PN Comprehensive Practice A [2020]
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435 terms 163 terms 314 terms 175 term
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A nurse is reinforcing teaching with a client who is to self- administer the medication subcutaneously.
administer epoetin alfa. Which of the following
instructions should the nurse include?
A nurse enters the room of an adolescent client and finds keep the client in a side-lying position.
them on the floor experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take rationale: the nurse should keep the client in a side-lying position to facilitate
when the seizure subsides? drainage of any secretion and prevent aspiration
A nurse is caring for a client who is in the final stages of the client asks the nurse to help them die peacefully in their sleep.
cancer. Which of the following client situations should the
nurse identify as an ethical dilemma? rationale: the situation presents and ethical issue for the nurse because the client
is asking for a variation of active euthanasia, also known as assisted suicided,
which is in violation of the code of ethics for nurses. The nurse is legally and
ethically unable to support this decision by the client and should ask for
assistance with this dilemma.
A nurse is caring fur a client who has a phobia elevators, the client remains relaxed when thinking about the phobia.
Which of the following should me nurse recognize as an
indication of a positive client response to systematic: rationale: The purpose of desensitization therapy is to teach the client to use
desensitization? relaxation techniques to overcome the anxiety caused by the phobia The nurse
should recognize the clients lack of anxiety when thinking about the phobia as a
positive response to
the therapy.
A nurse is checking the reflexes of a newborn. Which of Stroke the sole of the newborn's foot upward and toward the great toe.
the following techniques should the nurse use to elicit the
Babinski reflex?
, A nurse is reviewing the laboratory report of a client who WBC 25, 000 mm
is 2 days postoperative following thoracic surgery. Which
of the following laboratory results should the nurse rationale: The nurse should identify a WBC count of 25,000/mm3 is above the
report to the provider? expected reference range and is an indication that the client might have a
postoperative infection; therefore, the nurse should report this finding to the
provider.
A nurse in an urgent care clinic is completing a client wheeze
examination. After listening to the client's lungs, which of
the following adventitious sounds should the nurse [audio]
document? (Click on the audio button to listen to the
clip.) rationale: the nurse should document this sound as a wheeze. A wheeze is a high
pitched musical sound that is heard when air moved through narrowed airway
during either inspiration or expiration.`
A nurse is preparing to administer an 1M immunization to lets give the medication to your doll first.
a preschooler. Which of the following statements should
the nurse plan to make prior to performing the injection?
A nurse is reviewing the medical record of a client who is INR 5.0
receiving warfarin and has atrial fibrillation. Which of the
following laboratory values should the nurse report to rationale: The international normalized ratio (INR) is a measurement of the body's
the provider? blood clotting ability. A client receiving warfarin to prevent clot formation related
to atrial fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or greater
indicates that the client is at risk for bleeding. Therefore, the nurse should notify
the provider about this laboratory value.
Why PT of 18 is wrong: rationale The prothrombin time (PT) is a measurement of
the body's blood clotting ability. A prolonged PT is an indication of prolonged
bleeding. A client receiving warfarin to prevent clot formation related to atrial
fibrillation should have a PT of 1.3 to 1.5 times the control of 11.0 to 12.5 seconds.
The client's PT is 1.4 times the control value of 12.5 seconds. Therefore, the nurse
does not need to report this value to the provider.
A nurse is caring for a client who is scheduled for ensure the dialysate solution is at room temperature,
peritoneal dialysis. Which Of the following actions should
the nurse take first? rationale: Evidence-based practice indicates the nurse should administer the
dialysate solution at a temperature of 37' C (98.6' F); therefore, the first action the
nurse should take is to warm the prescribed solution.
A nurse is reviewing the critical pathway of a client who is document the finding as a variance.
4 days postoperative following a total knee arthroplasty.
The client's vital signs are oral temperature 39.10 C (102.40 rationale: Whenever a client does not meet the goals or outcomes in the critical
F), heart rate 116/min, respiratory rate 24/min, and blood pathway due to unexpected findings or a need for additional interventions. the
pressure 152/92 mm Hg. Which of the following actions nurse should document the details as a variance in the critical pathway. In this
should the nurse take? case. it is a negative variance. If the client progresses faster than the pathway
specifies, it is a positive variance.
