Geschreven door studenten die geslaagd zijn Direct beschikbaar na je betaling Online lezen of als PDF Verkeerd document? Gratis ruilen 4,6 TrustPilot
logo-home
Tentamen (uitwerkingen)

ATI PN COMPREHENSIVE PREDICTOR FORM A,B AND C LATESTEXAM 2023 100% VERIFIED SOLUTION WITH 165 QUESTIONS AND ANSWERS

Beoordeling
-
Verkocht
-
Pagina's
83
Cijfer
A+
Geüpload op
01-04-2023
Geschreven in
2022/2023

ATI PN COMPREHENSIVE PREDICTOR FORM A,B AND C LATESTEXAM 2023 100% VERIFIED SOLUTION WITH 165 QUESTIONS AND ANSWERSATI PN COMPREHENSIVE PREDICTOR FORM A | QUESTIONS AND ANSWERS| LATEST 1. A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following instructions should the nurse include? ANS: Use lower-body strength RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back 2. A nurse is participating in a quality improvement study about the effectiveness of client pain management in the unit. Which of the following strategies should the nurse use to collect data? ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr after administration RATIONALE: The nurse should collect data from clients' charts about pain ratings before and after pain management interventions 3. A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching? ANS: "Your HIV status will be shared with members of your health care team." RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team who provides direct care for the client, just like any other diagnoses 4. A nurse is planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the client's room? ANS: Suction catheter RATIONALE: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway 5. A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? ANS: Coronary artery diseaseRATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension 6. A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider? ANS: 250 mL of sanguineous drainage over the last 3 hr RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately 7. A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. Which of the following findings should the nurse report to the provider as an indication of hyperglycemia? ANS: Polyuria RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia and report this finding to the provider 8. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? ANS: "I will dispose of my needles in a plastic laundry detergent container." RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container. 9. A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take? ANS: Encourage the client to reminisce about the past RATIONALE: The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicit feelings of happiness 10. A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider? ANS: PR interval 0.24 seconds RATIONALE: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval indicates a heart block; therefore, the nurse should report this finding provider 11. A nurse on a medical unit is reviewing a client's medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent form? ANS: Lumbar punctureRATIONALE: The nurse should identify that a client needs to provide consent for general treatment, as well as a separate written, informed consent for any treatment that has an element of risk, such as a lumbar puncture 12. A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift. Which of the following clients should the LPN ask the charge nurse to reassign to a registered nurse (RN)? ANS: A client who has a new colostomy and requires the development of a teaching plan RATIONALE: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client's need for a teaching plan regarding the new colostomy and request that this client is reassigned to an RN. The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established 13. 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 one of the following interprofessional team members? ANS: Occupational therapist RATIONALE: The nurse should identify the need for a referral to an occupational therapist to teach the client how to use special eating utensils 14. A nurse is preparing to perform blood glucose monitoring for a client who has type 1diabetes Mellitus. Which of the following actions should the nurse take first? ANS: Hold the finger for testing in a dependent position RATIONALE: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen 15. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include? ANS: Apply the stockings in the morning RATIONALE: The nurse should instruct the client to apply the elastic stockings in the morning and remove them at the end of the day before bedtime 16. A nurse in a provider's office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (Select all that apply.) ANS: Store the child's clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 min. Dry bed linens and clothing in a hot dryer for at least 20 min. RATIONALE:Transmission of lice occurs via contact with personal items. Boiling hair care items in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by washing in hot dryer for at least 20 min is an appropriate strategy 17. 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? ANS: Use intermittent urinary catheterization for the client on at 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. 18. A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take? ANS: Tell the client they should not experience any discomfort RATIONALE: The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort 19. 