ATI RN Comprehensive Predictor 2019 Exam Questions and Answers, Exams of Nursing

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Nursing Assessment and

Intervention for Clients with

Various Medical Conditions

Caring for a Client with Bipolar Disorder and

Acute Mania

Appropriate Actions for the Nurse

Obtain a prescription for restraint within 4 hours.

The nurse should obtain a prescription for restraint within 4 hours, as this is the appropriate timeframe for obtaining a prescription for restraints.

Document the client's condition every 15 minutes.

The nurse should document the client's condition every 15 minutes to closely monitor the client's status and any changes.

Check the client's peripheral pulse rate every 30 minutes.

The nurse should check the client's peripheral pulse rate every 30 minutes to monitor for any changes or signs of distress.

Do not request a renewal of the prescription every 8 hours.

Renewing the prescription every 8 hours is not necessary, as the initial prescription should be valid for the duration of the client's acute mania.

Postoperative Care for a School-Age Child

with Perforated Appendicitis

Appropriate Nursing Actions

Offer small amounts of clear liquids 6 hours following surgery (assess for gag reflex first).

The nurse should offer small amounts of clear liquids 6 hours after surgery, once the client's gag reflex has been assessed and found to be intact.

Administer analgesics on a scheduled basis for the first 24 hours.

The nurse should administer analgesics on a scheduled basis for the first 24 hours to manage the client's postoperative pain.

Do not give cromolyn nebulizer solution every 6 hours (for asthma).

The client does not have a diagnosis of asthma, so there is no need to administer cromolyn nebulizer solution.

Do not apply a warm compress to the operative site every 4 hours.

Applying a warm compress to the operative site is not an appropriate intervention for this client.

Prioritizing Client Assessments during

Change-of-Shift Report

Clients Requiring Immediate Assessment

A client who has a hip fracture and a new onset of tachypnea.

The client with a hip fracture and tachypnea should be assessed first, as this may indicate a potentially life-threatening condition.

A client who has epidural analgesia and weakness in the lower extremities.

The client with epidural analgesia and lower extremity weakness should be assessed next, as this may indicate a complication related to the epidural.

A client who has sinus arrhythmia and is receiving cardiac monitoring.

The client with sinus arrhythmia and cardiac monitoring should be assessed, as cardiac monitoring may indicate a need for intervention.

A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.

The client with diabetes mellitus and a hemoglobin A1C of 6.8% can be assessed last, as this does not indicate an immediate concern.

Applying a Transdermal Nicotine Patch

Appropriate Nursing Actions

Apply the patch immediately after removing it from the protective pouch.

The nurse should apply the patch immediately after removing it from the protective pouch to ensure optimal absorption.

Shave hairy areas of skin prior to application (apply to hairless, clean, and dry areas to promote absorption; avoid oily or broken skin).

The nurse should shave hairy areas of skin prior to applying the patch to promote absorption and avoid skin irritation.

Do not wear gloves to apply the patch to the client's skin.

Wearing gloves is not necessary when applying a transdermal patch.

Remove the previous patch and fold it in half with the sticky sides pressed together before discarding.

The nurse should remove the previous patch, fold it in half with the sticky sides pressed together, and then discard it.

Prioritizing Client Assessments during

Change-of-Shift Report

Client Requiring Immediate Assessment

A client who received a pain medication 30 minutes ago for postoperative pain.

The client who received a pain medication 30 minutes ago for postoperative pain should be assessed first, as the client may be experiencing the effects of the medication or require further pain management.

A client who was just given a glass of orange juice for a low blood glucose level.

The client who was given orange juice for a low blood glucose level should be assessed next, as this may indicate a need for further intervention to stabilize the client's blood glucose.

A client who has 100 mL of fluid remaining in his IV bag.

The client with 100 mL of fluid remaining in the IV bag can be assessed last, as this does not indicate an immediate concern.

A client who is scheduled for a procedure in 1 hour.

The client scheduled for a procedure in 1 hour can be assessed last, as the client can wait for the procedure.

Risks for Aspiration during Enteral Tube

Feedings

Factors that Increase Aspiration Risk

A history of gastroesophageal reflux disease (GERD).

Clients with a history of GERD are at an increased risk of aspiration during enteral tube feedings.

Receiving a high osmolarity formula.

