PN Comprehensive Predictor A [2020] answered, with rationales.

PN Comprehensive Predictor A [2020] A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa. Which of the following instructions should the nurse include? Correct Answer- administer the medication subcutaneously. A nurse enters the room of an adolescent client and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take when the seizure subsides? Correct Answer- keep the client in a side-lying position. rationale: the nurse should keep the client in a side-lying position to facilitate drainage of any secretion and prevent aspiration A nurse is caring for a client who is in the final stages of cancer. Which of the following client situations should the nurse identify as an ethical dilemma? Correct Answer- the client asks the nurse to help them die peacefully in their sleep. 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, Which of the following should me nurse recognize as an indication of a positive client response to systematic: desensitization? Correct Answer- the client remains relaxed when thinking about the phobia. rationale: The purpose of desensitization therapy is to teach the client to use 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 the following techniques should the nurse use to elicit the Babinski reflex? Correct Answer- Stroke the sole of the newborn's foot upward and toward the great toe. A nurse is reviewing the laboratory report of a client who is 2 days postoperative following thoracic surgery. Which of the following laboratory results should the nurse report to the provider? Correct Answer- WBC 25, 000 mm rationale: The nurse should identify a WBC count of 25,000/mm3 is above the 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 examination. After listening to the client's lungs, which of the following adventitious sounds should the nurse document? (Click on the audio button to listen to the clip.) Correct Answer- wheeze [audio] 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 a preschooler. Which of the following statements should the nurse plan to make prior to performing the injection? Correct Answer- lets give the medication to your doll first. A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider? Correct Answer- INR 5.0 rationale: The international normalized ratio (INR) is a measurement of the body's 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 peritoneal dialysis. Which Of the following actions should the nurse take first? Correct Answer- ensure the dialysate solution is at room temperature, 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 4 days postoperative following a total knee arthroplasty. The client's vital signs are oral temperature 39.10 C (102.40 F), heart rate 116/min, respiratory rate 24/min, and blood pressure 152/92 mm Hg. Which of the following actions should the nurse take? Correct Answer- document the finding as a variance. rationale: Whenever a client does not meet the goals or outcomes in the critical pathway due to unexpected findings or a need for additional interventions. the nurse should document the details as a variance in the critical pathway. In this case. it is a negative variance. If the client progresses faster than the pathway specifies, it is a positive variance. A nurse is performing a dressing change for a client who is 3 days postoperative. Which of the following findings should the nurse report to the provider? Correct Answer- Yellow green drainage at the incision line. rationale: Yellow green purulent or odorous drainage indicates the wound is infected. the nurse should report this finding. rationale 2: pink incision line with slight crusting, serosanguineous drainage on the old dressing, slight swelling around staples- are all expected finding for the client A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider? Correct Answer- Generalized petechiae rationale: Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of newborns who had a nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the newborn's body can indicate infection or a decreased platelet count and should be reported to the provider. A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to which of the following interprofessional team members? Correct Answer- Occupational therapist. rationale: to teach client how to use special eating utensils. A nurse is assisting with a discussion about STIs with a group of adolescents at a health fair. Which of the following statements should the nurse make? Correct Answer- an infection with gonorrhea can result in infertility. rationale: gonorrhea can lead to PID and tubal scarring which can result in infertility in female clients. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching? Correct Answer- strain the urine to collect stone fragments. rationale: The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation. A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the electronic health record to locate information about the client's personal health insurance? Correct Answer- admission sheet A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take? Correct Answer- Tell the client they should not experience any discomfort. rationale: the nurse applies the handheld scanner over the area of the balder and this is a noninvasive procedure so it does not require written consent. A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion? Correct Answer- My doctors glasses have lasers that will burn holes in my brain if i look at them. rationale: The client's statement demonstrates a belief that is contrary to reality that someone intends to cause them harm using unrealistic means. Therefore, the nurse should identify this statement as a delusion of persecution. A nurse in a provider's office is reinforcing teaching with a client who is to follow a 2,000 mg sodium-restricted diet. Which of the following client food selections indicates an understanding of the teaching? Correct Answer- canned peaches. rationale: canned peaches have a low sodium content. why not; cottage cheese, lean ham and wheat crackers, all have high sodium content., A nurse is reinforcing teaching with a female client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? Correct Answer- i will use condoms in addition to birth pills to decrease my risk of becoming pregnant. rationale: Rifampin can interact with and reduce the effectiveness of oral contraceptives. Therefore, the nurse should instruct the client to use a secondary method to prevent pregnancy. A nurse is participating in a quality improvement study about the effectiveness of client pain management on the unit. Which of the following strategies should the nurse use to collect data? Correct Answer- review clients chart for their rating of pain before pain medication was administered and 1 hr after administration. A nurse is caring for a client who is crying and states that their provider informed them that they have a tumor and will need a biopsy. Which of the following responses should the nurse make? Correct Answer- what have you done to help yourself get though stressful situation before? A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination? Correct Answer- use intermittent urinary catheterization for the client regular intervals. rationale: A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch. A nurse is caring for a newborn who is 12 hr old. The nurse should expect the newborn's stool to have which of the following characteristics within the first 24 hr following birth? Correct Answer- Dark greenish black and viscous. ****************************CONTINUED***************************