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? ANS: "What have you done to help yourself get through stressful situations before?" RATIONALE: This is a therapeutic response. The nurse is aware that the client is under stress and encourages comparison to investigate whether they have experience dealing with a stressful situation 20. 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 hour following birth? ANS: Dark greenish-black and viscous RATIONALE: The first stool passed by a newborn is the meconium that develops in utero. It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood 21. A licensed practical nurse is assisting with the preparation of a client for insertion of a peripherally inserted central venous catheter (PICC). Which of the following actions should the nurse take? ANS: Witness the client's signature on the informed consent form. RATIONALE: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse should witness the client's signature on the consent form after ensuring the client has an understanding of the procedure, including its risks and benefits22. A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client's meal tray? ANS: Spaghetti noodles with red sauce RATIONALE: The nurse should identify that spaghetti noodles with red sauce is appropriate for a client who adheres to a kosher diet. 23. A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color RATIONALE: The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding 24. A nurse is assisting with the care of a client who is postpartum and has a deep-vein thrombosis. The client has been receiving heparin IV infusion. Which of the following medications should the nurse ensure is readily available? ANS: Protamine sulfate RATIONALE: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin 25. A nurse is reinforcing teaching with a client about how to replace their two piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest? ANS: Hold the skin taut while removing the barrier RATIONALE: Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin 26. A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following responses should the nurse make? ANS: "What is your current understanding about the purpose of AA?" RATIONALE: The nurse should identify the client's understanding about the purpose ofAA to provide further information about the program and meetings and to facilitate a referral if needed. For treatment to be successful, the nurse should involve the client in the care decision-making process. This ensures the treatment program meets the client's individual needs and demonstrates caring by the nurse27. 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? ANS: 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 to the Provider 28. A nurse is providing comfort to the partner of a client who has died. Which of the following statements should the nurse make? ANS: "Journaling about your relationship might help with the grieving process." RATIONALE: Journaling provides a means for the client to identify thoughts and feelings and to recognize and come to terms with the positive and negative aspects the client's relationship with their partner 29. A nurse is assisting with an educational session for newly licensed nurses about partner violence. Which of the following characteristics should the Nurse included as placing a vulnerable person at risk for partner violence? ANS: Recent confirmation of pregnancy RATIONALE: The nurse should include pregnancy as a characteristic placing a vulnerable person at risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship due to the attention the child receives 30. A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury. Which of the following instructions for safe lifting technique should the nurse include? ANS: "You should hold a box close to your body when lifting it up." RATIONALE: The client should hold the box as close to their body as possible to maintain balance and prevent injury 31. A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include? ANS: "Apply a water-based lubricant around the nostrils to prevent irritation."RATIONALE: The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy 32. A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect? ANS: The client calls their partner to ask what they should wear each day RATIONALE: Clients who have dependent personality disorder have problems making everyday decisions without input from others 33. A nurse is caring for a client who is scheduled for a mastectomy the following day. The client is tearful and tells the nurse that they are not ready to have this procedure done at this time. Which of the following responses should the nurse make? ANS: "Would you like for me to talk to the surgeon with you?" RATIONALE: The nurse should advocate for the client's needs by offering to talk to the surgeon with the client. The nurse should also offer moral support and encourage the client to express their concerns and make a more informed decision 34. A nurse is documenting client care in the medical record. Which of the following entries should the nurse make? ANS: "Client remains NPO until x-ray procedure is complete." RATIONALE: The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation "NPO", which is an accepted abbreviation for "nothing by mouth." 