High osmolarity formulas can increase the risk of aspiration.

A residual of 65 mL 1 hour postprandial.

A high residual volume 1 hour after a feeding can indicate delayed gastric emptying and increase the risk of aspiration.

Sitting in a high-Fowler's position during the feeding.

Sitting in a high-Fowler's position during the feeding does not increase the risk of aspiration and may, in fact, help prevent it.

Cushing's Disease and Laboratory Values

Expected Laboratory Findings

Serum glucose level - increased.

Clients with Cushing's disease often have elevated serum glucose levels due to the increased production of cortisol.

Serum calcium level - decreased.

Clients with Cushing's disease may have decreased serum calcium levels due to the effects of excess cortisol on calcium metabolism.

Lymphocyte count - decreased.

Clients with Cushing's disease may have a decreased lymphocyte count due to the immunosuppressive effects of excess cortisol.

Serum potassium level - decreased.

Clients with Cushing's disease may have decreased serum potassium levels due to the effects of excess cortisol on fluid and electrolyte balance.

Managing Magnesium Sulfate Toxicity

Appropriate Nursing Actions

Administer calcium gluconate IV.

Calcium gluconate is the appropriate treatment for magnesium sulfate toxicity, as it helps to counteract the effects of the excess magnesium.

Do not position the client supine.

Positioning the client supine is not an appropriate intervention for managing magnesium sulfate toxicity.

Do not prepare an IV bolus of dextrose 5% in water.

Administering an IV bolus of dextrose 5% in water is not the appropriate treatment for magnesium sulfate toxicity.

Do not administer methylergonovine IM.

Administering methylergonovine IM is not an appropriate intervention for managing magnesium sulfate toxicity.

Factors Increasing the Risk of Client Violence

Best Predictor of Future Violence

Previous violent behavior.

A history of previous violent behavior is the best predictor of future violence.

Experiencing delusions.

Experiencing delusions can increase the risk of violence, but it is not the best predictor.

Male gender.

While male gender is a risk factor for violence, it is not the best predictor.

A history of being in prison.

A history of being in prison is a risk factor for violence, but it is not the best predictor.

Sterile Dressing Change Procedure

Appropriate Nursing Actions

Open the outermost flap of the sterile kit away from the body.

The nurse should open the outermost flap of the sterile kit away from the body to maintain the sterile field.

Place the sterile dressing within 2.5 cm (1 inch) of the edge of the sterile field.

The nurse should place the sterile dressing within 2.5 cm (1 inch) of the edge of the sterile field to maintain the sterile field.

Set up the sterile field above waist level.

The nurse should set up the sterile field above waist level to maintain the sterile field and prevent contamination.

Do not place the cap from the solution sterile side up on a clean surface.

The nurse should not place the cap from the solution sterile side up on a clean surface, as this could contaminate the sterile field.

Promoting Nighttime Sleep in Older Adults

Appropriate Nursing Instructions

Eat a light snack before bedtime.

Eating a light snack before bedtime can help promote sleep.

Stay in bed at least 1 hour if unable to fall asleep.

Staying in bed for at least 1 hour if unable to fall asleep can help establish a sleep routine.

Do not take a 1-hour nap during the day.

Taking a 1-hour nap during the day can interfere with nighttime sleep.

Do not perform exercises prior to bedtime.

Performing exercises prior to bedtime can be stimulating and interfere with sleep.

Initial Home Health Visit for an Older Adult

Living Alone

Appropriate Nursing Actions

Identify environmental hazards in the home.

Assessing the home environment for potential hazards should be the nurse's first priority during the initial home visit.

Educate the client about current medical diagnosis.

Educating the client about their medical diagnosis can be done after the initial environmental assessment.

Refer the client to a meal delivery program.

Referring the client to a meal delivery program can be done after the initial assessment and education.

Arrange for client transportation to follow-up appointments.

Arranging for client transportation to follow-up appointments can be done after the initial assessment and education.

Assessing Remote Memory in Clients with

Mild Dementia

Appropriate Nursing Question

"What high school did you graduate from?"

Asking the client about their remote memory, such as what high school they graduated from, is an appropriate way to assess their remote memory.

Do not ask, "Can you tell me who visited you today?"

Asking about recent events, such as who visited the client today, assesses recent memory, not remote memory.

