Nursing Care Prioritization and Delegation, Exams of Nursing

Download Nursing Care Prioritization and Delegation and more Exams Nursing in PDF only on Docsity! 1 1. Christine (1-10) ✅ 2.Kristine (11-20)✓ 3. Lorena (21-30)✓ 4. Chiugo (31-40)✓ 5. Rukhsar (41-50)✓ 6. Michael (51-60) ✅ 7. Kourtney (61-70) ✓ 8. Laura (71-80)✓ 9. Dio (81-90)✅ 10. Daniel (91-100) ✅ 11. Shaunte (101-110)✓ 12. Navjot (111-120) ✅ 13. Philip(121-130) ✅ 14. Julie (131-140)✓ 15. Sara (141-150) ✅ 16. Jacqueline H.(151-160) ✓ 17. Brian(161-170)✓ 18. Robin (171-180)✓ Main Priority ➔ 2016: Utilize all ATI resource you have. Stay organized. Don't Panic. Stop, drop and roll as needed. Everyone type out & answer your own questions (10 questions each!!) “Coming together is a beginning; keeping together is progress; working together is SUCCESS” DUE Friday 8/18 @ 1500 FYI numbers that are highlighted in yellow are confirmed ✓→ typed ✅→ completed w/ rationale Verify all answers: 2 Ryan, Paul & Jackie → 1-90 Camille, Kate & Jo → 91-180 1. Missing 2. A nursing planning care for a school-age child who is 4 hrs. 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 hrs. following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hrs. (for asthma) c. Apply a warm compress to the operative site every 4 hrs. d. Administer analgesics on a scheduled basis for the first 24 hrs. Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short‑term (24 to 48 hrs.) 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. 3. 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. 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? 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 sides pressed together) Rationale https://medlineplus.gov/druginfo/meds/a601084.html: How to apply 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 5 a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison Rationale ATI MH p185: Risk factors also include: history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Rationale ATI COMMUNITY p50: Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1- inch) border around any sterile drape or wrap that is considered contaminated. 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. 11. 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 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. 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. 13. 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? 6 a. “Can you tell me who visited you today?” b. “What high school did you graduate from?” c. “Can you list your current medications?” 7 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 = HYPOGLYCEMIC d. HbA1c level less than 7% 15. 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 d. The client is having adverse effects due to combination antimicrobial therapy Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive impairment (http://emedicine.medscape.com/article/816447-clinical#b4 also states that 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. 16. 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 17. 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 hr. b. 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 10 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 an elevated AST level following administration of azithromycin Rationale: circulation is affected; ABCs 23. 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. Dry mouth→ anticholinergic effects b. Sedation → c. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to the provider. ATI PHARM 110 Rationale: e book pg. 69 Ch. 10 24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? P . 177 Ch. 26 a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths b. The cord stump will fall off in 5 days- about 10 - 14 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry. 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas b. Potato pancakes c. Wheat crackers d. Canned barley soup Rationale: no wheat, flour, or barley 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech → alterations in speech 11 d. Hypochondriasis ( anxiety disorder) pg. 108 eBook Ch. 20 Rationale : e book pg. 79 under expected findings Ch. 15 12 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the client’s legs b. Place a towel roll under the client’s neck c. Apply an orthotic to the client’s foot 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. 28. 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 29. A nurse in the emergency department is performing triage for multiple clients following a 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 hypo perfusion. -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 gun shot 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-1 criteria. High level amputations meet ESI level 1. 15 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. 39. 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 40. 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 the nurse'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 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” Which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have questions about your mom dying. Let’s talk about it. Rationale: 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? 16 a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L 17 b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information - HIPPA rules b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner 45. 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 lbs.). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3% 46. A nurse is caring for a client who is 4 hrs. postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage 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. 47. 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 20 *52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? Ch 4 p. 23 funds 21 a. Heightened perceptual field b. Rapid speech -severe c. Feelings of dread d. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) CONFIRMED a. Tremors b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis e. Inability to concentrate 54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension (Upper Hypertension) b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses Rationale: Pg.112 (Pediatrics) A narrowing of the major artery (the aorta) that carries blood to the body. This narrowing affects blood flow where the arteries branch out to carry blood along separate vessels to the upper and lower parts of the body. CoA can cause high blood pressure or heart damage. *55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd) Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: ● legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) ● education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) ● immunization against infectious diseases. 22 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? 