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, hacking cough Use a cover sheet when sending a fax from the health care unit. - A nurse manager is developing a faculty policy about using a fax machine to communicate information from a client's electronic medical record (EMR). Which of the following actions should the nurse include in the policy Administer a beta-blocking medication to the client - A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experience in a dull, burning pain in the leg that was amputated. Which of the following should the nurse take to treat the client's neuropathic pain. Pregabalin PO twice daily - A nurse is assessing a client who has fibromyalgia. Which of the following treatment modality prescriptions should the nurse expect for the client's mixed pain. Scrambled eggs - A nurse is planning the menu for a client who practices Seventhday Adventist. Which of the following food selections should the nurse make? Take NSAIDs for body aches and pains - A nurse Is providing teaching to a client who has chronic fatigue syndrome. Which of the following statements should the nurse make. Tell me what is causing your anger at this moment - A nurse is using therapeutic communication to attempt deescalation with a client who is yelling at staff members. Which of the following statements should the nurse make Recommend a single coding system for each department to use. - A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. Which of the following actions should the nurse manager take to promote interoperability? Administer ondansetron to the client prior to chemotherapy administration - A nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemothaerapy-induced nausea and vomiting (CINV) during her previous round of treatment. Which of the following interventions should the nurse include in the clients plan of care? Perform moderate exercise daily Add more whole grains to your diet Increase your fluid intake - A nurse is teaching a client about strategies to prevent recurrent constipation. Which of the following instruction should the nurse include? Request the AP use another computer to enter the data. - A nurse is documenting an assessment in a clients electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take. Can you describe what the pain feels like? - A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to assess the quality of the client's pain? Remove the mask by securely holding the ties and moving it away