Do not ask, "Can you list your current medications?"

Asking the client to list their current medications assesses their immediate memory, not their remote memory.

Do not ask, "What did you have for breakfast yesterday?"

Asking about the client's activities from the previous day assesses their recent memory, not their remote memory.

Diabetes Management Goals for an

Adolescent

Appropriate Nursing Goal

HbA1c level less than 7%.

The target HbA1c level for an adolescent with type 1 diabetes is less than 7%.

Do not set a goal of HbA1c level greater than 8%.

An HbA1c level greater than 8% is not an appropriate goal for an adolescent with type 1 diabetes.

Do not set a goal of blood glucose level greater than 200 mg/dL at bedtime.

A blood glucose level greater than 200 mg/dL at bedtime is not an appropriate goal for an adolescent with type 1 diabetes.

Do not set a goal of blood glucose level less than 60 mg/dL before breakfast.

A blood glucose level less than 60 mg/dL before breakfast would be considered hypoglycemic and is not an appropriate goal.

Phenytoin Interactions and Adverse Effects

Appropriate Nursing Conclusion

The client is experiencing adverse effects due to combination antimicrobial therapy.

The client's ataxia and incoordination are likely due to the interaction between phenytoin and the new prescription for isoniazid and rifampin, which can increase the metabolism of phenytoin and lead to adverse effects.

Do not conclude that the client is experiencing an adverse reaction to rifampin.

The adverse effects are not specifically due to rifampin, but rather the interaction between the medications.

Do not conclude that the client's seizure disorder is no longer under control.

The adverse effects are not related to a lack of seizure control, but rather the medication interaction.

Do not conclude that the client is experiencing an adverse reaction to phenytoin.

The adverse effects are due to the interaction between phenytoin and the new antimicrobial medications, not a reaction to phenytoin alone.

Postoperative Rhinoplasty Complications

Nursing Action Required

Increase in frequency of swallowing.

An increase in the frequency of swallowing may indicate bleeding and requires immediate action by the nurse.

Moderate sanguineous drainage on the drip pad.

Moderate sanguineous drainage on the drip pad may also indicate bleeding and requires immediate action.

Bruising to the face.

Bruising to the face is a common side effect of rhinoplasty and does not require immediate action.

Absent gag reflex.

An absent gag reflex may be due to the anesthesia and does not necessarily require immediate action.

Nursing Care for a Child in the Acute Phase of

Kawasaki Disease

Appropriate Nursing Interventions

Give scheduled doses of acetaminophen every 6 hours.

Administering scheduled doses of acetaminophen is an appropriate intervention to manage the fever associated with Kawasaki disease.

Monitor the child's cardiac status.

Closely monitoring the child's cardiac status is crucial, as Kawasaki disease can lead to cardiovascular complications.

Do not administer antibiotics via intermittent IV bolus for 24 hours.

Antibiotics are not the primary treatment for Kawasaki disease, and administering them in this manner is not an appropriate intervention.

Do not provide stimulation with children of the same age in the playroom.

Providing stimulation with other children is not an appropriate intervention for a child in the acute phase of Kawasaki disease, who requires rest and close monitoring.

Discouraging Adolescent Tobacco Use

Most Effective Consequence

Use of tobacco decreases the level of athletic ability.

Highlighting the impact of tobacco use on athletic ability is most likely to discourage adolescents from using tobacco, as it is a consequence that is relevant and important to this age group.

Do not state that use of tobacco might lead to alcohol and drug abuse.

While this is a potential consequence, it may not be as effective in discouraging adolescent tobacco use.

Do not state that smoking in adolescence increases the risk of developing lung cancer later in life.

While this is a serious consequence, it may not be as immediate or relevant to adolescents.

Do not state that smoking in adolescence increases the risk of lifelong addiction.

While this is a valid concern, it may not be as effective in discouraging adolescent tobacco use as the impact on athletic ability.

Monitoring Laboratory Values for a Client

Prescribed Spironolactone

Appropriate Laboratory Value to Monitor

Serum potassium.

Spironolactone is a diuretic that can lead to hyperkalemia, so monitoring the client's serum potassium level is an appropriate action.

Do not monitor total bilirubin.

Monitoring total bilirubin is not a primary concern for a client taking spironolactone.

Do not monitor urine ketones.

