ATI RN VATI COMPREHENSIVE PREDICTOR 2024 FORM C 180 QUESTIONS AND CORRECT ANSWERS|GRADED A, Exams of Nursing

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QUESTIONS AND CORRECT ANSWERS|A

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ATI RN VATI

COMPREHENSIVE

PREDICTOR 2024

FORM C 180

QUESTIONS AND

CORRECT

ANSWERS|A

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D TO SCORE A)

QUESTIONS AND CORRECT ANSWERS|A GRADE(DOWNLOAD

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**A client is postoperative following a lumbar discectomy and is having difficulty voiding. The nurse should recognize that which of the following medications place the client at risk for urinary retention?

Ketorolac

Hydromorphone (Dilaudid) Bethanechol (Urecholine)

Tobramycin (Nebcin)

**A nurse is caring for an older adult client in a long-term care facility who is disoriented and continues to get out of bed without assistance. Which of the following images indicates the nurse is using an appropriate intervention to minimize the risk of injury due to a fall?

D

**A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with a registered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned which of the following tasks? Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin.

Create a plan of care for a newly admitted client.

Obtain a stool specimen from a client who has ulcerative colitis----

Administer an NG tube feeding to a client who had a stroke

**A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse?

You will need to go to your room until you can calm down okay The TV is loud enough for everyone to hear it

You are being inconsiderate. Please stop talking so loudly

Let’s go to another room to talk about what is upsetting you

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**A client tells a nurse that he would like to observe kosher dietary laws. The nurse should recognize which of the following?

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A vegetarian diet is the preferred diet

Dairy products are served separately from meat

Fasting during daylight is required during a month-long holiday Fish with scales and fins should not be eaten

**A nursing unit receives new glucose monitoring equipment from staff development with the promise that in-service education will be given soon. Which of the following instructions should the nurse give to the assistive personnel (AP) who is preforming glucose monitoring on the unit? Contact the staff development department for instruction

Continue using the current glucose monitors

Check for accuracy and proper functioning of the new monitor

Read the instruction manual before attempting to use the new monitor

**Which of the following should the nurse document as an indication of the IV infiltration in a client’s forearm?

Redness along vein Tissue sloughing at the site

Forearm that is warm to the touch

Pallor surrounding the infusion site

**A client requests information about advanced directives. Which of the following is the appropriate response by the nurse?

Advanced directives are written instructions regarding end of life care

Advanced directives provide education on palliative care issues

Advanced directives require the provider’s approval before changes can be implemented Advanced directives help determine legal competency

**A nurse is caring for a client who is on telemetry. Which of the following ECG findings should the nurse report to the charge nurse?

One P wave prior to each QRS complex

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PR interval 0.24 seconds QRS duration 0.06 seconds

Ventricular rate 75/min

**A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex?

Startle the infant by clapping hands

Stroke the sole of the infant’s foot upward and toward the great toe

Hold the infant upright and allow one foot to touch the table’s surface Place an object in the palm of the infant’s hand

**A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated failure to provide oral care for clients. Which of the following actions should the nurse take?

Provide oral care for clients after the AP has completed other care Develop an educational session about the importance of oral care for all Aps

Discuss the unacceptable behavior with the AP while reinforcing expectations

Suspend the AP for 3 days pending disciplinary action

**A nurse is caring for a client who has terminal cancer. Which of the following statements by the client’s family should indicate the nurse that they are coping with their situation?

Dad I remember the time we all went to the lake fishing Dad I truly believe that it’s not your time to leave us

I feel like I don’t know what to do anymore I think we need to concentrate on whose house we plan to meet at for our holiday get-together

**A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take? Apply an abdominal binder

Have the client lie flat in bed.

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Cover the exposed area with sterile, saline-soaked dressing

Place gentle pressure on the exposed organ with sterile gauze

**A nurse in a skilled nursing facility is caring for a client who is receiving warfarin (Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive guaiac. Which of the following laboratory values should the nurse report to the provider?

Hematocrit 40%

International normalized ratio of 4.

Hemoglobin 15 g/dL--

Prothrombin time 18 seconds

** A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril (Capoten). Which of the following over-the-counter medications should the nurse instruct the client to avoid? Acetaminophen (Tylenol)

Diphenhydramine

Ibuprofen (Advil) Guaifenesin (Robitussin)

**A nurse is reinforcing teaching for a client who is in her first trimester of pregnancy. Which of the following physiological changes should the nurse instruct the client to expect during the first trimester?