35. A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? ANS: Observe the client's facial expressions during communication RATIONALE: The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying 36. A nurse is collecting data from a client who reports recent methamphetamine use. Which Of the following manifestations should the nurse expect?ANS: Dilated pupils RATIONALE: The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance 37. A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend to the charge nurse for discharge? ANS: A client who has pneumonia and is currently receiving oral antibiotics RATIONALE: The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation 38. A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client? ANS: Walking outside with a staff member RATIONALE: During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the one-on-one nature of the activity provides the client with a sense of security 39. A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first? ANS: Gloves RATIONALE: The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE. 40. 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? ANS: 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 formation41. A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider? ANS: Muscle pain RATIONALE: The nurse should instruct the client to report findings of muscle pain or tenderness to the provider. These findings can be manifestations of myopathy, or muscle injury, which is a potential serious adverse effect of atorvastatin 42. A nurse is caring for a client who is recovering from a motor vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make? ANS: "I cannot give you this information. You will need to speak with your employee." RATIONALE: Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclosed in a health care setting. The nurse should inform the employer they will need to speak with the client directly 43. A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take? ANS: Provide the client with a handheld event marker to record fetal activity RATIONALE: The nurse will provide the client with a handheld event marker for use in documenting fetal movement. The client will press the button every time they feel the fetus move throughout the test, which is then logged on the paper tracing recording the heart rate and activity of the Fetus 44. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching? ANS: "I should wear a soft scarf around my neck when I am outside." RATIONALE: A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun Exposure 45. A nurse is reinforcing teaching with an older adult client who has severe left-sided heart failure. Which of the following statements should the nurse make?ANS: "Rest for 15 minutes between activities." RATIONALE: The nurse should instruct the client to increase activity gradually and tourist for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardiac Workload. 46. A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following positions should the nurse plan to place the client during the procedure? ANS: Upright with arms resting on the overbed table RATIONALE: The nurse should position the client upright with arms resting on the overbed table to widen the intercostal spaces and improve access to the pleural fluid 47. A nurse is talking with a client who says the provider agreed to initiate a do-notresuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first? ANS: Check for documentation that the provider spoke with the client about theDNR RATIONALE: The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements 48. A nurse is observing a client who is in the first stage of labor. Which of the following interventions should the nurse recommend for this client? (Select all that apply.) ANS: Squatting using an exercise ball. Counterpressure to the sacral area. Pelvic rocking. RATIONALE: Squatting using an exercise ball can help relax the pelvis and perineal area and can relieve pain during contractions.Counterpressure to the sacral area can help decrease pain by relieving pressure on the spinal nerves caused by the fetus's occiput.Pelvic rocking can relieve backache during the first stage of labor. To perform this action, the client hollows their back and then arches it to relieve back pain. 49. A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? ANS: A visitor who develops a bruise on their head following a syncopal episodeRATIONALE: The nurse should complete an incident report for an injury involving a client or visitor 50. A client is requesting information from a nurse about creating a health care proxy. Which Of the following statements should the nurse make? ANS: "The person you appoint will make healthcare decisions for you if you cannot do so yourself." RATIONALE: The nurse should instruct the client that a health care proxy designates a surrogate to make health care decisions when the client is no longer able to make decisions for themselves. 51. A client in a mental health facility unjustly accuses a nurse of stealing money from their room. Which of the following therapeutic responses Should the nurse make? ANS: "Tell me how you decided who took your money." RATIONALE: This response by the nurse is an example of therapeutic communication,in which the nurse validates the client's concern by encouraging them to describe their perception 52. A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take? ANS: Flush the feeding tube with water before and after administering the medication RATIONALE: To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration 53. A nurse is planning care for a 5-year-old child who is 8 hr postoperative following a tonsillectomy. Which of the following interventions should the nurse include in the plan of care? ANS: Administer PRN analgesics regularly for the first 24 hr. RATIONALE: The nurse should administer analgesics for the first 24 hr even if they are ordered on