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MAIN VERSION PRIORITY ONE
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- A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hr (for asthma) c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
Rationale Fundamentals ATI PDF p229 : Managing acute severe pain with short-term (24 to 48 hr) around-the-clock administration of opioids is preferable to following a PRN schedule.
ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated on ATI.
- A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea Rationale Med Surg ATI PDF p457 : s/s of fat embolism (dyspnea, increased RR,decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress,
tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur after injury usually within 12-48 hrs
- A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sidespressed together)
R a t ion a le htt ps ://m e dlin e plu s. go v /drugin fo / me ds /a 601084. ht m l : H o w t o a pply patch Rationale ATI Skills Module Medication Administration : Topical medications include lotions, creams, ointments, patches, and paste. Because topical medications are absorbed by the skin, wear gloves when applying them to protect yourself against accidental exposure
Shaving may cause skin irritation and change the absorption of the drug.
- A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
a. A client who was just given a glass of orange juice for a low blood
glucose level
b. A client who is schedule for a procedure in 1 hr (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain Rationale Med Surg ATI PDF p529 : assess for improvement or worsening of hypoglycemia. Repeat the
administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens.
- A nurse is caring for a client who is receiving intermittent enteral tube feedings.Which of the following places the client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level;should be ABOVE waist level
Rationale POTTER & PERRY SKILLS & TECH p187 : Remove sterile seal and cap from bottle in upward motion.
- A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
- A home health nurse is preparing for an initial visit with an older adult client who livesalone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first.
- A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. “Can you tell me who visited you today?”
b. “What high school did you graduate from?”
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
Rationale ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g. birthdate). OR ask the client to state a fact from their past that is verifiable.
Memory of events that occurred in the distant past.
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? P .528 med surg ch 82 a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON COMPLIANT b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMICd. HbA1c level less than 7%
- A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control
c. The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy R a t io n ale: htt p:// www. w e bm d.co m / dr ugs / 2 / dr ug- 4 15 7 / dila n t in - o r al/ det ails # int e r a ct io n s Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive im pairm e n t (htt p: //e m e dicine .m e ds ca pe .co m /art icle / 81 6447 - clinica l# b4 als o s t at e s t h a t this is an indication of phenytoin toxicity); According to my Davis Drug Guide book, progressive s/s of phenytoin toxicity include ataxia, nystagmus, confusion, nausea, slurred speech & dizziness.
- A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing → may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC
- A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hrb. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom
- A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in lifec. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
Rationale ATI PDF p:33 PEDS Age appropriate activities for highschool students: sports, video games, music, social events.
19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? P. 146 ch 19 CONFIRMED a. Total bilirubin b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic
risk
d. Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
- A nurse has agreed to serve as an interpreter for an older adult client who is assignedto another nurse. Which of the following statements by the nurse indicates an understanding of this role?
a. “I will let the client know that I am available as the interpreter.”
b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m available today, but when I’m not, you can use a family member.”
d. “I will let the client know that an interpreter is unavailable during the night shift.” Rationale ATI PDF p: Makes most sense (best rationale yet)
21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? P. 156 ch 23 MATERNITY PDF
b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to passstool c. A 2 day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hr postoperative and has hypoactive bowel sounds
b. A client who has fractured left tibia and pallor in the affected
extremity
c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin
a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normalthey can be is RESPIRATORY DISTRESS
Rationale: circulation is affected; ABCs
- A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? a. Weight gain b. Dry mouth→ anticholinergic effects c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening
Rationale: e book pg 69 ch 10
d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reportedto the provider. ATI PHARM 110
d. Position a pillow under the client's knees
Rationale: Casting or splinting techniques are used to provide a constant stretch to the soft tissues surrounding a joint. It is most effective when used to increase motion of a joint from prolonged immobilization. It is also popular for treating contractures resulting from an increase in muscle tone from nerve injury. After an initial holding cast is applied for seven to 10 days, a series of positional casts are applied at weekly intervals. Before the application of each new cast, the joint is moved as much as can be tolerated by the patient,
and measured by a goniometer. When as much motion as possible is obtained after stretching, another final cast is applied to maintain the newly acquired motion.
- A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?
a. Provide anticipatory guidance classes to parents through public
schools
b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution
ATI COMMUNITY: Providing education to achieve community health goals is a component of identifying and intervening to meet health needs of the local community, which is responsibility to local health departments.
- A nurse in the emergency department is performing triage for multiple clients followinga disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → ESI Level 2 required immediate pain control per Triage, hypotension with signs of hypoperfusion.