Monitoring urine ketones is not a relevant laboratory value for a client taking spironolactone.

Do not monitor platelet count.

Monitoring platelet count is not a primary concern for a client taking spironolactone.

Serving as an Interpreter for a Client

Appropriate Statement by the Nurse

"I will let the client know that I am available as the interpreter."

The nurse should inform the client that they are available to serve as the interpreter, as this is the appropriate way to fulfill this role.

Do not state, "I will receive a small fee for interpreting for this client."

Discussing a fee for interpreting services is not an appropriate statement for the nurse to make.

Do not state, "I am glad I'm available today, but when I'm not, you can use a family member."

The nurse should not suggest using a family member as an interpreter, as this may not be the most appropriate or reliable option.

Do not state, "I will let

Platelets

Normal Range and Risk for Bleeding

Platelets normally range from 100,000/mm³ to 300,000/mm³. Levels below 150,000/mm³ are considered a risk for bleeding.

Anorexia Nervosa Findings

Expected Findings

Iron: 90 mcg/dl Prealbumin: 10 mcg/dl (normal: 16-40 mcg/dl) Serum creatinine: 0.8 mg/dl Calcium: 9.5 mg/dl

Delegating Tasks to an LPN

Appropriate Assignments

A client who has fractured a femur yesterday and is expecting shortness of breath (SOB)

Inappropriate Assignments

A client who sustained a concussion and has unequal pupils A client who has a hemoglobin (Hgb) of 6.3 g/dl and a prescription for packed red blood cells (RBCs)

Nursing Actions for Fetal Heart Rate

Deceleration

Appropriate Actions

Stop the oxytocin infusion Perform a vaginal examination Initiate an amnioinfusion

• • • • • • • • • • • •

Addressing Discrepancies in IV Infusion

Appropriate Actions

Contact the charge nurse to see if the prescription was changed.

Inappropriate Actions

Complete an incident report and place it in the client's medical record. Submit a written warning for the nurse involved in the incident.

Contraindications to Clozapine

Administration

Contraindications

White blood cell (WBC) count: 2,900/mm³ (normal range: 4,800-15,000/ mm³)

Non-Contraindications

Fasting blood glucose: 100 mg/dl Hemoglobin (Hgb): 14 g/dl Heart rate: 58/min

Breastfeeding with Hepatitis C

Appropriate Response

You may breastfeed unless your nipples are cracked or bleeding.

Inappropriate Responses

You must use a breast pump to provide breast milk. You must use a nipple shield when breastfeeding. You may breastfeed after your baby develops his antibiotics.

Priority Nursing Assessment after

Transurethral Resection of the Prostate

Priority Assessment

Level of consciousness

Other Assessments

Skin turgor

• • • • • • • • • • • • •

Deep-tendon reflexes Bowel sounds

Nursing Actions for Hyperthermia

Appropriate Action

Administer oral acetaminophen

Inappropriate Actions

Submerge the adolescent feet in ice water Cover the adolescent with a thermal blanket (this is for hypothermia)

Guidelines for Belt Restraints

Appropriate Guidelines

Remove the client restraints every 4 hours

Inappropriate Guidelines

Attach the restraints to the bed's side rails Request a PRN (as needed) restraints prescription for clients who are aggressive

Priority Intervention for Full-Thickness Burn

Priority Intervention

Initiating IV fluid resuscitation

Other Interventions

Providing pain management Offering emotional support Preventing infection

Responding to a Client's Questions about

Dying

Appropriate Response

You sound like you have questions about your mom dying. Let's talk about it.

• • • • • • • • • • • • •

Inappropriate Responses

Hospice will take good care of your mom, so I wouldn't worry about that. Let's talk about your mom's cancer and how things will progress from here. Tell me how you are feeling about it. Tell her not to worry. She still has plenty of time left.

Identifying Appropriate Follow-Up Care

Appropriate Follow-Up

A client who is taking bumetanide and has a potassium level of 3. mEq/L (normal) A client who is scheduled for a colonoscopy and taking sodium phosphate A client who is taking warfarin and has an INR of 1.8 (normal if taking warfarin)

Initial Tasks for a Community Health Nurse

Referral

Appropriate First Task

Contact the family by phone

Inappropriate Tasks

Implement the nursing process Schedule a time for the home visit

Responding to a Client's Request for Privacy

Appropriate Response

Is there a reason you don't want your partner to know about your procedure?