Leukorrhea

Shortness of breath Pedal edema

Perineal pressure

** A nurse is collecting data from a client who has a peptic ulcer disease. Which of the following should the nurse identify as the priority finding?

Gnawing epigastric pain

Heartburn

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Regurgitation

Hematemesis

**A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following behavioral indications should the nurse expect?

Dependence

Euphoria

Memory Loss Hypervigilance

**A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion?

My doctor’s glasses have lasers that will burn holes in my brain if I look at him The movie had an explosion. I once drove a green truck. Where is the ketchup

The voice keeps telling me to go kick the table over. Why won’t it stop

I can’t sit here because the purple monkey on the ceiling will jump on me

**A nurse is caring for a client who sustained a broken leg while assisting other from a structural fire. The client states I am glad those people were saved but I sure wish I was not hurt. Which of the following is an appropriate response by the nurse? You are a real hero. I am sure that makes your injuries worthwhile

It is difficult to experience personal injuries for whatever reason

Things will get better before long

Let’s talk about this later when we have more time

**A nurse is reinforcing teaching for a client who has a new prescription for lithium carbonate (Lithobid). Which of the following instructions should the nurse include?

Eliminate all foods containing tyramine Drink 2 to 3 liter of fluid each day

Take lithium carbonate on an empty stomach

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Reduce your daily sodium intake to 1,000 mg

**A nurse in a provider’s office is reinforcing teaching with a client who is receiving peritoneal dialysis via a newly inserted catheter. For which of the following should the nurse instruct the client to contact the provider?

Bloody peritoneal fluid Clear peritoneal fluid

Cloudy peritoneal fluid

Straw-colored peritoneal fluid

**A child is brought to the clinic by his parents with injuries inconsistent with the reported cause. A nurse suspects physical abuse. Which of the following actions should the nurse take?

Interview the child with the parents in the room

Ask the provider to talk to the child and parents

Make a note in the chart to check the child during the next visit

Report the suspected abuse to the appropriate agency

**A nurse is reviewing discharge instructions with a client who has undergone a lumbar laminectomy. Which of the following should the nurse include?

Use a soft mattress for sleeping Practice bending from the waist several times daily

Sit in a straight backed chair

Wear shoes with a slightly raised heel to promote body alignment

**A nurse is reinforcing teaching with a client about cancer prevention, the nurse should instruct that frequent consumption of which of the following foods increases the risk of cancer?

Tuna

Lamb Chicken

Turkey

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** A nurse is reinforcing teaching to a client who is scheduled for a lumbar puncture. Which of the following should the nurse include in the teaching? Nausea is common adverse effect after this procedure

You should increase your fluid intake after this procedure

You will be instructed to remain in an upright position for the first 4 hours after the procedure The provider will apply a pressure bandage to the puncture site

**A newborn is scheduled to have a heel stick for blood glucose testing every 4hr. The newborn’s blood glucose on admission was less than 40 mg/dL. Which of to the following additional clinical manifestations should the nurse observe for in this newborn?

Jitteriness

Bradycardia

Inconsolability Insomnia

**A nurse is contributing to the plan of care for a client who has a prescription for range of motion exercise of the shoulder. To promote shoulder hyperextension, which of the following exercises should the nurse recommend?

Move his arm behind his body with his elbow straight

Move his arm in a full circle

Raise his arm out to the side and reach it above his head with his palm facing away from his head Raise his arm from his side straight forward and then up above his head.

**A nurse is receiving change-of-shit report for four clients. Which of the following clients should the nurse attend to first? A client who requests to be moved to a room closer to the nurse’s station

A client who is postoperative and had received morphine twice during the last 8hrs

A client whose urinary output was 100 mL for the past 12hr

A client who insists on speaking with the provider prior to discharge

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**A nurse is reinforcing teaching regarding home safety to a client who has diabetes mellitus and is being discharged after an admission for hepatitis B. Which of the following client statements indicates an understanding of the teaching? I will recap my used syringes and throw them away in a plastic bag

I will take Tylenol for aches and pains

I will use my own eating utensils and dishes at home Houseguest will need to wear masks when they come to visit me

**A nurse in a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescription is accurately transcribed by the nurse?

Alprazolam (Xanax) 0.5 mg PO QHS for sleep

Regular insulin (Humulin R) 10 U SC at 0800 Docusate sodium (Colace) 250 mg PO QOD

Potassium chloride (Micro-K) 20mEq PO every morning

**A nurse is caring for a client who has altered mental status and has become increasing belligerent. Which of the following medications prescriptions, if written for this client, should the nurse question?