Save
Students also studied
Comprehensive Predictor/NCLEX St... ATI PN Comprehensive Predictor 20... ATI LPN Comprehensive Predictor E... VATI Co
435 terms 163 terms 314 terms 175 term
karen_garcia022 Preview Genesis_Royal1 Preview karen_garcia022 Preview rob
A nurse is reinforcing teaching with a client who is to self- administer the medication subcutaneously.
administer epoetin alfa. Which of the following
instructions should the nurse include?
A nurse enters the room of an adolescent client and finds keep the client in a side-lying position.
them on the floor experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take rationale: the nurse should keep the client in a side-lying position to facilitate
when the seizure subsides? drainage of any secretion and prevent aspiration
A nurse is caring for a client who is in the final stages of the client asks the nurse to help them die peacefully in their sleep.
cancer. Which of the following client situations should the
nurse identify as an ethical dilemma? rationale: the situation presents and ethical issue for the nurse because the client
is asking for a variation of active euthanasia, also known as assisted suicided,
which is in violation of the code of ethics for nurses. The nurse is legally and
ethically unable to support this decision by the client and should ask for
assistance with this dilemma.
A nurse is caring fur a client who has a phobia elevators, the client remains relaxed when thinking about the phobia.
Which of the following should me nurse recognize as an
indication of a positive client response to systematic: rationale: The purpose of desensitization therapy is to teach the client to use
desensitization? relaxation techniques to overcome the anxiety caused by the phobia The nurse
should recognize the clients lack of anxiety when thinking about the phobia as a
positive response to
the therapy.
A nurse is checking the reflexes of a newborn. Which of Stroke the sole of the newborn's foot upward and toward the great toe.
the following techniques should the nurse use to elicit the
Babinski reflex?
, A nurse is reviewing the laboratory report of a client who WBC 25, 000 mm
is 2 days postoperative following thoracic surgery. Which
of the following laboratory results should the nurse rationale: The nurse should identify a WBC count of 25,000/mm3 is above the
report to the provider? expected reference range and is an indication that the client might have a
postoperative infection; therefore, the nurse should report this finding to the
provider.
A nurse in an urgent care clinic is completing a client wheeze
examination. After listening to the client's lungs, which of
the following adventitious sounds should the nurse [audio]
document? (Click on the audio button to listen to the
clip.) rationale: the nurse should document this sound as a wheeze. A wheeze is a high
pitched musical sound that is heard when air moved through narrowed airway
during either inspiration or expiration.`
A nurse is preparing to administer an 1M immunization to lets give the medication to your doll first.
a preschooler. Which of the following statements should
the nurse plan to make prior to performing the injection?
A nurse is reviewing the medical record of a client who is INR 5.0
receiving warfarin and has atrial fibrillation. Which of the
following laboratory values should the nurse report to rationale: The international normalized ratio (INR) is a measurement of the body's
the provider? blood clotting ability. A client receiving warfarin to prevent clot formation related
to atrial fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or greater
indicates that the client is at risk for bleeding. Therefore, the nurse should notify
the provider about this laboratory value.
Why PT of 18 is wrong: rationale The prothrombin time (PT) is a measurement of
the body's blood clotting ability. A prolonged PT is an indication of prolonged
bleeding. A client receiving warfarin to prevent clot formation related to atrial
fibrillation should have a PT of 1.3 to 1.5 times the control of 11.0 to 12.5 seconds.
The client's PT is 1.4 times the control value of 12.5 seconds. Therefore, the nurse
does not need to report this value to the provider.
A nurse is caring for a client who is scheduled for ensure the dialysate solution is at room temperature,
peritoneal dialysis. Which Of the following actions should
the nurse take first? rationale: Evidence-based practice indicates the nurse should administer the
dialysate solution at a temperature of 37' C (98.6' F); therefore, the first action the
nurse should take is to warm the prescribed solution.
A nurse is reviewing the critical pathway of a client who is document the finding as a variance.
4 days postoperative following a total knee arthroplasty.
The client's vital signs are oral temperature 39.10 C (102.40 rationale: Whenever a client does not meet the goals or outcomes in the critical
F), heart rate 116/min, respiratory rate 24/min, and blood pathway due to unexpected findings or a need for additional interventions. the
pressure 152/92 mm Hg. Which of the following actions nurse should document the details as a variance in the critical pathway. In this
should the nurse take? case. it is a negative variance. If the client progresses faster than the pathway
specifies, it is a positive variance.