Inappropriate Responses

Your partner can be a great source of support for you at this time. The provider will be tactful when talking to your partner.

Calculating Percentage of Weight Loss

Correct Percentage

7.5%

• • • • • • • • • • • •

Incorrect Percentages

15%

8.1%

13.3%

Interventions for Postpartum Urinary

Retention

Appropriate Intervention

Insert an indwelling urinary catheter.

Inappropriate Interventions

Perform fundal massage Pour water from a squeeze bottle over the client's perineal area Apply cold therapy to the client's perineal area (should be warm)

Discharge Teaching for Fentanyl Patch

Appropriate Instructions

Apply the patch to your forearm.

Inappropriate Instructions

Avoid hot tub while wearing the patch. Avoid high-fiber foods while taking this medication. Remove the patch for 8 hours every day to reduce the risk for tolerance.

Interventions for Pressure Injury Prevention

Appropriate Interventions

Assess pressure points every 24 hours. Turn and reposition the client every 2 hours while in bed and every 1 hour while in a chair.

Inappropriate Intervention

Place the client upright on a donut-shaped cushion (not appropriate for a client with paraplegia)

• • • • • • • • • • • • • •

Establishing Therapeutic Relationship

Appropriate Statements

We should establish our roles in the initial session. Let's talk about how you can change your response to stress.

Inappropriate Statement

We should discuss resources to implement in your daily life (more appropriate for later phases)

Safe Foods with Phenelzine

Safe Foods

Whole grain bread Avocados

Unsafe Foods

Pepperoni pizza Smoked salmon (contains tyramine, which is contraindicated with phenelzine)

Sequence of Actions for a Fire in the Client's

Room

Transport the client to another area of the nursing unit. Activate the facility's fire alarm system. Close all nearby windows and doors. Use the unit's fire extinguisher to attempt to put out the fire.

Findings of Mild Anxiety

Expected Findings

Heightened perceptual field Feelings of dread Purposeless activity Tremors Diaphoresis Inability to concentrate

• • • • • • •

• • • • • •

Identifying Hypoglycemia

Hypoglycemic Findings

Tremors

Non-Hypoglycemic Findings

Polydipsia (indicates hyperglycemia) Acetone breath odor (indicates diabetic ketoacidosis)

Expected Findings in Coarctation of the Aorta

Expected Finding

Upper extremity hypotension

Inappropriate Findings

Increased intracranial pressure Frequent nosebleeds

Primary Prevention Strategies for Abuse

Appropriate Strategy

Teach parenting skills to families at risk for abuse.

Inappropriate Strategies

Instruct healthcare professionals to identify abusive situations (screening is secondary prevention) Locate financial support to open a shelter for abuse survivors (tertiary prevention) Connect abuse survivors with legal counsel (tertiary prevention)

Appropriate Delegation to Assistive Personnel

Appropriate Delegations

Documenting the report of pain for a client who is postoperative Applying a condom catheter for a client who has a spinal cord injury

Inappropriate Delegations

Administering oral fluids to a client who has dysphagia Reviewing active range-of-motion exercise with a client who had a stroke

• • • • • • • • • • • • • •

Client Understanding of Peptic Ulcer Disease

Teaching

Appropriate Understanding

"I will take sucralfate with meals three times per day."

Inappropriate Understandings

"I will decrease my daily protein intake to 15 grams per day." "I will use ibuprofen as needed to control abdominal pain."

Interventions for Xerostomia after Radiation

Therapy

Appropriate Intervention

Provide humidification of the room air

Inappropriate Interventions

Offer the client saltine crackers between meals Suggest rinsing his mouth with an alcohol-based mouthwash Instruct the client on the use of esophageal speech

Potential Contraindication for Lavender Oil

Use

Contraindication

The client has a history of asthma

Non-Contraindications

The client takes vitamin C daily The client has a history of alcohol use disorder The client takes furosemide twice daily

Monitoring for Adverse Effects of

Amitriptyline

Expected Adverse Effect

Increased salivation (will cause dry mouth due to anticholinergic effects)

• • • • • • • • • • • •

Inappropriate Adverse Effect

Weight loss (amitriptyline can cause weight gain) Hypertension (amitriptyline can cause orthostatic hypotension)

Contraindication for Oral Contraceptive Use

Contraindication

Fibrocystic breast condition

Non-Contraindications

Asthma Fibromyalgia

Witnessing a Client's Signature on a Consent

Form

Appropriate Statement

"You should not have this procedure if you are allergic to iodine."