Haloperidol (Haldol) Lorazepam (Ativan)

Zolpidem (Ambien)

Alprazolam (Xanax)

**A nurse is caring for a client who is experiencing acute kidney failure. The nurse should monitor the client for which of the following acid-base imbalances?

Metabolic alkalosis

Metabolic acidosis Respiratory alkalosis

Respiratory acidosis

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**A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients should the nurse recommend for treatment first? A client who has a fever and abdominal pain in the upper aspect of the right lower quadrant

A client who has shortness of breath after taking a dose of amoxicillin (Amoxil)

A client who has hemoptysis and has taken medication for tuberculosis (TB) for 2 months A client who has a purple stoma following an open colon resection with a colostomy 2 weeks ago.

**A nurse on a medical unit is preforming an audit on his client assisgnment. For which of the following should the client have a separate signed informed consent form. Chest radiography

Echocardiogram

Indwelling urinary catheter

Lumbar puncture

** A nurse in an acute care hospital is planning to discharge an adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer before discharge.

Measles, mumps, and rubella (MMR) immunization

Pneumococcal polysaccharide (PPSV) immunization Varicella immunization

Herpes zoster immunization

** A nurse is reinforcing teaching to a client regarding care of her newborn. The nurse determines that the teaching is effective when the client points to which part of the newborn’s head and states it will take 12 to 18 months for the soft stop to close.

(top of the head near face)

**A parent of a 3yr old child tells the nurse that he cannot get his child to sit at the table to eat a full meal. Which of the following responses by the nurse is appropriate?

Provide the child with foods of the same texture rather than a variety of unfamiliar foods

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Engage the child in conversation during meals to encourage him to eat like the rest of the family

Encourage active play prior to meals to increase the child’s appetite

Offer the child heathful snacks frequently, rather than expecting him to fully eat at mealtimes

**A nurse in a providers office is caring for four clients. Which of the following should the nurse see first.

A client who is at 38 weeks gestation and reports urgency and frequency of urination

A client who is at 37 weeks gestation and reports edema of the ankles

A client who is at 36 weeks gestation and reports painless vaginal bleeding A client who is at 34 weeks gestation and reports abundant amounts of odorless vaginal mucus

**A nurse and an assistive personnel (AP) are caring for four clients in a long-term-care facility. For which of the following situations is it necessary to complete an incident report?

A client throws an object across the dinning room

A client refuses his morning medications

A client who is prescribed full liquid diet receives a clear liquid diet

A client who is confused walks into another client’s room

** A nurse working in the clinic receives a phone call from a mother whose child has just ingested the contents of a bottle of acetaminophen (Tylenol). Which of the following is an appropriate response by the nures? Adminster syrup of ipecac to the child to induce vomiting

Take the child to the emergency department

Give the child a glass of milk to drink

Monitor the child’s level of consciousness

**A client is scheduled for colon cancer surgery in the morning. The night nurse learns that the client has decided not to have the surgery, even through he has already signed the informed consent form. Which of the following actions should the nurse take?

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Inform the client that a signed consent form is legally in effect for 24hr Report the situation to the surgeon who obtained the informed consent

Reinforce client teaching about the purpose of the procedure

Notify the client’s family about the refusal of treatment

**A nurse is caring for a newborn who is 1hr old. The mother received fentanyle (Sublimaze) 30 min before delivery. For which of the following should the nurse monitor for in the newborn?

Hyperbillrubinemia

Hypoglycemia Respiratory depression

Increased heart rate

**A nurse is reinforcing discharge teaching with the parent of a school-age child who had a tonsillectomy. Which of the following statements by the parent indicates an understandin of the instructions?

I will encourage my child to drink 4 ounces of orange juice twice a day I will allow my child to chew gum to prevent throat pain

I will ensure my child uses a straw to drink fluids

I will give my child chocolate ice cream

** A nurse is reviewing the laboratory results for an infant receiving gentamicin intermittent IV bolus twice daily and notes the serum creatinine is 0.9 mg/dL. The nurse is aware that this result can indicate an adverse effect on which of the following systems? Hepatic

Renal

Gastrointestinal

Endocrine

**A is reinforcing teaching with an adolescent client about a scheduled blood draw of HbA1c. The nurse knows that the client understands the purpose for this test when the client states that this test will measure his average blood glucose level over the past

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2 to 3 days

6 weeks

2 to 3 months 6 months

**A nurse is caring for a client in Buck’s traction. Which of the following interventions should the nurse perform while the client is in this traction?