25 c. Urinary retention- ANTICHOLINERGIC EFFECTS- dry. Also, tachycardia, blurred vision, constipation d. Hypertension- orthostatic hypotension it will cause instead 62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. Hypertension : p . 245 Ch. 31 pharm c. Fibromyalgia d. Fibrocystic breast condition 63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure Rationale: fund ati pg. 27 64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. “You should not have this procedure if you are allergic to iodine.” b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” Rationale: med-surg ati pg. 39. Nursing actions: assess for allergy to shellfish or iodine, which would require the use of a different contrast media 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, Hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 26 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? P . 125 Ch. 21 a. Initiate IV fluid replacement- BLOOD IS TOO VISCOUS = obstruction = tissue hypoxia. CONFIRMED b. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to Reyes disease . d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safely securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? a. b. C and D not shown From the two pictures shown I think it is B. Rationale: https://www.whattoexpect.com/first-year/infant-car-seat-safety Dress baby comfortably, set the seat at 45 degrees, rear facing until 2 years old, make sure baby’s head is secure (usually with special cushioned inserts), the straps on a rear facing safety seat should be at or below baby’s shoulders, strap and fasten them at armpit level, straps should lie flat and untwisted; tight enough so that you get fit two fingers between harness and baby’s collarbone 68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion- assess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr.- 2- 4 hours for blood transfusion p . 250 c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- prime blood administration set with NS only d. Administer the blood via a 21-gauge IV needle- page 249 says 18 -20 gauge 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? CONFIRMED 27 a. Summon a security guard 30 79. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? Pg. 106 Ch. 10 pediatrics a. perform the procedure prior to meals-AVOID Before or AFTER meals b. perform the procedure twice a day c. administer a bronchodilator after the procedure- must be given BEFORE d. hold hand flat to perform percussions on the child- NO has to be CUPPED!!! 80. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls→ correct approach; yellow bracelet indicates fall risk c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication → If they’re conscious and can swallow and the NGT is clamped, OK! However, Malpractice (Professional Negligence) A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. 81. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness. R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? P . 106 CH 19 PEDS a. Take pancrelipase b. Complete oral hygiene c. Eat a meal 31 d. Use an albuterol inhaler ATI PEDS 85 Administer a bronchodilator medication or nebulizer 32 treatment prior to postural drainage if prescribed. 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P . 164 Ch. 27 med/surg a. Monitor the dorsalis pedis pulse every 15 minutes → circulation b. Maintain strict bedrest for first 12 hr.- only for prescribed time, older adults usually are up to 4 hours. c. Keep the client NPO for 24 hr.- doesn’t say anything about restrictions AFTER the procedure , and NPO b4 the procedure is up to 8 hours. d. Place the client in Fowler’s position- supine they must be http://micunursing.com/cardiaccathpreandpostcare.htm → Generally, the nurse should monitor vital signs, and distal pulses every 15 minutes X 4, every 30 minutes X 2, then every hour X 2, then routine. If there is any change in the patient's neurovascular status for physician should be notified immediately. 84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? a. Offer high-calorie, high protein snacks to the client b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? a. Non-maleficence - b. Veracity c. Autonomy d. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? p . 287 Ch. 43 A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns 35 Refer to speech language therapist for dysarthria and dysphagia. 36 91. A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% Glycosylated hemoglobin (HbA1c): best indicator of an average blood glucose level for the past 120 days 92. A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication? A. BUN B. Blood pressure C. Respiratory rate D. aPTT Beta blocker - blood pressure medication. 93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? A. Encouraging the client to use jet therapy on her lower back for 1 hr. - (as long as a patient in active labor has no contraindications, she can generally stay in the bath for 30-60 mins) B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen (some therapies vary - such as TENS may require trained practitioners and sometimes specialized equipment) C. Using effleurage on a client’s lower abdomen - (light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions) D. Instructing a client’s partner how to apply counter pressure to the client’s sacral spine for 30 min - (consistent pressure is applied using the heel of the hand/fist against the client’s sacral area to counteract pain in the lower back) 37 94. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of- shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 40 99. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? A. Lorazepam .5 mg PO one tablet daily (needs a preceding zero - “0.5” ) B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 100. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face Preeclampsia B. Urinary frequency Pressure on bladder from enlarging uterus C. Faintness upon rising D. Bleeding gums Caused by increase of blood flow to gums, normal 101. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest From pathological skin-picking B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 Idgaf betch D. Xerostomia Dry mouth 102. A nurse is assessing a client who is 2 hrs. postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus 103. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming” (can be brief that sometimes they are mistaken for daydreaming and may not be detected for months) B. “The child usually has an aura prior to onset” C. This type of seizure last 30-60 sec” (begin and end abruptly) D. “This type of seizure has a gradual onset” (generalized onset) 41 104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use (supply a latex-free cart) B. Tape stockinet over monitoring device and cords (place all monitoring devices, cords/tubes in stockinet and secure with tape to prevent direct skin contact) C. Schedule the client as the last surgery of the day (allergen from latex can circulate in the air for an hour after procedure where latex was used - schedule surgery FIRST case of the day) D. Remove stopcocks from IV tubing (Use IV tubing ports without latex ports - utilize STOPCOCKS if available) http://latexallergyresources.org/articles/aana-latex-protocol 105. A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication? (there is an exhibit. The answer the person picked was A) A. Dumping syndrome B. Ketoacidosis C. Hepatotoxicity D. Thyroid storm 106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room (private room) B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft. from the client (6ft for reg visitors, no preggerz allowed) E. Close the door to the client's room 107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem 42 108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one Don’t just offer, prepare gifts ahead of time so the sibling doesn’t feel left out. Provide a gift from the infant to give to sibling B. Move your son to a toddler bed when the baby arrives 2 months before C. Tell your son to kiss the baby Don’t force interactions b/t child and the baby D. Teach your son to change the baby diapers - allow older siblings to help in providing care for the infant 109. A nurse is obtaining a nutritional health Hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics C. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen Peritonitis D. Bounding pulse A condition in which the normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left‑to‑right shunt) ●● Murmur (machine hum) ●● Wide pulse pressure ●● Bounding pulses ●● Asymptomatic (possibly) ●● Heart failure 111. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occurs. 45 120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site necrosis with extravasation - discontinue IV b. Blood pressure 92/68 mm Hg - Increases workload of the heart, works to increase BP/HR c. Urine output 35mL/hr. d. Pedal pulse of +1 bilaterally Rationale: Page 277. PHARM ATI. ADVERSE EFFECT: Necrosis. 121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward first (Both crutches ONLY forward first) Rationale: . CRUTCH INSTRUCTIONS ● Do not alter crutches after fitting. ● Follow the prescribed crutch gait. ● Support body weight at the hand grips with elbows flexed at 30°. ● Position the crutches on the unaffected side when sitting or rising from a chair. 122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot (4 years old) B. Kick a ball forward C. Climb Stairs with alternate feet 3 years old → 2 years old climbs stairs by placing both feet on each step D. Ride a tricycle (3-6 years old) 123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. I’m sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. 46 Rationale: Case Manager Role: Also, D is the most therapeutic. ● Coordinating care, particularly for clients who have complex health care needs 47 ● Facilitating continuity of care ● Improving efficiency of care and utilization of resources 124. A nurse is assessing a client following an ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures Rationale: . COMPLICATIONS WITH ISCHEMIC STROKE . Dysphagia and aspiration . ● Dysphagia can result from neurological involvement of the cranial nerves that innervate the face, tongue, soft palate, and throat. As a result, the client’s risk of aspiration is great. . ● Not all clients who have experienced a stroke have dysphagia, but all should be evaluated prior to reestablishing oral nutrition and hydration. 125. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedural weight. B. Check the client's serum albumin levels (Check possible albumin for possible complication not for effectiveness) C. Examine for leakage at the site of the procedure D. Confirm that the client is able to urinate (To check for complication not effectiveness) Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and remove ascites fluid in the abdominal wall. 50 129. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? 51 A. Withdraw the client's TV privileges if he does not attend group therapy use therapeutic communication techniques, avoid power struggles B. Place the client in seclusion when exhibits signs of anxiety (Seclusion when on Acute Manic Episode) C. Encourage the client to take frequent rest periods. D. Encourage the client to spend time in the day room. May escalate behavior because of stimulation Rationale: Page 76 of Mental Health Book. NURSING CARE involves implement frequent rest period. 130. A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. (Stage IV Kidney Disease) B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. 131. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area 132. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet - People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato 133. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Seizure disorder 52 b. Polycystic ovary syndrome 55 142.A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client’s extremities. d. Place the clients right hand in supination position. Rationale: Med-surg eBook pg. 84, Assess for swallowing and gag reflex, may cause aspiration if client has difficulty swallowing, keep NPO until cleared. B and C are also nursing actions but not priority. 143. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. “I will decrease my protein intake during the third trimester”( increase protein for basic growth) b. “I will need to increase my insulin doses later in my pregnancy” c. “I will increase my carbs at breakfast and limit them the rest of the day” d. “I will decrease my calorie consumption during the first trimester”(increase calorie) Rationale: OB eBook pg. 26,monitor and limit intake of carbs which include sweets and desserts, due control blood glucose levels. From the second trimester of pregnancy, especially after 18 weeks your insulin requirements will usually start to rise. By around 30 weeks you may need as much as two or three times your daily pre- pregnancy insulin dose. This is because the hormones made by the placenta interfere with the way your insulin normally works - as the pregnancy hormones rise, so does your need for insulin. Link: http://pregnancyanddiabetes.com.au/en/for-women-with-diabetes/contraception/diabetes-during-pregnancy/insu lin-changes-during-pregnancy/ 144.A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau’s sign b. Assess the client’s skin turgor c. Check the client’s motor strength d. Measure the client’s pupil size Rationale: Med/surg PDF pg. 277 Sign for hypocalcemia, tetany. Early sign of hypocalcemia and paresthesia of fingers and lips. 145. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. “I should clean my stoma with warm water”( can use low pH soap and water) b. “ My stoma should be bright pink or red”(pink, red and moist) 56 c. “I should change the stoma pouch every day” d. “I should cut my pouch opening ⅛ inch larger than my stoma”(allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. 146.A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hr.) Rationale: OB PDF pg.61, decreased or absent DTRs. 147.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs.). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 148.A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “Your desire to be an organ donor must be documented in writing” b. “I cannot be a witness for your consent to donate”( nurses can witness consent to donate) c. “You must be at least 21 years of age to become an organ donor”( no age limit) d. “Your name cannot be removed once you are listed on the organ donor list”( can remove whenever they want, it's a choice by the client not forced once it's signed) Rationale: Leadership PDF pg. 37 advance directives and will are all written and documented 149.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr. while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr.( fluid restriction, monitor fluid intake and I/O, may overload the patient since they are already in HF they will have edema) 57 Rationale: Med-surg PDF pg. 199 medication for HF , ACE to help pump blood easily, afterload reducing agents. 150.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen 5mL syringe d. Obtain the urinalysis specimen before the culture specimen Rationale: Urine collection ATI video, clamp for collection of urine, allows urine collection to be easier with urine in the tube. 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension Rationale: Pg. 474 in Chapter 43 Fluid Imbalances. Diarrhea falls under risk factors of fluid imbalances. Orthostatic hypotension is one of the manifestation to assess for. 152. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively. Rationale: Pg. 129 in ATI Chapter 15 Personality Disorders. BPD falls under Cluster B and is characterized by “instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often tries self-injury and may be suicidal.” 153. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension Rationale: 60 c. Decreased Hematocrit - fluid volume excess d/t super dilation d. Neck vein distention - fluid volume excess 61 152. A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder p .76 Ch. 14 mental health a. The client is overly concerned about minor details b. The client exhibits impulsive behavior - spending money giving away money or possessions. c. The client is exceptionally clingy to others d. The client might act seductively 153. A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ? a. 3+ deep tendon reflexes b. Protruding hemorrhoids???????? c. Urinary frequency Ch. 4 p. 21 maternal- COMMON d. Supine hypotension - teach them side lying position . - COMMON 154. 157. A nurse is assessing a client’s PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? P. 199 Ch. 32 MED/SURGE a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension Rationale: Med Surg ATI page 382: Avoid NA, K, Mg, Phosphorus. 161. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict 62 c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred Assess the situation first prior to trying to solve it. 65 b. ST segment elevations_ Remember this could possibly lead to infarctions c. 2 PVCs per minute d. Widened P wave ST elevation = infarction or injury 167. A nurse is observing a newly licensed nurse who is administering Total Parenteral Nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the TPN IV tubing to administer the clients next dose of antibiotics- start another IV/lock for antibiotic, can’t use with TPN d. Increases the TPN infusion rate each hour until the prescribed rate is achieved 168. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? a. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your responsibility to contain it b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - no comparison 169. A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations -either or is fine b. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the right way c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear d. Count respirations for 1 minute if the rhythm is irregular 170. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the client’s biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPPA stuff c. contact the laboratory manager regarding the situation - you are not high enough up the chain to do that d. Notify the facilities legal department - no need to go that far 66 171. A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infections d. Migraines with aura Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease. 172. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 (Normal 8-10) b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache 173. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure. b. Position the client over an overbed table prior to the procedure. c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hr. prior to the procedure. Rationale: MS RM 10.0 Ch.47 p.299; Preprocedural nursing actions: Have the client void, or insert an indwelling urinary catheter. 174. A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia b. Chorioamnionitis fetal tachycardia c. Fetal anemia fetal tachycardia d. Maternal fever fetal tachycardia Rationale: MN RM 10.0 Ch.13 p.87; FHR <110/min; complications: Uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, prolonged umbilical cord compression, fetal congenital heart block, anesthetic medications, viral infection, maternal hypoglycemia, fetal heart failure, maternal hypothermia 175. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic? 67 a. “You should make sure your partner takes the prescribed medication.” b. “Why do you think your partner’s symptoms are progressing so quickly?” c. “You did the right thing by bringing your partner in for treatment.” d. “Can you talk about what was happening with your partner at home?” 176. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver function test d. Serum creatinine Rationale: MH RM 10.0 Ch.23 p.124; Hepatotoxicity ATI Pharmacology - complication hepatotoxicity → assess baseline liver function & monitor liver function regularly 177. A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” b. “The PCA will deliver a double dose of medication when you push the button twice.” c. “You should push the button before physical activity to allow maximum pain control.” d. “You can adjust the amount of pain medication you receive by pushing on the keypad.” 178. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure. 179. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Potassium 3.2 mEq/L b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? a. “How long have you been hearing the voices?” b. “What are the voices telling you?”