Informed Consent for Medical Procedures

Explanation of the Procedure

The nurse should ensure that the client is provided with a thorough explanation of the medical procedure they are about to undergo. This includes describing the steps involved in the procedure, the purpose of the procedure, and what the client can expect during the process.

Expected Outcome of the Procedure

The nurse should inform the client about the anticipated outcomes of the procedure, including any potential benefits or improvements in the client's condition that may result from the intervention.

Potential Complications

The nurse should educate the client about the possible risks or complications that may arise from the procedure, such as side effects, adverse reactions, or unexpected outcomes.

• • • • • •

Possible Alternative Treatments

The nurse should provide the client with information about any alternative treatment options that may be available, including their potential risks and benefits, so that the client can make an informed decision.

Cost of the Procedure

The nurse should ensure that the client is aware of the financial implications of the procedure, including any associated costs or fees that the client may be responsible for.

MRI Scan Teaching

Tattoos

The nurse should inform the client that they should not undergo an MRI scan if they have a tattoo, as the magnetic field of the MRI can interact with the metallic components in some tattoo inks, potentially causing burns or other complications.

Protective Eyewear

The nurse should not instruct the client to wear protective eyewear during the MRI procedure, as this is not a standard practice.

Transdermal Patches

The nurse should inform the client that they will be asked to remove any transdermal patches, such as nicotine or medication patches, prior to the MRI scan, as the magnetic field can interfere with the function of these devices.

Nutritional Recommendations for

Postmenopausal Women

Vitamin D

The nurse should recommend that the postmenopausal client increase her dietary intake of vitamin D, as this nutrient is essential for maintaining bone health and preventing osteoporosis in this population.

Sickle Cell Anemia Management

Fluid Replacement

The nurse should initiate intravenous fluid replacement as part of the plan of care for a child experiencing a vaso-occlusive crisis due to sickle cell anemia, as this helps to improve blood flow and reduce pain.

Pain Medication

The nurse should administer acetaminophen or ibuprofen, rather than aspirin, to manage the pain associated with a sickle cell crisis, as aspirin can increase the risk of Reye's syndrome in children.

Ambulation

The nurse should encourage rest and avoid ambulation during a sickle cell crisis, as increased physical activity can further deplete the client's oxygen levels and exacerbate the crisis.

Car Seat Safety

Proper Car Seat Positioning

The nurse should assess the parent's understanding of how to properly secure the infant in the car seat, as this is a critical safety measure to prevent injury in the event of a motor vehicle accident.

Blood Transfusion Procedure

Vital Sign Monitoring

The nurse should check the client's vital signs prior to initiating the blood transfusion, and then continue to monitor the client's vital signs closely, especially during the first 15-30 minutes of the transfusion, to detect any adverse reactions.

Infusion Rate

The nurse should set the infusion pump to administer the blood over an appropriate duration, typically 2-4 hours, to ensure a safe and controlled rate of administration.

Tubing Flushing

The nurse should flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion to ensure that the tubing is properly primed and ready for use.

Needle Size

The nurse should use an appropriate-sized intravenous needle, typically a 16- or 18-gauge, to administer the blood, as larger needles can cause unnecessary discomfort and tissue damage.

Client Leaving Against Medical Advice

Explain the Risks

The nurse should take the time to explain to the client the potential risks and consequences of leaving the facility against medical advice, in an effort to encourage the client to reconsider their decision.

Incident Report

The nurse should complete an incident report to document the client's decision to leave against medical advice, as this serves as a record of the event and can help protect the healthcare facility in the event of any legal or regulatory issues.

Postpartum Home Visit Assessment

Responsive Parenting

The nurse should view the client's statement "I try to respond to the baby quickly" as a positive sign, as it indicates the parent is attuned to the infant's needs and is engaging in responsive caregiving.

Sleep Expectations

The client's statement "I think the baby should be sleeping through the night by now" may be a sign of unrealistic expectations, as newborns typically do not sleep through the night until several months of age.