an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics regularly provides a steady state of analgesia. With pain being managed, children are more likely to consume fluids, remain hydrated, and avoid delayed discharge or readmissions for fluid volume deficit.54. A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include? ANS: "You should increase your fluid intake while receiving this medication through the PCA pump." RATIONALE: The client should increase their fluid intake to prevent or relieve the adverse effect of constipation while receiving morphine through the PCA pump 55. A nurse is using the FLACC scale to determine the pain level of an 11-month-old infant who is postoperative. Which of the following factors should the nurse consider when using this pain scale? ANS: Level of activity RATIONALE: The nurse should consider the infant's activity level when using the FLACC pain scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolability (C). 56. A nurse is receiving a change-of-shift report for four clients. The nurse should plan to collect data from which of the following clients first? ANS: A client who has asthma and had frequent exacerbations on the previous shift RATIONALE: When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experienced several exacerbations of asthma on the previous shift, which can result in an obstruction of the client's airway 57. A nurse is caring for a newborn who is 1 hr old. The mother received fentanyl 30 min before birth. For which of the following adverse effects should the nurse monitor the newborn? ANS: Respiratory depression RATIONALE: Fentanyl, an opioid agonist, rapidly crosses the placenta, and it is present in fetal blood within 1 min. The nurse should monitor the newborn for respiratory depression, which is an adverse effect of fentanyl 58. A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen? ANS: The client takes the medication once daily at bedtime RATIONALE: Montelukast, a leukotriene modifier, is taken once a day formaintenance at bedtime 59. A nurse is assisting with planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care? ANS: Administer atropine to reduce the client's respiratory secretions RATIONALE: The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle." 60. A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect? ANS: The toddler is inadequately dressed for the weather RATIONALE: Inappropriate dress is a suggestive finding of physical neglect. The nurse should collect further data for other indicators of physical neglect 61. 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? ANS: 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 secretions and prevent aspiration 62. A nurse is contributing to the plan of care for a client who has a prescription for rangeof-motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension? ANS: Move the arm behind the body with the elbow straight RATIONALE: Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight 63. A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which of the following client statements should the nurse use as an example of rationalization? ANS: "I didn't get a good grade because my teacher doesn't like me." RATIONALE: The nurse should recognize this statement as the use of rationalization by a client. Rationalization is used as a means of justifying unreasonable feelings, thoughts,or actions64. A nurse is caring for an older adult client who is experiencing difficulty sleeping. Which Of the following actions should the nurse take? ANS: Offer the client a snack of whole grain crackers before bedtime RATIONALE: The nurse should provide the client a light carbohydrate snack, such as whole grain crackers, before bedtime 65. A nurse is preparing a client for an enteral feeding and notices that the pump at the client's bedside is warm to the touch. Which of the following actions should the nurse take? ANS: Unplug the equipment and remove it from the room RATIONALE: If the nurse identifies a potential safety hazard with the equipment, the nurse should remove the pump from the client's room to prevent injury to the client. Thenurse should then follow facility protocol regarding faulty equipment 66. A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors rather than nightmares? ANS: "My child goes back to sleep right away." RATIONALE: The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmares has difficulty returning to sleep because of continued fear 67. A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first? ANS: Complete a fall risk assessment on the client RATIONALE: The first action the nurse should take when using the nursing process is to collect data from the client. By completing a fall risk assessment, the nurse can identify the client's risk forfalls and can then assist in planning interventions to prevent client injury 68. A nurse is reinforcing teaching about a high-protein diet with a client who has HIV. Which of the following foods should the nurse recommend as containing the highest amount of protein per serving? ANS: 2 Tbsp peanut butter RATIONALE: The nurse should recommend 2 Tbsp of peanut butter because it contains approximately 7 g of proteins 69. A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as an indication of a positive client response to systematic desensitization?ANS: The client remains relaxed when thinking of 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 client's lack of anxiety when thinking about the phobia as a positive response to the therapy 70. A nurse is assisting with the admission of a client who has rubeola. Which of the following transmission-based precautions should the nurse plan to initiate for this client? ANS: Airborne RATIONALE: The nurse should initiate airborne precautions for a client who has rubeola. This includes a private room with negative-pressure airflow and an air filtration system. Facility personnel are required to wear an N95 respirator while in the client's room 71. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching? ANS: Drink high-protein and high-calorie nutritional supplements RATIONALE: The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that can lead to hypermetabolism and wasting of the client's muscle mass 72. A nurse is working in a long-term care facility. Which of the following actions should the nurse take when using computer-based client records? ANS: Shred printouts of client care information when they are no longer needed RATIONALE: Nurses should destroy documents that contain information regarding client care when they are no longer needed to avoid compromising client confidentiality 73. A nurse is assisting a client who is postoperative to sit on the side of the bed. Which ofthe following actions should the nurse take? ANS: Elevate the head of the client's bed RATIONALE: The nurse should elevate the head of the client's bed to decrease the distance the client has to move to sit on the side of the bed 74. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty.Which of the following actions should the nurse take? ANS: Place an abduction wedge between the client's legs when in bed RATIONALE: The nurse should place an abduction wedge between the client's legs while in bed to prevent adduction of the legs and hip dislocation following a total hip arthroplasty75. A nurse is assisting with teaching a group of local residents at a community health fair about the Dietary Approaches to Stop Hypertension (DASH) diet. Which of the following statements by a resident indicates an understanding of the teaching? ANS: "I will keep my intake of sodium less than 2,300 milligrams per day." RATIONALE: DASH principles include limiting daily sodium intake to less than 2,300mg/day. Individuals who have an increased risk for hypertension such as clients who have kidney disease and diabetes, should reduce intake of sodium to 1,500 mg/day 76. 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 102.4, heart rate 116/min, respiratory rate 24/min, and blood pressure 152/92 mm Hg. Which of the following actions should the nurse take? ANS: Document the findings 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 77. A nurse in a long-term care facility notices a client who has Alzheimer's disease standing at the exit doors at the end of the hallway. The client appears to be anxious and agitated. Which of the following actions should the nurse take? ANS: Escort the client to a quiet area on the nursing unit RATIONALE: A client who has Alzheimer's disease experiences chronic confusion.Guiding the client to a quiet, familiar area will help decrease agitation 78. A nurse is reviewing laboratory results for a client who is receiving mechanical ventilation. Which of the following findings should the nurse recognize as a potential complication of mechanical ventilation? ANS: pH 7.5 RATIONALE: The nurse should identify that a pH level of 7.5 indicates alkalosis and is above the expected reference range. Excessive ventilation can cause this finding 79. A nurse is administering morning medications to a client. The client questions the nurse regarding a medication that they do not recognize. Which of the following actions should the nurse take first? ANS: Verify the prescription in the client's medical record RATIONALE: The first action the nurse should take when using the nursing process is to collect more data. By verifying the prescription in the client's medical record, the nurse can ensure that the medication is prescribed for the Client80. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following information? ANS: Motor response RATIONALE: The nurse should collect data about the client's motor response and assign the response a score of 1 to 6, according to the Glasgow Coma Scale 81. A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include? ANS: Administer by subcutaneous injection RATIONALE: The nurse should include that enoxaparin should be injected into the subcutaneous tissue 82. A nurse is monitoring a school-age child who has anemia and is receiving a transfusion of packed RBCs. Which of the following statements by the child indicates a possible hemolytic transfusion reaction that the nurse should report to the charge nurse and the provider? ANS: "I am really cold. May I have another warm blanket?" RATIONALE: The nurse should recognize that a report from the child of feeling cold or having chills is a possible indication of a hemolytic transfusion reaction. This reaction occurs when the RBCs being infused are destroyed by the child's immune system. The nurse should stop the transfusion immediately, take a set of vital signs, and notify the charge nurse and provider 83. A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril. Which of the following over-the-counter medications should the nurse instruct the client to avoid? ANS: Ibuprofen RATIONALE: Ibuprofen, or any other nonsteroidal anti-inflammatory medications, can reduce the antihypertensive effects of this medication. Therefore, the nurse should instruct the client who is taking captopril to avoid taking ibuprofen 84. A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following