Allow the weights to hang freely Inspect the skin every 24hr

Remove the weights every 24hr

Let the client use the bedside commode

**A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following?

Motor response

Vital signs

Short-term memory Gait

**A nurse is reinforcing teaching to a client who has a new prescription for atorvastatin (Lipitor). For which of the following shold the nurse tell the client to monitor and report to the provider?

Anorexia Muscle tenderness

Facial flushing

Insomnia

**A nurse working in a clinic is collecting data on a toddler. Which of the following findings should the nurse identify as suggestive of physical neglect?

The toddler is inadequately dressed for the weather

The toddler has irriation to the external genitalla

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The toddler has symmetrical burns to both legs

The toddler does not react when the nurse adminsters an injection

**A parent of a 2month old infant asks the nurse how she will know if her baby is growing appropriately. Which of the following is an appropriate response by the nurse?

Your baby should weigh 2.5 time his height by 6 months

Your baby should gain 1 pound per month during the first 6 months Your baby’s weight should be double his birth weight b y 4 to 6 months

Your baby should grow half an inch per month during the first 6 months

**A nurse is contributine to a teaching plan for a group of male adolescents regarding use of anabolic steroids. Which of the following should the nurse include in the teaching as risk of using anabolic steroids?

Decreased appetite

Reduced height potential

Increased dental caries Impaired vision

**A client who is 1 day postoperative is unable to ambulate. The nurse should recognize that which of the following will promote venous return? Encouraging the client to cough and deep breathe

Maintaining a sequential compression device

Elevating the head of the bed

Massaging the clients legs

**A nurse reinforces the use of a mask prior to a family entering the room of a client who has tuberculosis (TB). Which of the following information should the nurse include?

Prior to entering the room, make sure the client puts on a mask If you leave the client’s room for a break, you can reuse your mask upon returning

Wearing a mask will help protect you from the client’s illness

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Masks are part of the hospital protocol, but family members do not have to wear them

**A nurse is caring for a client recently diagnosed with adenocarcinoma of the lung. While discussing teatment option with the client, the family asks the nurse about the use of herbal medications for treatment. The nurse should respond by stating, Herbal medicines

Are untested for both safety and efficacy

Will protect against progression of your cancer Are frequently cheaper than conventional medications

Must be prescribed by a provider

**A client who is pregnant presents to the emergency department with a broken arm. The client appears anxious and gives conflicting stories about how the injury occurred. The client’s spouse is hovering over her and answering questions for her. What should the nurse do to handle this situation? Disregard the spouse’s remarks while continuing with data collection

Request that the spouse go to the waiting room

Bring a second nurse into the examination room

Ask the client’s spouse to refrain from answering for the client.

**A nurse is caring for a client who has a history of long-term alcohol use disorder. The client has a prescription for disulfiram (Antabuse). The nurse should recognize that the use of this medication is a form of which of the following types of therapy? Operant conditioning

Systemtic desensitization

Aversion therapy

Cognitive therapy

**A nurse is caring for a client who has impaired vision. Which of the following strategies should the nurse include in the plan of care?

Keep the door to the client’s bathroom slightly ajar

Hold the client’s arm while standing even with the client’s shoulders while ambulating

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During ambulation, the nurse should stand just ahead of the client and offer his arm for guidance

Place frequently used items on the bedside table

**A nurse has administerd lorazepam (Ativan) to a client who is scheduled for surgery within the next hour. Which of the following actions should the nurse take? Instruct the client to remain in bed

Ensure that the informed consent form has been signed

Assist the client to the bathroom to void

Reinforce teaching about deep breathing and coughing exericses

**A nurse is preparing to insert a nasogastric tube for a client. Identify the sequence the nurse should follow after performing proper hand hygiene and preparing equipment at the bedside

Place the client in high-Fowler’s position Determine which naris has the greatest airflow

Measure the distance to insert the tube

Lubricate 7.5 to 10 cm (3-4 in) of the end of the tube

Instruct the client to hyperextend her neck

**A nurse is reinforcing teaching about pancrelipase (Pancreaze) with the parent of a child who has cystic fibrosis. Which of the following instructions should the nurse include in the teaching?

Place the medicine under the tongue

Take the medication after a meal

Sprinkle the contents of the capsule on food Chew each capsule thoroughly

**A nurse brings her adolescent son to an urgent care center, stating that “he is high on something and needs help.” The client is exhibiting agitation and paranola, and reports visual hallucinations. The nurse should suspect intoxication with which of the following substances?

