ATI PN Comprehensive B 2020
Diabetes Mellitus: reports waking during the night, with tremors and anxiety
- Eat a bedtime snack
The symptoms described by the client indicate hypoglycemia. Eating a snack at
bedtime will help prevent hypoglycemic episodes during the night
Clients with latex allergy: What to use?
- Indwelling Urinary Catheter
The nurse should identify that most indwelling urinary catheters are made of
rubber, which is a form of latex. A rubber indwelling urinary catheter should not
be used for a client who has a latex allergy. The nurse should obtain an indwelling
urinary catheter made of silicone for a client who has a latex allergy.
Client with altered mental status and has become aggressive, what prescription to
clarify with provider prior to admission?
- Zolpidem (correct answer)
Zolpidem is a sedative-hypnotic medication used to treat insomnia. It is not
indicated for treatment of confusion and aggressive behavior. Zolpidem can cause
agitation and should be used with caution for clients who have a history of mental
illness. Therefore, the nurse should clarify this prescription with the provider prior
to administration.
Haloperidol:
Haloperidol is an antipsychotic medication that can be prescribed to treat
aggressive behavior. Haloperidol, when used in conjunction with psychosocial
interventions and de-escalation techniques, has been found to be effective in the
treatment of aggressive and violent behavior.
Lorazepam:
Lorazepam is an antianxiety medication that can be prescribed to treat aggressive
behavior. Lorazepam, when used in conjunction with psychosocial interventions
and de-escalation techniques, has been found to be effective in the treatment of
aggressive and violent behavior.
,Alprazolam:
Alprazolam is an antianxiety medication that can be prescribed to treat aggressive
behavior. Alprazolam, when used in conjunction with psychosocial interventions
and de-escalation techniques, has been found to be effective in the treatment of
aggressive and violent behavior.
Reviewing laboratory result for a client who is at 29th weeks of gestation. Which
to report to provider?
Hint: always look the out of reference lab result: - Platelet 95,000 ( normal range:
150,000 to 400,000)
The nurse should recognize that this platelet count is below the expected reference
range for a client who is pregnant and might be indicative of HELLP syndrome.
Other manifestations of HELLP syndrome include malaise and epigastric pain. The
nurse should immediately notify the provider of this result.
Assisted Personnel is drowsy while performing task, what you do you need to do? -
Report the AP's observation to the Unit Nurse's manager:
The nurse should report their observations to the unit's nurse manager because they
have a duty to report any behavior that poses a risk to client safety.
Informing a client that the nurse is going to administer an injection even though the
client refuses. - This is an example of assault, which is the threat of unlawful
touching of an individual. The nurse should respect the client's right to refuse
treatment and not administer an injection against the client's wishes.
Your weight gain should be the same for someone without diabetes: - A client who
is pregnant and has diabetes mellitus should gain the same amount of weight as a
client without diabetes mellitus.
What is the nurse to expect in multiple sclerosis:? - Ataxia
The nurse should expect a client who has multiple sclerosis to manifest ataxia,
which is a lack of coordination and movement. Other manifestations include
fatigue, impaired memory, diplopia, and bowel and bladder incontinence.
, Advance directive are written instructions regarding end-of life care - The nurse
should inform the client that advance directives allow the client to make decisions
and provide written instructions regarding end-of-life care. These directives take
effect if the client is unable to make their own health care decisions.
A nurse should write an incident report when: - When the nurse administered
insulin Lispro to a client who has DM and is NPO
Lispro is a rapid-acting insulin given with or just after meals because the onset of
action is 15 to 30 min after administration. A client who is NPO will not receive a
meal and can have a potentially serious drop in blood glucose levels. Therefore, the
nurse should complete an incident report after ensuring the safety of the client and
notifying the client's provider.
A nurse is preparing to administer a rectal suppository to a school age child - Use
one finger to insert the suppository past the anal sphincter
The nurse should apply clean gloves and use one finger to gently insert the
suppository past both anal sphincters to ensure that the child does not expel the
suppository after insertion.
Newborn vital sign: The nurse should measure temperature on - Axillary
The nurse should obtain the newborn's temperature using the axillary method
because this method is accurate and safe for newborns. Axillary temperatures are
expected to range from 36.5º to 37.5º C (97.7º to 99.5º F) in newborns.
Ipratropium Inhaler - Should wait 1 minute before taking second puff of the
medication
The client should wait 1 min between puffs of medication to increase absorption.
Performing postmortem care - Gently close the client's eyelids
The nurse should hold the client's eyelids closed for a few seconds to ensure that
they remain closed.
Hypothyroidism and Rx for levothyroxine - You will need to take the medication
for the rest of your life.
