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ati concept based assessment
A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse plan to include? A) The client should be offered toileting every 2 hours. B) The provider can write restraints on an as-needed basis. C) Children younger than 9 years old can be in mechanical restraints for up to 1 hour. - correct answer C) Children younger than 9 years old can be in mechanical restraints for up to 1 hour. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make? A) Get out of bed if you cannot fall asleep in 30 minutes B) Alcoholic beverages should only be consumed as late as mid-evening C) Exercise may tire you out and encourage sleep - correct answerA) Get out of bed if you cannot fall asleep in 30 minutes A nurse is assessing a preschooler who has a urinary tract infection (UTI). Which of the following findings should the nurse expect? A) Increased thirst B) Urticaria C) Headache D) Constipation - correct answer D) Constipation A nurse is planning to use an interpreter in her interactions with a patient. Which of the following statements are correct in regards to using an interpreter? A) Questions should be translated as needed to convey the meaning of the questions, not necessarily word-for-word. B) Ask the patient's partner to act as an interpreter.
C) Direct the interview questions to the interpreter. - correct answerA) Questions should be translated as needed to convey the meaning of the questions, not necessarily word- for-word. True or False? Recommendations for safe levels of alcohol consumption for a healthy woman include consuming no more than seven drinks in a week. - correct answer TRUE True or False? Recommendations for safe levels of alcohol consumption for a healthy man under the age of 65 include consuming no more than seven drinks each day. - correct answerFALSE No more than four drinks each day for healthy man under age 65. Which of the following is an example of a therapeutic communication response to depressive or suicidal comments made by the patient? A) disapproving of the negative comments made by the patient B) changing the subject to something more pleasant C) false reassurances to ease their negative feelings D) restating what the patient says - correct answerD) restating what the patient says True or False? Sore throat and other flu-like symptoms are expected with chronic fatigue syndrome. - correct answerTRUE Which of the following should the nurse recognize as nonverbal indicators of pain? (Select all that apply) A) Slow, steady breathing B) Muscle tension C) Dilated pupils D) Increased sleep time - correct answerB, C A patient with Alzheimer's disease is at risk of developing _____________ incontinence of urine.
A) droplet B) airborne C) contact D) protective equipment - correct answerA) droplet An N95 respirator mask is provided for health care staff who are caring for clients who require ____________ precautions. A) droplet B) contact C) airborne - correct answerC) airborne The presence of ___________ in the urine is a manifestation of a UTI. (Select all that apply) A) bilirubin B) nitrates C) ketones D) crystals - correct answerB, D True or False? Conflict with nursing peers does not require an incident report to be filed. - correct answerTRUE unless involved in harm or near-harm done to anyone The nurse should use a medicine cup to measure oral medication volumes that are greater than __________ to reduce the risk for calculation error. A) 1-2mL B) 2-4mL C) 5-10mL - correct answerC) 5-10mL In regards to taking telephone orders from a prescriber, the nurse should have the provider cosign the order within ______ hours to reduce the risk for medication error.
A) 48
B) 72
C) 12
D) 24 - correct answerD) 24 True or False? The fire department should be called before the fire extinguisher is used. - correct answerTRUE Peripheral edema and jugular vein distention are manifestations of... A) right sided heart failure B) infection C) systemic mycoses D) sepsis - correct answerA) right sided heart failure The nurse should expect to administer which medication for a client who requires preoperative sedation? A) Oxycodone B) Alprazolam C) Sumatriptan D) Midazolam - correct answerD) Midazolam A nurse in a provider's office is planning medication teaching for a client who has erectile dysfunction. The nurse should prepare teaching for which of the following medications? A) Sildenafil B) Nitrofurantoin C) Esomeprazole D) Propranolol - correct answerA) Sildenafil
C) 8
D) 12 - correct answerB) 4 The nurse should initiate ___________________ for clients who are severely immunocompromised, such as clients undergoing stem cell transplantation. This includes a private room with positive airflow. A) airborne precautions B) droplet precautions C) a protective environment D) contact precautions - correct answerC) a protective environment The nurse should limit the volume to _______mL when injecting into the deltoid muscle. A) 0.5 - 1 B) 1 - 2 C) 3 - correct answerA) 0.5 - 1 _____________________ is a beta blocker that is prescribed for the treatment of certain cardiovascular disorders, such as angina, arrhythmias, and hypertension. A) Propranolol B) Esomeprazole C) Nitrofurantoin D) Sildenafil - correct answerA) Propranolol True or False? Hot foods can worsen nausea. Serving foods at room temperature can make them more palatable. - correct answerTRUE An adolescent who is _____________ is considered emancipated and is legally able to provide informed consent. (Select all that apply) A) married/divorced