-Patients with signs and symptoms of compartment syndrome are at high risk for extremity loss and should be assigned ESI level 2. Other patients with high-risk orthopedic injuries include any extremity injury with compromised neurovascular function, partial or complete amputations, or trauma mechanisms identified as having a high risk of injury such as serious acceleration, deceleration, pedestrian struck by a car, and gunshot or stab wound victims. Patients with possible fractures of the pelvis, femur, or hip and other extremity dislocations should be carefully evaluated and vital signs considered. These fractures can be associated with significant blood loss. Again, hemodynamically unstable patients who need immediate life-saving intervention such as high-level amputations meet ESI level- criteria. High level amputations meet ESI level 1.
-Patients with inhalation injuries from closed space smoke inhalation or chemical exposure should be considered high-risk for potential airway compromise. If the patient presents with significant airway distress and requires immediate intervention, they meet level- criteria. Patients with third-degree burns should also be considered high-risk and be assigned ESI level 2. It is possible that they will require transfer to a burn center for definitive care.
30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED
a. Hgb 12.8 g/dl - 12- 16
b. Prealbumin 10 mcg/dl (normal: 16 - 40)
c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl
Rationale: prealbumin is low (normal is 18-36). Prealbumin = nutritional status ATI MH 111 Hypoalbuminemia
- A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegateto the LPN?
b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs
33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor. Which of the following nursing actions should the nurse take? p. 88 ch 13 maternity
b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion
- A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record.
c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident.
- A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?
b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl
b. Compare the current infusion with the prescription in the client's medication record.
a. A client who is postoperative following a bowel resection with an NGT set to continuous suction
a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normalrange
a. Continue the monitor the fetal heart rate- - Not a problem- absent or lateare a problem however CONFIRMED
d. Heart rate 58/min
ATI PHARM 116 Complications
- A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?
a. You may breastfeed unless your nipples are cracked or bleeding.
b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics.
Rationale: CDC states that: There is no documented evidence that breastfeeding spreads HCV. Therefore, having HCV-infection is not a contraindication to breastfeed. HCV is
- A nurse is caring for a client who has hyperthermia .Which of the following actions forthe nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen d. Initiate seizure precautions Rationale: Hyperthermia occurs when a person's body temperature rises and remains above the normal; 98.6°F Most frequently, this occurs during the heat of summer and among the elderly. However, it may also be triggered by other medical conditions or certain medications. Rapid cooling may be the single most important action to prevent death or permanent disability. To mitigate organ damage, the goal should be to reduce rectal temperature to below 40°C within 30 minutes of beginning cooling therapy. The question does not indicate whether it is malignant hyperthermia which could have been caused by a medication. The question simply asks that the person has hyperthermia.
- A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include.
a. Document the client's conditions every 15 minutes
b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours
- A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is thenurse's priority intervention?
P. 482 ch 75 CONFIRMED
a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing
- A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage?
a. 7.5%
b. 15%
c. 8.1%
d. 13.3%
Rationale : 15lb/200lb = 0.075 x 100 = 7.5% weight loss percentage
- A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage ( massage if fundus is boggy)
b. Pour water from a squeeze bottle over the client’s perineal area.
c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client’s perineal area.( warm)
- A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?
a. Avoid hot tub while wearing the patch
b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance.
Rationale: According to manufacturer, do not expose the site to heat sources such as heating pad, electric blanket, sauna, hot tub, heated waterbed, excessive sun exposure, or hot climate. The body absorbs too much medicine with excessive heat.
*48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? Ch 55 p. 333
b. Place the client upright on a donut-shaped cushion- UPright causes increased pressure on the sacrum c. Assess pressure points every 24 hr.- must assess FREQUENTLY so i would rule out b then yeah it does. d. Turn and reposition the client every 3 hrs while in bed. - must be q 2 hours in bed , 1 hour in chair.
Rationale: impairment or loss of motor or sensory function in areas of the body served by the thoracic, lumbar, or sacral neurological segments owing to damage of neural elements in those parts of the spinal column. It spares the upper limbs but, depending on the level, may involve the trunk, pelvic organs, or lower limbs.
- A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nursemake during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress
d. We should establish our roles in the initial session.
Rationale : Orientation Phase:
- The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship).
- Trust, respect, honesty and effective communication are key principles in establishing arelationship.
- The expectations the nurse and the client have of each other and of their relationship are discussed and clarified
a. Teach the client to shift his weight every 15 min while sitting (cannot dothis because he is paraplegic)