Methamphetamines

Opioids

Anbolic steroids

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Alcohol

**A nurse enters the room of a client who had a bone marrow transplant 3 days ago for treatment of leukemia. Which of the following observations warrents intervention?

The client’s meal tray contains stewed tomatoes

A visitor brought the client a bouquest of flowers

The client is using an electric razor to shave

An assistive personnel is removing a bag of biohazardous materials

**A nurse is collecting data from a client who is primigravida and at 25 weeks of gestation. The client is tearful and tells the nurse, “I’m sorry, I’m just nervous and emotional today.” Which of the following actions should the nurse take first? Help the client identify a support person to talk to

Recoomend the client join a support group for first time mothers

Assist the client to schedule childbirth classes

Explore the client’s underlying concerns

**A nurse is caring for a client who has expressive aphasia following a cerbrovascular accident. Which of the following communication methods is appropriate for the nurse to use with this client?

Ask open-ended questions

Speak slowly with a raised voice Provide a picture board

Limit the use of gestures

**A nurse is caring for a client who is postoperative following an open reduction with internal fixation of the ankle. The client reports pain, and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical resident, who responds, “It has always been like that.” Which of the following actions should the nurse take first?

Notify the nursing supervisor

Administer the prescribed pain medication Recheck the client in 30 min

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Reposition the client to improve anatomical alignment

**A nurse is reinforcing teaching to a client about the adverse effects of propranolol (Inderal). For which of the following effects should the nurse instruct the client to observe?

Bradycardia

Cough

Paresthesias

Urinary retention

**A nurse is caring for a postpartum client who is breastfeeding. Which of the following is appropirate for the nurse to reinforce about breastfeeding?

Look for slowed suck/swallow pattern as a sign that the newborn is finished eating Ensure that the newborn has the entire areola in the mouth during feeding

Begin feeding the newborn on the same breast each time

Push the back of the newborn’s head toward the nipple

**A nurse is reinforcing teaching for a client who has a new prescription for metronidazole (Flagyl), The nurses should instruct the client to expect which of the following adverse effects while taking this medication?

Reddish brown urine

Increased saliva production Photophobia

Peripheral edema **A nurse is admitting a client who is at risk for suicide. Which of the following is the nurse’s highest priority? Search the client’s personal belongings.

Place the client in a room close to the nurses’ station

Ask the client to sign a no-suicide contract

Review the client’s SAD PERSONS scale assessment

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**A nures enters the room of an adolescent client and observes him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take when the seizure subsides? Insert a tongue blade in the client’s mouth

Assist the client to an upright posiiton

Offer clear fluids through a straw

Keep the client in a side-lying position

**A nurse is reinforcing discharge teaching for a client who has a new prescription for digoxin (Lanoxin). Which of the following should the nurse include in the instructions as an indication of digoxin toxicity? Visual changes

Skin irritation

Fever

Angina

**A female client presents to an outpatient clinic. Which of the following findings place the client at risk for coronary artery disease?

The client’s LDL level The client’s daily alcohol consumption

The client’s weight for her height

The client’s blood pressure

**A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?

Bulging fontanel Capillary refill 6 seconds

Moist mucous membranes

Urine specific gravity 1.

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**A nurse is reinforcing teaching for a clientwho has a new prescription for sublinguail nitroglycerin (Nitrostat). Which of the following statements indicates client understanding?

I will take half a tablet before I exercise I can take up to four tablets to relieve my pain

I will put the tablets in a medication container for easy acess

I may develop a headache after taking this medication

**A nurse is caring for a client who has a new diagnosis of HIV. The client states, “I don’t want anyone else to know that I have HIV.” Based on the recommendations of the Centers for Disease Control and Prevention, which of the following is an appropriate response by the nurse?

Your HIV status will be protected by HIPPA regulations

Your HIV status needs to be reported to the state health department We must report your HIV status to your employer

Your HIV status is protected under the Patient Care Partnership

**A nurse is reinforcing discharge teaching with a client regarding self-administration of epid insulin (Humulin R). Which of the following instructions should the nurse include?

Shake the insulin vial before administering

Administer insulin at room temperature

Administer insulin 15 min prior to each meal

Dissolve solid deposits by warming the insulin before administering

**A nurse is reinforcing teaching to a client who has schizophrenia and his family regarding treatment options. Which of the following statements by the nurse is appropriate?

