ATI RN CONCEPT BASED ASSESSMENT LEVEL 1 ONLINE PRACTICE A

ATI RN CONCEPT BASED ASSESSMENT LEVEL 1 ONLINE PRACTICE A Clinical manifestations of heart failure - cool extremities 6 month infant has bacterial pneumonia. clinical manifestations of b. pneumonia - nasal flaring Acute asthma exacerbation what actions should the nurse take first - apply humidified oxygen with a simple mask Diabetes foot care - ill wash my feet everyday with soap and lukewarm water Decreased urinary output. what findings should be identified as a risk factor for the development of pyelonephritis? - diabetes mellitus Acute cholecystitis (select all) - fever, dyspepsia, and eructation Client has appendicitis. what actions should the nurse take - place the client in semifowler's position Caring for a client following collection of admission data. what should the nurse identify as a priority? - client reports coughing and a change of voice whenever he eats Client has respiratory acidosis due to opioid oversedation - ensure the patient airway using a chin-lift maneuver Which client is at risk for developing respiratory acidosis? - client who has abdominal ascites? Teaching about newborns and crib use - dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or sheet Findings that indicate a therapeutic response to anti hyperlipidemia medication - HDL 50 mg/dL Teaching to parents about epinephrine auto-injector - "give a second injection if the first fails to reverse your child's symptoms" Client is experiencing a panic attack - stay with the client until manifestations subside Mix NPH insulin and insulin steps - cloudy, clear, clear, cloudy Gastroenteritis with dehydration. which med should the nurse administer? - ondansetron Adverse effect of acetaminophen - elevated aspartate aminotransferase levels Potassium level of 6 mEq/L would cause ECG to look like what? - Tall T waves 6 month old infant with mild dehydration - capillary refill greater than 2 seconds Acute pyelonephritis findings - urinary burning A client has COPD and a resp. rate of 22 and reports SOB. what would the nurse do - place the client in high-fowlers position A client has metabolic acidosis due to salicylate overdose. what findings should the nurse expect? - flushed, dry skin Hypermagnesemia clinical manifestation - bradycardia Client has external fixator to the right lower arm, what would indicate that the client has compartment syndrome? - numbness of the fingers on the right arm A client has AIDS, what lab data would determine if the client is at risk for malnutrition - albumin level Client is 1 hour post op from open carpal tunnel release to treat injury - elevate the client's arm above the heart Discharge teaching for the parent of a newborn - "do not bathe your new born immediately after she eats" A client is at 13 weeks gestation with hyperemesis gravidarum - "drink fluids between, rather than with, meals" Client has calcium oxalate renal calculi. what would u teach them - "limit the amount of spinach in your diet" A school age child has asthma and SOB. what findings would be priority? - inaudible lung sounds An adolescent client has a skin infection caused by MRSA - "I will soak in a bathtub filled one-fourth full of water and one-half cup of bleach" An adolescent has infectious mononucleosis. what would be a manifestation of this - onset of abdominal pain A client is experiencing an asthma attack. what would the nurse use to assess the client's respiratory status - peak expiratory flow meter testing A nurse is teaching a client about foot care with peripheral neuropathy - "file your toenails straight across to prevent ingrown toenails" Clinical manifestations of heat stroke - oliguria A client has a sodium level of 124 mEq/L, what manifestations should the nurse expect? - orthostatic hypotension A client's parent recently died. what would place the client at risk for maladaptive grieving? - the client lost his house in a fire one month ago The parent has a child with pediculosis capitis. what would the nurse tell the parent? - to comb the child's hair daily with an extra fine tooth comb A parent has a child with scabies. what would the parent say to indicate understanding of teaching? - "i should wash my child's bed linens and clothing in hot water and detergent" A client has peripheral arterial disease. what would be a finding of this? - dependent rubor A nurse is providing teaching to a client with MRSA. what would be an understanding of this disease for the client to say? - "I will wash all uninfected skin areas with a fresh washcloth" What would be a manifestation that the nurse should expect for an infant who might have otitis media? - enlarged postauricular lymph nodes A client has hyperthyroidism and has been taking methimazole for 6 months. what indicates a therapeutic response? - the client reports sleeping longer during the night Metabolic alkalosis would give u what lab value? - potassium 3 mEq/L A client is going in