client findings indicates a therapeutic effect of this medication? ANS: Reports a decrease in the number of stools RATIONALE: Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which result in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic response to the medication85. A nurse is caring for a client who has borderline personality disorder and states, "I am going to kill my partner when I get out of here." Which of the following actions should the nurse take? ANS: Notify the client's care team about the threats against their partner RATIONALE: The nurse should notify the client's care team about the threats the client makes toward others. Failure of the nurse to report threats made toward others is considered negligence 86. A nurse is reinforcing teaching about advance directives with a client. Which of the following statements by the client indicates an understanding of the teaching? ANS: "I can change my health care decisions even if I have advance directives." RATIONALE: The nurse should instruct the client that they are free to make changes to advance directives at any time. Treatment decisions might change as a client's health status changes 87. A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex? ANS: Stroke the sole of the newborn's foot upward and toward the great toe RATIONALE: The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at the heel, to elicit the Babinski reflex 88. A nurse is monitoring a client who is 12 hr postoperative following a cholecystectomy and received morphine 30 min ago for pain. The nurse should identify which of the following findings as an adverse effect of the medication? ANS: Respiratory rate 10/min RATIONALE: A respiratory rate of 10/min indicates respiratory depression, which is an adverse effect of morphine 89. A nurse is caring for a client who is scheduled for peritoneal dialysis. Which of the following actions should the nurse take first? ANS: Ensure the dialysate solution is at room temperature RATIONALE: Evidence-based practice indicates the nurse should administer the dialysate solution at a temperature of 98.6; therefore, the first action the nurse should take to warm the prescribed solution 90. 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? ANS: WBC 25,000/mm RATIONALE: The nurse should identify a WBC of 25,000/mm 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 provider91. A nurse in a long-term care facility is reviewing standard precaution guidelines with an assistive personnel (AP). The nurse should instruct the AP to use which of the following to clean up a blood spill? ANS: Chlorine bleach solution RATIONALE: The nurse should instruct the AP to use a bleach solution to clean up a blood spill. A 1:10 bleach-to-water solution will destroy all bloodborne pathogens 92. A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. Which of the following instructions should the nurse include as a measure to assist with the possible adverse effects of this medication? ANS: Perform daily gum massage RATIONALE: Gingival hyperplasia is a common adverse effect of this medication.Massaging the gums will help minimize this effect 93. A nurse is monitoring a client who is receiving IV fluids. For which of the following findings should the nurse stop the infusion? ANS: Edema above the catheter insertion site RATIONALE: Edema above the catheter site indicates infiltration. The nurse should stop the IV infusion 94. A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse include? ANS: Place the client in a private room RATIONALE: The nurse should place a client who has viral meningitis in a private room to prevent the transmission of the virus. Direct contact with a contaminated surface or the saliva, mucus, or feces of the person who has the infection transmits viral meningitis 95. A nurse is reviewing the medical history of a client who is scheduled for colonoscopy to establish a diagnosis of diverticulitis. Which of the following findings should the nurse identify as increasing the client's risk for developing diverticular disease? ANS: Chronic constipation RATIONALE: Diverticular disease is a disorder in which pouches or saclike projections occur in the bowel mucosa through weakened areas of the muscular layer of the intestines. The nurse should identify chronic constipation as a risk factor for diverticular disease 96. A nurse is making assignments for the upcoming shifts. Which of the following tasks should the nurse plan to delegate to an assistive personnel(AP)? ANS: Perform post mortem care for a client who died 1 hr agoRATIONALE: Performing post mortem care is within the range of function for an AP.Therefore, the nurse should delegate this task to an AP 97. 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? ANS: The client asks the nurse to help them die peacefully in their sleep RATIONALE: This situation presents an ethical issue for the nurse because the client isasking for a variation of active euthanasia, also known as assisted suicide, 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 98. A nurse in a long-term care facility is collecting data from a client who has been receiving betaxolol to treat glaucoma. Which of the following findings is an adverse effect of this medication? ANS: Bradycardia RATIONALE: Betaxolol is a beta blocker that can produce systemic effects, such as bradycardia 99. A nurse in a long-term care facility is documenting the care of an older adult client. Which of the following information should the nurse include in the weekly nursing care summary? ANS: Hydration status RATIONALE: Older adults are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client's hydration status and include this information in the weekly nursing care summary 100. A nurse in an inpatient mental health facility is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? ANS: Record the amount of food the client consumes RATIONALE: The nurse should record the amount of food the client cosumnes to ensure the client is consuming adequate nutrition 101. A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actions should the nurse take? A. Assure the client that a family member will stay with the body after death RATIONALE: The nurse should assure the client that a family member will remain with the body until burial102. A nurse is caring for a client who is receiving telemetry. Which of the followingECG findings should the nurse report to the charge nurse? A. PR interval 0.24 seconds. 103. A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients should the nurse recommend for treatment? A. a client who is experiencing shortness of breath after taking Amoxicillin. 104. 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 medical record to locate information about the clients personal health insurance? A. admission sheet. 105. A nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. Which of the following statements should the nurse make? A. you should increase your fluid intake after this procedure. 106. A nurse is reinforcing teaching about puberty with a group of prepubescent female clients. Which of the following information Should the nurse be included in the teaching? A. you will likely gain weight before you start to get taller. 107. 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? A. an infection with gonorrhea may result in infertility. 108. A nurse in a provider's office is caring for a client who is at 34 weeks of gestation.Which of the following instructions should the nurse anticipate providing to the client? A. monitor your blood pressure using your right arm daily. 109. A nurse is preparing to administer amoxicillin 875 mg PO every 12 hours. The amount available is amoxicillin oral suspension 400 mg/5mL. How many mL should the nurse administer per dose? A. 11.110. A nurse is collecting data from a client who has chronic hepatitis. In which of the following locations should the nurse expect the client to point to indicate hepatic tenderness? The client with chronic hepatitis will experience hepatic tenderness in the upper right quadrant, which is where the nurse should palpate. this is the area where the liver is located 111. A nurse is monitoring a client who is receiving lactated ringers 500 mL over 4 hr.The drop factor of the manual IV tubing is 10gtt/mL. The nurse should check that the manual IV infusion is delivered at how many gtt/min? A. 21. 112. A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include? A. apply capsaicin cream four times a day. 113. A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first? ANS: Obtain a set of the client's vital signs RATIONALE: The first action the nurse should take when using the nursing process is to collect data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the nurse can identify the need for Intervention 114. A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A and is incontinent of stool. Which of the following infection control precautions should the nurse instruct the AP to use? ANS: Contact RATIONALE: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of stool, then contact precautions are indicated 115. 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? ANS: Admission sheet RATIONALE: The nurse will find client data, such as date of birth,occupation, and the client's source of health insurance, on the client's admission sheet 116. A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider? ANS: 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 the newborns who has 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 117. A nurse in a provider's office is obtaining the health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority for the nurse to ask? ANS: "Do you know if you're allergic to iodine?" RATIONALE: The greatest risk to the client is an allergic reaction to the contrast agent,which contains iodine. Therefore, the priority question is to identify the client's allergies 118. 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? ANS: 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 119. A nurse is evaluating the safe use of electrical equipment by a newly hired assistive personnel (AP). Which of the following actions by the AP demonstrates an understanding of the proper use of electrical Equipment? ANS: Grasps the plug of a device in the client's room to pull it straight out from the wall RATIONALE: The nurse should recognize that by grasping the plug, rather than the cord, the AP is demonstrating an understanding of proper equipment use and preventing risk of injury from electronic equipment.120. A nurse is reinforcing discharge teaching with the parents of a school age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching? ANS: "I will soak my child's toothbrush in warm water to soften it before my child uses it." RATIONALE: The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge tipped disposable toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity 121. A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion? ANS: A client hits another client because they thought the other client was talking about them RATIONALE: The nurse should request a prescription for seclusion for a client who hits another client to protect the client and others from physical Injury 122. 