Social Support

The client's statement "I have several friends who come by to help out with the baby" suggests the presence of a supportive social network, which can be a protective factor against child abuse.

Seeking Community

The client's statement "I want to meet other parents to see if they are going through the same thing" indicates a desire to connect with others, which is a positive sign and not necessarily a risk factor for child abuse.

Gastroenteritis Assessment

Fever and Tachycardia

The nurse should report the client's temperature of 38°C (100.4°F) and pulse rate of 124 beats per minute to the provider, as these findings may indicate the presence of dehydration or a more serious underlying condition.

Decreased Appetite and Irritability

The nurse should also report the client's decreased appetite and irritability, as these are common symptoms of gastroenteritis and may require further evaluation or intervention.

Dehydration Indicators

The nurse should report the client's pale appearance, 24-hour fluid deficit of 30 mL, and sunken fontanels and dry mucous membranes, as these are all signs of significant dehydration that require prompt treatment.

Language Barrier in Postpartum Care

Professional Interpreter

The nurse should request a professional interpreter, preferably a female interpreter, to facilitate effective communication with the client and gather the necessary information, as using a child or the client's partner as a translator is not recommended.

Pernicious Anemia Monitoring

Vitamin B12 Level

The nurse should evaluate the client's vitamin B12 level to assess the effectiveness of the treatment for pernicious anemia, as this is the primary laboratory value that reflects the client's response to vitamin B12 supplementation.

Delegation to Assistive Personnel

Tracheostomy Suctioning

The nurse should not delegate the task of suctioning a new tracheostomy to assistive personnel, as this requires specialized skills and knowledge to perform safely and effectively.

NG Tube Removal

The nurse should not delegate the removal of a nasogastric tube to assistive personnel, as this task also requires specific nursing skills and knowledge to ensure the client's safety.

Postmortem Care

The nurse can delegate the task of performing postmortem care to assistive personnel, as this does not require specialized nursing skills.

Central Venous Access Device Dressing Change

The nurse should not delegate the task of changing the dressing on an implanted central venous access device to assistive personnel, as this requires sterile technique and specialized nursing knowledge to prevent complications.

Postpartum Bladder Function Assessment

Fundus Position

The nurse should assess the position of the client's uterine fundus, which should be at or below the umbilicus, as a fundus that is 2 fingerbreadths above the umbilicus may indicate the client's inability to void properly.

Uterine Tone

The nurse should also assess the client's uterine tone, which should be firm, as uterine atony (a soft, boggy uterus) may indicate the presence of postpartum hemorrhage, which can also contribute to the client's difficulty voiding.

Fundus Position and Midline

The nurse should note the position of the client's uterine fundus, which should be in the midline, as a fundus that is shifted to the right may indicate the presence of a distended bladder, which can also impair the client's ability to void.

Acute Glomerulonephritis Manifestations

Oliguria

The nurse should expect the client with acute glomerulonephritis to experience oliguria (decreased urine output), rather than polyuria (increased urine output).

Hypertension

The nurse should expect the client to experience hypertension, rather than hypotension, as a result of the kidney dysfunction associated with acute glomerulonephritis.

Hematuria and Proteinuria

The nurse should expect the client to have hematuria (blood in the urine) and proteinuria (protein in the urine), as these are common findings in acute glomerulonephritis.

Weight Gain

The client with acute glomerulonephritis is likely to experience weight gain, rather than weight loss, due to fluid retention and edema.

Sertraline Adverse Effects

Increased Urinary Frequency

The nurse should include increased urinary frequency as a potential adverse effect of sertraline, as this is a common side effect of selective serotonin reuptake inhibitors (SSRIs).

Dry Cough

The nurse should not include dry cough as a potential adverse effect of sertraline, as this is not a commonly reported side effect of this medication.

Metallic Taste

The nurse should include metallic taste in the mouth as a potential adverse effect of sertraline, as this can occur with the use of SSRIs.

Newborn Genetic Screening

Water Intake

The nurse should not inform the parents that their newborn will be given water to drink prior to the genetic screening test, as this is not a standard practice.

Repeat Testing

The nurse should inform the parents that the genetic screening test will be performed once, typically within the first 24 hours of life, and does not need to be repeated at 2 months of age.