Nursing Scenarios and Best Practices, Exams of Nursing

Download Nursing Scenarios and Best Practices and more Exams Nursing in PDF only on Docsity! Comprehensive Final ATI Solutions A charge nurse in a long-term care facility notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the charge nurse plan to take? - answer ✅✅Send an e-mail to each non-adherent employee that includes a link to upcoming educational sessions. A charge nurse in a skilled nursing facility notes several recent conflicts among staff on different shifts. Which of the following strategies should the charge nurse plan to use to resolve these conflicts? - answer ✅✅Set up a series of meetings for all staff members to attend to discuss issues. A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? - answer ✅✅Instruct clients who are able to ambulate to leave A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make? - answer ✅✅"The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common." A community health nurse is contributing to the plan of care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for the first? - answer ✅✅A 4-day-old newborn who has an elevated bilirubin level and requires photo-therapy A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following statements should the nurse provide further reinforcement of teaching? - answer ✅✅"I prefer tub baths to showering." A health care facility's leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first? - answer ✅✅Collect the staff's input about planning and implementing the change A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? - answer ✅✅The client watches television in her bed during the day. A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? - answer A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which of the following actions indicate to the nurse the AP understands how to perform this task? - answer ✅✅locks the brakes on the bed and the wheelchair before moving the client A nurse in an acute care clinic is talking with a client who reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss nonpharmacological approaches that will help relieve her pain. Which of the following interventions should the nurse suggest? - answer ✅✅Applying warm compresses to sore joints A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, "Can i vote in the upcoming presidential election?" Which of the following responses should the nurse make? - answer ✅✅"We can work together to fine out how you can get a mail-in ballot." A nurse in an urgent care center is collecting data from a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse? - answer ✅✅A client who is difficult to arouse and is unable to respond to questions A nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of the following finds should the nurse report to the provider as indication of impending airway obstruction? - answer ✅✅Nasal Flaring A nurse in an urgent care center is reviewing lab results for several clients who have manifestations of influenza. Which of the following clients should the nurse report to the provider immediately? - answer ✅✅An infant whose WBC count is 24,000/mm3 A nurse is a substance use disorder program is interacting with a client. Which of the following statements indicates that the client is using internationalization as a way of coping with the anxiety of admission? - answer ✅✅"I have read that problems with substances can have a variety of predisposing factors." A nurse is assigned to care for several clients who are postoperative. The nurse should identify the client taking which of the following medications is at risk for delayed would healing? - answer ✅✅Prednisone to treat persistent arthritis exacerbations A nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse recommend to include? - answer ✅✅The importance of colonoscopy screening starting at age 50 years old. A nurse is assisting to prepare for the transfer of a client from the postanesthesia care unit (PACU) following a subtotal thyroidectomy. Which of the following equipment should the nurse have available at the client's bedside? - answer ✅✅Tracheostomy tray A nurse is assisting with developing a plan of care for a client who has gasteroesophageal reflux disease (GERD). The nurse should suggest monitoring the client for which of the following complications? - answer ✅✅Aspiration A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for this client? - answer ✅✅Walking with a staff member A nurse is assisting with the admission of a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After the admission history is complete, which of the following actions should the nurse reccommend? - answer ✅✅Attach a latex allergy alert identification band A nurse is assisting with the admission of a client to the medical unit and asks him if he as advance directives. The client states, therapy. Which of the following types of medications should the nurse expect to administer? - answer ✅✅Corticosteroids A nurse is caring for a client who has a platelet count of 50,000 /mm3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? - answer ✅✅Apply pressure to the catheter removal site for 10 min. A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? - answer ✅✅"Let's set up a meeting time with the doctor to discuss your options for home care." A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make? - answer ✅✅"Tell me what concerns you the most about being hospitalized." A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider? - answer ✅✅Meperidine A nurse is caring for a client who has deep partial and full- thickness burns and requires a topical antimicrobial drug. The nurse should reinforce with the client that the goal of this medication therapy is to reduce which of the following outcomes? - answer ✅✅Bacterial growth A nurse is caring for a client who has dehydration. Which of the following lab values should the nurse expect for this client? - answer ✅✅Hct 55% A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is teh nurse's priority? - answer ✅✅Performing hand hygiene before and after contact with the client A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? - answer ✅✅An irregularly shaped brown lesion with light blue areas on the neck A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication? - answer ✅✅Pulse oximetry of 85% A nurse is caring for a client who is taking acarbose to treat type 2 diabetes mellitus. For which of the following adverse effects of this medication should the nurse monitor? - answer ✅✅Diarrhea A nurse is caring for a client who is taking warfarin. Which of the following lab values should the nurse recognize as an effective response to the medication? - answer ✅✅INR 3.0 A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die," and is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse's priority? - answer ✅✅Attempt to reduce environmental stimuli A nurse is caring for a client who takes warfarin to treat chronic atrial fibrillation and has early manifestations of alzheimer's disease. The client's partner asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make? - answer ✅✅"It is likely that ginkgo biloba will interfere with the effectiveness of his other medications." A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? - answer ✅✅A 10-piece wooden puzzle A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? - answer ✅✅"Does anyone smoke around or in the same house as your child?" A nurse is collecting data from a school-age child who has celiac disease. Which of the following findings should the nurse expect? - answer ✅✅Steatorrhea A nurse is collecting data from a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection? - answer ✅✅Candidiasis A nurse is contributing to the plan of care for a client who had a stroke and is to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend to take prior to initiating each feeding? - answer ✅✅Elevate the head of the bed A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make? - answer ✅✅Maintain the head of the bed at 30 degrees A nurse is discussing fire safety with newly hired nurses. The nurses should identify which of the following actions as the priority if a fire occurs in the healthcare facility? - answer ✅✅Evacuate clients from the unit A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? - answer ✅✅The client has had an exposure to tuberculosis. A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding? - answer ✅✅Arm cast for a spiral fracture of the forearm A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction? - answer ✅✅Stop the infusion A nurse is observing a client who has schizophrenia and is in the dayroom when another client asks him if two items of clothing math. He replies, "A math. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these these statements as which of the following speech alterations? - answer ✅✅Associative looseness A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? - answer ✅✅Record urinary output after emptying the indwelling urinary catheter. A nurse is preparing to administer 10 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take? - answer ✅✅Use separate syringes for administering insulin glargine and NPH insulin A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's beside and preform which of the following verification procedures? - answer ✅✅Compare the medical record number and name on the MAR with the client's identification band. A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse recommend for the client's plan of care? - answer ✅✅Offering the client a diet high in fluid and fiber A nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The client's 3. "Depress the canister while taking a slow deep breath." 4. "Hold your breath for 10 seconds." A nurse is reinforcing teaching with a client about treatment options for profound sensorinerual hearing loss. The nurse should include which of the following information about the function of the cochlear implants? - answer ✅✅Transmits impulses directly to auditory nerve endings nerve endings A nurse is reinforcing teaching with a client who has a new prescription for doxycyclin. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication? - answer ✅✅Photo-sensitivity A nurse is reinforcing teaching with a client who has a new prescription for sertraline. The client asks the nurse if he should continue to take St. John's wort for depression. Which of the following instructions should the nurse give the client? - answer ✅✅Stop taking the herbal supplement while taking the medication. A nurse is reinforcing teaching with a client who has a spinal cord injury and will need to perform intermittent urinary self- catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? - answer ✅✅"I will perform intermittent self- catheterization every 2-3 hours." A nurse is reinforcing teaching with a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following information should the nurse reinforce with the client? - answer ✅✅"Your risk for ectopic pregnancy increases with an IUD." A nurse is reinforcing teaching with a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client to report which of the following manifestations to the provider? - answer ✅✅Chest pain A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse make? - answer ✅✅"You don't have to give up pasta; just adjust the amount you eat." A nurse is reinforcing teaching with a client who is going to have an EEG in the morning. Which of the following information should the nurse provide the client? - answer ✅✅"Shampoo your hair before the procedure, and don't put any styling products on it afterward." A nurse is reinforcing teaching with a client who is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include? - answer ✅✅"Your procedure will only take 10 or 15 min. for each eye." A nurse is reinforcing teaching with a family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions? - answer ✅✅"It will help our child if we structure our daily routine." A nurse is reinforcing teaching with a school-age child who has just had a fiberglass cast application following a lower- extremity fracture. Which of the following instructions should the nurse reinforce with the child and his parents about care during the first 48 hr? - answer ✅✅"Keep the cast above the level of your heart." A nurse is reinforcing teaching with an assistive personnel (AP) about dietary restrictions for a client who is taking phenelzine to treat depression. The AP's selection of which of the following foods for the client's lunch indicates an understanding of the instructions? - answer ✅✅Chicken salad A nurse is reinforcing teaching with the parent of a child who has severe reactive airway disease about glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it orally. Which of the following information should the nurse provide the parent? - answer ✅✅Oral glucocorticoids are more likely to slow linear growth in children. A nurse is talking with a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include? - answer ✅✅"Extended periods of immobility increase your risk for osteoporosis." A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent? - answer ✅✅"Use a stable, relaxing routine, such as a bath and story time, before bed." A nurse is talking with the parent of 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further instructions? - answer ✅✅"My baby loves to play with the pillows in her crib." A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PaCO2 40, and HCO3 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? - answer ✅✅Metabolic Acidosis A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? - answer ✅✅Speak to the client with clear, calm, caring statements A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client? - answer ✅✅Build trust with the client by sitting quietly with him. A nurse on a pediatric mental health unit is caring for a school- age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation? - answer ✅✅"Tell me about your favorite video game." A nurse on a pediatric unit is assisting with the plan of care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parent's presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan because it offers which of the following benefits? - answer ✅✅Allows the child to manipulate toy medical equipment A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? - answer ✅✅A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? - answer ✅✅Lateral A nurse participating in a community health fair is providing information to a client who has BP of 150/90 mmHg during a blood pressure screening. Which of the following actions should the nurse take? - answer ✅✅Give the client a written record of his BP to bring to his provider A nurse responds to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first? - answer ✅✅Check airway patency A provider tells a client who reports practicing Hinduism that, 12-weeks of gestation, she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? - answer ✅✅"Let's discuss other foods that are also high in protein that you could substitute for meat." During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing client's information? - answer ✅✅In the unit medication room