B) serving in the military C) widowed D) mature enough - correct answerA, B, C The nurse should identify that which of the following clients are at risk for rheumatic carditis: A) Client with a history of long-term aspirin use B) Client with a history of a ulcerative colitis C) Client with history of group A beta-hemolytic Streptococci infection D) Client with sedentary lifestyle - correct answerC) Client with history of group A beta- hemolytic Streptococci infection A nurse is teaching about applying National Patient Safety Goals when taking a verbal prescription for a patient. Which of the following instructions should the nurse include? A) Have the provider cosign the prescription within 48 hr. B) Write the abbreviation "TO" or "VO" next to the prescription. C) Allow nursing students to take verbal prescriptions. - correct answerB) Write the abbreviation "TO" or "VO" next to the prescription. The nurse should identify that many clients who practice the Islamic faith gather for group worship on __________. A) Thursdays B) Sundays C) Saturdays D) Fridays - correct answerD) Fridays The nurse should identify that a client who has _________________ is at risk for a bowel obstruction. A) History of a high-fiber diet B) Type 1 DM
The nurse should teach parents and guardians of toddlers to supervise their children at all times in a bathtub or swimming pool to prevent drowning. Hepatitis B, and hepatitis C are transmitted via... A) respiratory route B) contaminated stool C) blood & bodily secretions - correct answerC) blood & bodily secretions Which of the following statements is true regarding the use of nicotine gum in smoking cessation? A) The client should not use nicotine gum longer than a total of 6 months. B) The client should chew nicotine gum on a regular schedule, every 2 to 3 hr, rather than PRN. C) The client should not eat or drink anything for 15 min before chewing the gum. D) All the above - correct answerD) All the above A nurse is preparing to instill ear drops to a 3-year-old child. Which of the following techniques is correct? A) Pull the auricle down and back. B) Pull the auricle down and out. C) Pull the auricle up and back. D) Pull the auricle up and out. - correct answerA) Pull the auricle down and back. This is the correct technique used for infants and young children under the age of 4. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? A) Hold the dropper 2 cm (1 in) above the naris. B) Assist the client to a side-lying position. C) Instruct the client to stay in the same position for 2 min.
D) Tell the client to blow her nose gently before the instillation. - correct answerD) Tell the client to blow her nose gently before the instillation. True or False? The major adverse effect of calcium carbonate is constipation. The nurse should recommend the client increase bulk in the diet. - correct answerTRUE clinical manifestations of heart failure - correct answercool extremities 6 month infant has bacterial pneumonia. clinical manifestations of b. pneumonia - correct answernasal flaring acute asthma exacerbation what actions should the nurse take first - correct answerapply humidified oxygen with a simple mask diabetes foot care - correct answerill wash my feet everyday with soap and lukewarm water decreased urinary output. what findings should be identified as a risk factor for the development of pyelonephritis? - correct answerdiabetes mellitus acute cholecystitis (select all) - correct answerfever, dyspepsia, and eructation client has appendicitis. what actions should the nurse take - correct answerplace the client in semi-fowler's position caring for a client following collection of admission data. what should the nurse identify as a priority? - correct answerclient reports coughing and a change of voice whenever he eats client has respiratory acidosis due to opioid oversedation - correct answerensure the patient airway using a chin-lift maneuver which client is at risk for developing respiratory acidosis? - correct answerclient who has abdominal ascites? teaching about newborns and crib use - correct answerdressing your baby in a one- piece sleeper for bedtime will replace the need to use a blanket or sheet findings that indicate a therapeutic response to anti hyperlipidemia medication - correct answerHDL 50 mg/dL teaching to parents about epinephrine auto-injector - correct answer"give a second injection if the first fails to reverse your child's symptoms"
a school age child has asthma and SOB. what findings would be priority? - correct answerinaudible lung sounds an adolescent client has a skin infection caused by MRSA - correct answer"I will soak in a bathtub filled one-fourth full of water and one-half cup of bleach" an adolescent has infectious mononucleosis. what would be a manifestation of this - correct answeronset of abdominal pain a client is experiencing an asthma attack. what would the nurse use to assess the client's respiratory status - correct answerpeak expiratory flow meter testing a nurse is teaching a client about foot care with peripheral neuropathy - correct answer"file your toenails straight across to prevent ingrown toenails" clinical manifestations of heat stroke - correct answeroliguria a client has a sodium level of 124 mEq/L, what manifestations should the nurse expect?
