a client who is experiencing delirium? ✓ Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? ✓ 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? ✓ 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.
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) ✓ Nail polish should not be used near a client who is receiving oxygen. ✓ A "No Smoking" sign should be placed on the front door. ✓ A fire extinguisher should be readily available in the home. A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. c Passive smoking: Avoid enclosed areas with others who may be smoking. _a Carbon monoxide poisoning: Have water heaters inspected on an annual basis. b Food poisoning: Cook all meat at an appropriate temperature. When performing nasotracheal suctioning what technique should be used? Sterile asepsis bc the trachea is considered sterile and prevents infections A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug)
*Decreasing cost by improving client outcomes