Family therapy can assist clients and their families to learn effective coping skills

Cognitive remediation therapy is used to solve longstanding family problems resulting from the disease Use of medication is considered short-term therapy until symptoms are stabilized

Day treatment programs are the desired choice for achieving acute symptom stabilization

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**A nurse notices an assistive personnel (AP) of the unit taking naps in the break room instead of having a meal or a snack. She appears drowsy while performing routine tasks. Which of the following actions should the nurse take? Keep a record of the AP’s behavior over a period of time

Report the observations about the AP to the unit’s nurse manager

Ask other unit staff if they have observed the same behavior Determine if the AP is having problems at home

**A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate (TURP) surgery. Which of the following is appropriate to include in the plan of care

Discontinue the urinary catheter 24hr after surgery Adjust the bladder irrigation to keep the urine a bright yellow color

Use 50 mL sterile water to clear the urinary catheter of obstruction

Irrigate the bladder using sterile technique

**A nurse is collecting a urine specimen from a client with diabetes insipidus. The nurse should expect which of the following findings?

Proteinuria

Creatinine clearance of 100 mL/min/m Urine specific gravity of 1.002

Hematuria

**A nurse is reinforcing teaching with a newborn’s parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions?

I will give our baby sponge baths until the cord falls off

I will remove the cord clamp after 5 days

I will wrap the cord in petroleum jelly gauze

I will keep the cord protected by covering it with the diaper

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**A nurse is preparing to administer a dose of furosemide (Lasix) 30 min past the scheduled time. The nurse notes that there is a new potassium value alert on the client’s electronic record. The nurse should Review the laboratory value prior to preparing the medication

Administer the medication, and then review the client’s laboratory values

Hold the dose of medication until the provider makes rounds

Administer the medication, and notify the provider that new laboratory values are available

**A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead electrocardiogram (ECG). Which of the following actions should the nurse include in the plan of care? Place the client in Sims’ position

Put chest electrodes on the client’s breast

Instruct the client to remain still while the ECG is performed Cleanse the skin with providone-iodine prior to electrode placement

**A nurse is caring for an older adult client who is 48hr postoperative following abdominal surgery. The provider writes a prescription to advance the client to a regular diet. After evaluating the client, the nurse should notify the provider about which of the following findings? The client has absent bowel sounds

The client is unable to sit for long periodsof time The clients incision is draining serous fluid

The client reports loss ofappetite due to pain

**A nurse is collecting data from an older client who has a hip fracture. Which of the following findings should the nurse expect?

External rotation Muscle flaccidity

Leg lengthening

Hyperreflexia

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**A nurse is supevising an assistive personnel (AP) who is preparing to remove his personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse identifies understandingof the procedure when the AP removes which of the following items first?

Goggles

Gloves Gown

Respirator

**A nurse is reinforcing newborn care to a client whose newborn underwent clamp circumcision procedure. Which of the following statements made by the client indicates to the nurse a need for further teaching? I should apply petroieum jelly each time I change the diaper

I will apply gentle pressure if bleeding occurs

I will be sure to wipe off any yellow drainage

I should make sure my baby has at least six wet diapers in 24hrs

**A client newly diagnosed with diabetes mellitus inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (select all)

Local pharmacist

Personal tesimonial web sites Package inserts

Other clients in a diabetes support group American Diabetes Association

**A nurse in an urgent care facility is reinforing teaching to a client about the safe use of crutches. Which of the following statements indicates the client understands the teaching? I will wear leather-soled shoes when walking with my crutches

I will ensure the pad of the crutch fits snugly in my armpit

I will hold both crutches on the side opposite my injured leg when sitting

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TO SCORE A)

I will switch to using only one crutch when I regain some strength

**A nurse is reinforcing teaching on food selection for a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

Tomatoes

Apricots

Avocados

Carrots

**A nurse is caring for an adolescent who has meningitis. To prevent the adolescent from experiencing increase intracranial pressure, which of the following actions should the nurse take?

Keep the head of the bed flat Withhold pain medication until the client is in severe pain

Suction the airway when necessary

Keep the client’s door open for visual observation

**A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis, Which of the following actions should the nurse plan to take?

Inject 0.5 mL of medication Insert the needle at a 10degree angle

Ensure that the bevel of the needle is pointing down during administration

Aspirate the syringe prior to injecting the medication

** A nurse is reinforcing discharge teaching with a client about adverse effects of prescribed medications. The nurse should tell the client that if black, tarry stools are noted, the client should stop taking which oft eh following medications and notify the provider?

Acetaminophen (Tylenol) Aspirin (Ecotrin)

Guaifenesin (Robitussin)

Loratadine (Claritin)