- correct answerorthostatic hypotension a client's parent recently died. what would place the client at risk for maladaptive grieving? - correct answerthe client lost his house in a fire one month ago the parent has a child with pediculosis capitis. what would the nurse tell the parent? - correct answerto comb the child's hair daily with an extra fine tooth comb a parent has a child with scabies. what would the parent say to indicate understanding of teaching? - correct answer"i should wash my child's bed linens and clothing in hot water and detergent" a client has peripheral arterial disease. what would be a finding of this? - correct answerdependent rubor a nurse is providing teaching to a client with MRSA. what would be an understanding of this disease for the client to say? - correct answer"I will wash all uninfected skin areas with a fresh washcloth" what would be a manifestation that the nurse should expect for an infant who might have otitis media? - correct answerenlarged postauricular lymph nodes a client has hyperthyroidism and has been taking methimazole for 6 months. what indicates a therapeutic response? - correct answerthe client reports sleeping longer during the night metabolic alkalosis would give u what lab value? - correct answerpotassium 3 mEq/L
a client is going in for a laproscopic appendectomy. which of the findings would the nurse report? - correct answerreport of urinating small amounts twice daily a client has severe hypothermia. which actions should the nurse take - correct answercontact a specialized team to place the client on cardiopulmonary bypass a client has cellulitis in a lower extremity. what action should the nurse take? - correct answerelevate the extremity above heart level a client has frostbite to the fingers and toes, what would the nurse include in the teaching about frostbite? - correct answerplace the affected areas of frostbite in a warm water bath a young female client has GAD and is taking clonazepam. what would the nurse include in the teaching? - correct answer"this medication could cause you to have thoughts of self-harm" what is a manifestation of respiratory acidosis? - correct answerconfusion a client has a subdermal implant placed for contraception. what are the adverse effects of this? - correct answerirregular bleeding which of the following is a risk factor for peptic ulcers? - correct answerlong term use of NSAIDs a client has been practicing adaptive use of coping mechanisms. which one indicates the client's use of suppression? - correct answer"I avoid thinking about my problems that worry me until I have time to focus on a solution" a client has osteoporosis. what should be included in the teaching? - correct answerperform exercises to strengthen the abdominal core a client has hyperventilation. the client's ABG results are "7.5 pH, 29 mm Hg PaCO2, and 25 mEq/L HCO3-" what can be interpreted? - correct answerRespiratory alkalosis a client has hyperglycemic-hyperosmolar state related to complications of diabetes - correct answerhypotension a client has recently lost his partner to a terminal illness. the client asks how his 4 year old son should react to this death. - correct answerA preschooler often believes that death is reversible which of the communicable diseases diseases require reporting? - correct answergonorrhea
what should the nurse instruct to avoid in a patient who has gerd? - correct answercaffeinated coffee emergency department for someone who has been out of the country? (exhibit) - correct answersurgical mask which of the following medications should the nurse expect the provider to prescribe in C. difficile? - correct answervancomycin A nurse in a providers office is reviewing the medical record of a client who has COPD. which of the following findings should the nurse report to the provider? - correct answersputum culture shows gram positive bacteria nurse providing discharge teaching to a client with diverticulitis. what should she include? - correct answerconsume a clear liquid diet nurse teaching about ezetimibe with a client who has hyperlipidemia. What client statements is correct? - correct answeri will return to have my cholesterol checked in two weeks a nurse is assessing a client who has musculoskeletal trauma following a motor vehicle crash two days ago. what finding should she report? - correct answerpain report discharge teaching for a client who has a new diagnosis of COPD. which of the following statements shows PT understanding? - correct answerbreathe out slowly through pursed lips if i feel short of breath which of the following menu choices shows patient understanding of hyperlipidemia? - correct answerblack bean burger on a whole grain bun a nurse is participating screenings for osetoporosis. which of the following is a risk factor for the disease? - correct answerhip fracture 6 months ago client who has an intense fear of heights - correct answeracrophobia which of the following actions should the nurse take for a client who has possible appendicitis? - correct answerstart IV fluid replacement a nurse is assessing a preschool-age child who has chickenpox. how should the parent treat it - correct answeravoid giving aspirin a nurse is preparing to administer medication to a client who has a history of hypertension. what should the nurse administer for antihypertension therapy? - correct answerhydrochlorothiazide
exercise induced asthma and has new prescriptions for cromolyn. what should the nurse include in the teaching? - correct answeruse albuterol prior to planned exercise? a nurse is admitting an infant who has pertussis. what following action should the nurse take? - correct answerdroplet precautions warfarin to treat atrial fibrillation. what should nurse identify as adverse effect? - correct answerblack, tarry stools a nurse is preparing an in-service for coworkers about failure to thrive in infants. What should she include? - correct answercongenital heart disease assessing a client for manifestations of GERD. which of the following findings is indicitive of GERD? - correct answerglobus providing teaching for a client who has cataract surgery. which of the following shows that the client understands the teaching - correct answeravoid using the vacuum cleaner for several weeks a nurse is assessing a client who has DVT in the right lower leg. which of the following findings on the affected extremity should the nurse expect? - correct answerswelling a nurse in the emergency department is assessing a client who displays manifestations of a small bowel obstruction. which of the following findings should the nurse expect? - correct answerabdominal distention, vomiting, hyperactive bowel sounds a client has peptic ulcer disease and an upper gastrointestinal bleed. what manifestations should the nurse expect? - correct answerdark, tarry stools, bright red emesis, increased heart rate a client receiving gentamicin for the treatment of an infection related to renal calculi which lab finding would the nurse report immediately? - correct answercreatinine 2. a client has pneumonia. what is priority for the nurse? - correct answerobserve the client perform incentive spirometry a client has GAD and is experiencing a moderate level of anxiety. what manifestations should the nurse expect? - correct answerfocuses on the source of the anxiety a client has DVT and is receiving heparin via continuous IV. the client has a positive fecal occult blood test and abdominal tenderness upon palpation. what would the nurse expect the provider to prescribe? - correct answerprotamine sulfate a client has COPD and is learning about preventing pneumonia. which statement shows an understanding? - correct answer"I will wash my hands whenever i come home from the grocery store"