Diabetes Mellitus: reports waking during the night, with tremors and anxiety
- Eat a bedtime snack
The symptoms described by the client indicate hypoglycemia. Eating a snack at
bedtime will help prevent hypoglycemic episodes during the night
Clients with latex allergy: What to use?
- Indwelling Urinary Catheter
The nurse should identify that most indwelling urinary catheters are made of
rubber, which is a form of latex. A rubber indwelling urinary catheter should not
be used for a client who has a latex allergy. The nurse should obtain an indwelling
urinary catheter made of silicone for a client who has a latex allergy.
Client with altered mental status and has become aggressive, what prescription to
clarify with provider prior to admission?
- Zolpidem (correct answer)
Zolpidem is a sedative-hypnotic medication used to treat insomnia. It is not
indicated for treatment of confusion and aggressive behavior. Zolpidem can cause
agitation and should be used with caution for clients who have a history of mental
illness. Therefore, the nurse should clarify this prescription with the provider prior
to administration.
Haloperidol:
Haloperidol is an antipsychotic medication that can be prescribed to treat
aggressive behavior. Haloperidol, when used in conjunction with psychosocial
interventions and de-escalation techniques, has been found to be effective in the
treatment of aggressive and violent behavior.
Lorazepam:
Lorazepam is an antianxiety medication that can be prescribed to treat aggressive
behavior. Lorazepam, when used in conjunction with psychosocial interventions
and de-escalation techniques, has been found to be effective in the treatment of
aggressive and violent behavior.
,Alprazolam:
Alprazolam is an antianxiety medication that can be prescribed to treat aggressive
behavior. Alprazolam, when used in conjunction with psychosocial interventions
and de-escalation techniques, has been found to be effective in the treatment of
aggressive and violent behavior.
Reviewing laboratory result for a client who is at 29th weeks of gestation. Which
to report to provider?
Hint: always look the out of reference lab result: - Platelet 95,000 ( normal range:
150,000 to 400,000)
The nurse should recognize that this platelet count is below the expected reference
range for a client who is pregnant and might be indicative of HELLP syndrome.
Other manifestations of HELLP syndrome include malaise and epigastric pain. The
nurse should immediately notify the provider of this result.
Assisted Personnel is drowsy while performing task, what you do you need to do? -
Report the AP's observation to the Unit Nurse's manager:
The nurse should report their observations to the unit's nurse manager because they
have a duty to report any behavior that poses a risk to client safety.
Informing a client that the nurse is going to administer an injection even though the
client refuses. - This is an example of assault, which is the threat of unlawful
touching of an individual. The nurse should respect the client's right to refuse
treatment and not administer an injection against the client's wishes.
Your weight gain should be the same for someone without diabetes: - A client who
is pregnant and has diabetes mellitus should gain the same amount of weight as a
client without diabetes mellitus.
What is the nurse to expect in multiple sclerosis:? - Ataxia
The nurse should expect a client who has multiple sclerosis to manifest ataxia,
which is a lack of coordination and movement. Other manifestations include
fatigue, impaired memory, diplopia, and bowel and bladder incontinence.
, Advance directive are written instructions regarding end-of life care - The nurse
should inform the client that advance directives allow the client to make decisions
and provide written instructions regarding end-of-life care. These directives take
effect if the client is unable to make their own health care decisions.
A nurse should write an incident report when: - When the nurse administered
insulin Lispro to a client who has DM and is NPO
Lispro is a rapid-acting insulin given with or just after meals because the onset of
action is 15 to 30 min after administration. A client who is NPO will not receive a
meal and can have a potentially serious drop in blood glucose levels. Therefore, the
nurse should complete an incident report after ensuring the safety of the client and
notifying the client's provider.
A nurse is preparing to administer a rectal suppository to a school age child - Use
one finger to insert the suppository past the anal sphincter
The nurse should apply clean gloves and use one finger to gently insert the
suppository past both anal sphincters to ensure that the child does not expel the
suppository after insertion.
Newborn vital sign: The nurse should measure temperature on - Axillary
The nurse should obtain the newborn's temperature using the axillary method
because this method is accurate and safe for newborns. Axillary temperatures are
expected to range from 36.5º to 37.5º C (97.7º to 99.5º F) in newborns.
Ipratropium Inhaler - Should wait 1 minute before taking second puff of the
medication
The client should wait 1 min between puffs of medication to increase absorption.
Performing postmortem care - Gently close the client's eyelids
The nurse should hold the client's eyelids closed for a few seconds to ensure that
they remain closed.
Hypothyroidism and Rx for levothyroxine - You will need to take the medication
for the rest of your life.