for a laproscopic appendectomy. which of the findings would the nurse report? - report of urinating small amounts twice daily a client has severe hypothermia. which actions should the nurse take - contact a specialized team to place the client on cardiopulmonary bypass a client has cellulitis in a lower extremity. what action should the nurse take? - elevate the extremity above heart level a client has frostbite to the fingers and toes, what would the nurse include in the teaching about frostbite? - place the affected areas of frostbite in a warm water bath a young female client has GAD and is taking clonazepam. what would the nurse include in the teaching? - "this medication could cause you to have thoughts of self-harm" what is a manifestation of respiratory acidosis? - confusion a client has a subdermal implant placed for contraception. what are the adverse effects of this? - irregular bleeding which of the following is a risk factor for peptic ulcers? - long term use of NSAIDs a client has been practicing adaptive use of coping mechanisms. which one indicates the client's use of suppression? - "I avoid thinking about my problems that worry me until I have time to focus on a solution" a client has osteoporosis. what should be included in the teaching? - perform exercises to strengthen the abdominal core a client has hyperventilation. the client's ABG results are "7.5 pH, 29 mm Hg PaCO2, and 25 mEq/L HCO3-" what can be interpreted? - Respiratory alkalosis a client has hyperglycemic-hyperosmolar state related to complications of diabetes - hypotension a client has recently lost his partner to a terminal illness. the client asks how his 4 year old son should react to this death. - A preschooler often believes that death is reversible which of the communicable diseases diseases require reporting? - gonorrhea a client has osteoarthritis. what would the nurse include in teaching about exercise? - perform exercise even on d ays when joints are painful which area should the nurse assess on a patient with cholelithiasis? - A -- RUQ Which would suggest that a client's nutritional status is improving? - 1 kg weight gain over the past 2 days a client has AIDS and is experiencing anorexia. which would the provider prescribe to the client? - megestrol (increases appetite) a client has renal calculi. what would cause the nurse to notify the provider immediately? - oliguria with bladder distention a client is taking atorvastatin. which would suggest the medication is having an adverse effect? - aspartate aminotransferase (AST) 45 units/L a client's partner died 1 month ago. the client doesn't believe she can ever be happy again. what would the nurse say? - "What are some of the best times with your partner that you remember?" age-related macular degeneration has a risk factor of what? - hypertension a client is about to have an induction of labor due to fetal demise. what would the nurse do? - bathe, diaper, and dress the child before bringing the newborn to the client a client has hypokalemia. what fruits should the nurse recommend? - one small orange a client has renal calculi and is taking oxybutynin for pain. what would the nurse identify as an adverse effect of this medication? - distended bladder a client has gestational diabetes and ketoacidosis. what manifestation would be expected? - increased urination a client is being taught about how to prevent hearing loss from trauma. what would be included in the teaching? - "keep your mouth open when sneezing" a client has partial obstruciton of the large bowel. what would be a manifestation? - ribbon-like stools what lab results would be identified as na adverse effect of sulfasalazine? - WBC count 4,000/mm3 what should the nurse instruct to avoid in a patient who has gerd? - caffeinated coffee emergency department for someone who has been out of the country? (exhibit) - surgical mask which of the following medications should the nurse expect the provider to prescribe in C. difficile? - vancomycin A nurse in a providers office is reviewing the medical record of a client who has COPD. which of the following findings should the nurse report to the provider? - sputum culture shows gram positive bacteria nurse providing discharge teaching to a client with diverticulitis. what should she include? - consume a clear liquid diet nurse teaching about ezetimibe with a client who has hyperlipidemia. What client statements is correct? - i will return to have my cholesterol checked in two weeks a nurse is assessing a client who has musculoskeletal trauma following a motor vehicle crash two days ago. what finding should she report? - pain report discharge teaching for a client who has a new diagnosis of COPD. which of the following statements shows PT understanding? - breathe out slowly through pursed lips if i feel short of breath which of the following menu choices shows patient understanding of hyperlipidemia? - black bean burger on a whole grain bun a nurse is participating screenings for osetoporosis. which of the following is a risk factor for the disease? - hip fracture 6 months ago client who has an intense fear of heights - acrophobia which of the following actions should the nurse take for a client who has possible appendicitis? - start IV fluid replacement a nurse is assessing a preschool-age child who has chickenpox. how should the parent treat it - avoid giving aspirin a nurse is preparing to administer medication to a client who has a history of hypertension. what should the nurse administer for antihypertension therapy? - hydrochlorothiazide exercise induced asthma and has new prescriptions for cromolyn. what should the nurse include in the teaching? - use albuterol prior to planned exercise? a nurse is admitting an infant who has pertussis. what following action should the nurse take? - droplet precautions warfarin to treat atrial fibrillation. what should nurse identify as adverse effect? - black, tarry stools a nurse is preparing an in-service for coworkers about failure to thrive in infants. What should she include? - congenital heart disease assessing a client for manifestations of GERD. which of the following findings is indicitive of GERD? - globus providing teaching for a client who has cataract surgery. which of the following shows that the client understands the teaching - avoid using the vacuum cleaner for several weeks a nurse is assessing a client who has DVT in the right lower leg. which of the following findings on the affected extremity should the nurse expect? - swelling a nurse in the emergency department is assessing a client who displays manifestations of a small bowel obstruction. which of the following findings should the nurse expect? - abdominal distention, vomiting, hyperactive bowel sounds a client has peptic ulcer disease and an upper gastrointestinal bleed. what manifestations should the nurse expect? - dark, tarry stools, bright red emesis, increased heart rate a client receiving gentamicin for the treatment of an infection related to renal calculi which lab finding would the nurse report immediately? - creatinine 2.5 a client has pneumonia. what is priority for the nurse? - observe the client perform incentive spirometry a client has GAD and is experiencing a moderate level of anxiety. what manifestations should the nurse expect? - focuses on the source of the anxiety a client has DVT and is receiving heparin via continuous IV. the client has a positive fecal occult blood test and abdominal tenderness upon palpation. what would the nurse expect the provider to prescribe? - protamine sulfate a client has COPD and is learning about preventing pneumonia. which statement shows an understanding? - "I will wash my hands whenever i come home from the grocery store" what are manifestations of right-sided heart failure? - jugular vein distention a client had a cardiac catheterization. what instructors would the nurse include in the teaching to the child's guardian? - monitor the site daily for drainage a client's medication list to manage osteoarthritis? - lidocaine 5% patches, celecoxib, cyclobenzaprine, glucosamine a client recently lost her partner in a motor-vehicle crash. which reaction is a secondary stage of grieving? - feeling anger toward family members a client has GAD. which medications would the nurse administer? - escitalopram a client is at risk for developing glaucoma. which is a risk factor? - heredity a client has hypothyroidism. which is a manifestation? - cold intolerance a client has peripheral neuropathy of the lower extremities. which statement indicates understanding of teaching? - "i should limit wearing the same shoes 2 days in a row" ileostomy priority - purple stoma meter-dose inhaler understanding - deep breath, blow it out before inhale female obese - bmi 40 Starting epoetin - hypertension foot care - trim toenails straight discharge planning for gestational diabetes - determine knowledge manifestations fo hypoglycemia - fruit juice Rifampin - no alcohol amputation trauma - call 911, apply pressure, elevate extremity, find toe, place toe in bag Discharge teaching for hearing impairment - encourage the client to repeat left lower dvt - legs elevated in bed atherosclerosis self-care - increase fiber 30g/day Cholecystectomy - adhesive bandages fall off receiving potassium by IV, level back to normal - stronger hand grasp mild anxiety - follows directions mild hypothermia - slurred speech risk factor for cholecystitis - taking atorvastatin Preschooler with heart failure - offer small, frequent meals panic level anxiety - protect client from harm COPD disease management - use pursed-lip breathing toddler left lower leg fracture - toe movement limited morphine PCA - naloxone newborn hypothermia - hypoglycemia pertussis - droplet precautions Heparin antidote - protamine sulfate acute bacterial wound infection - set temp @ 72 left sided heart failure - nocturia, dyspnea