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? ANS: Wheeze 123. A nurse in an urgent care clinic is caring for a child who has a minor burn on his palm after touching the burner on a hot stove. Which of the following actions should the nurse take? 1. Clean the burn with mild soap and tepid water 2. Remove any embedded debris 3. Apply an antimicrobial ointment 4. Wrap the hand in a gauze dressing 5. Inform the parent of dressing change schedule 124.A nurse in a provider's office is collecting growth and development data from a 7month old infant during a well child visit. Which of the following images should the nurse identify indicates expected gross motor skills for the infant ANS: sitting and leaning forward using both hands for support is an expected finding for a 7 month old infant125.A nurse in a provider's office is caring for a client who is at 34 weeks of gestation.Which of the following instructions should the nurse anticipate providing to the client? ANS: monitor your blood pressure using your right arm daily 126.A nurse is collecting data from a school age child who has hypoglycemia. Which of the following clinical manifestations should the nurse expect? ANS: sweating 127.A nurse is assisting with the care of a client who has terminal cancer. Which ofthe following statements by the client's family should indicate to the nurse that they are coping with their situation? ANS: "Dad, I remember the time we all went fishing at the lake." 128.A nurse in a provider's office is caring for four clients. Which of the following clients should the nurse see first? ANS: A client who is 36 weeks of gestation and reports a painless vaginal Bleeding 129.A nurse is collecting a urine specimen from a female client who has diabetes insipidus. the nurse should expect which of the following findings? ANS: urine specific gravity of 1.002 130.A nurse is reinforcing teaching for a client who has Meniere's disease and a new prescription for meclizine. The nurse should inform the client that which of the following is an adverse effect of this medication? ANS: Sedation 131.A nurse is reinforcing teaching with a client who is scheduled for an exerciseECG stress test. which of the following actions should the nurse take? ANS: Recommend the client wear comfortable shoes during the test 132.A nurse is collecting data from an older adult client who has a gastric ulcer. Which of the findings should the nurse identify as a complication to report to the provider? ANS: hematemesis 133.A nurse is reinforcing teaching with a client who has asthma and has a prescription for theophylline. Which of the following statements should the nurse make? ANS: Discontinue drinking caffeinated beverages134.A nurse is caring for a client who is refusing a prescribed medication. Which ofthe following actions should the nurse take first? ANS: Identify the client's concerns about receiving the medication 135.A nurse is reviewing the electronic health records of four clients. Which of the following client conditions should the nurse recognize as reportable to a regulatory agency? ANS: A client who is newly diagnosed with tuberculosis 136.A nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take? ANS: Moisten the client's conjunctiva with sterile normal saline 137.A nurse is caring for a client who is receiving continuous feedings via a gastrostomy tube. Which of the following actions should the nurse plan to take? ANS: Flush the tube with 60 mL of water if it becomes clogged 138.A nurse is preparing to administer an IM immunization to a preschooler. Which ofthe following statements should the nurse plan to make prior to performing the injection? ANS: "Let's give the medicine to your doll first." 139.A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as delusional? ANS: "My doctor's glasses have lasers that will burn holes in my brain if I look at him." 140.A nurse is collecting data from an older adult client who has a hip fracture. Which of the following findings should the nurse expect? ANS: External rotation 141.A nurse is performing post mortem care for a client. Which of the following actions should the nurse take? ANS: Elevate the head of the client's bed.142.A nurse is preparing to perform tracheostomy care for a client. which of the following actions should the nurse take first? ANS: Open sterile packages 143.A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting along with fever and chills. Which of the following diagnostic tests should the nurse expect the provider to prescribe? ANS: Cerebrospinal fluid analysis 144.A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa.Which of the following instructions should the nurse include? ANS: Administer the medication subcutaneously 145.A nurse enters a client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse take first? ANS: Assist the client to a nearby waiting area 146.A nurse is caring for a client who is 12hr postop following gastrointestinal surgery and has an NG tube for gastric decompression. Which of the following actions should the nurse take? ANS: Keep the plugged tube above the level of the stomach when the client is ambulating 147.A nurse is caring for a client who is expressing sadness about the amputation of her leg 72 hr ago due to trauma. The nurse must leave the room but promises to return as soon as possible. Which of the following ethical principles is the nurse demonstrating when he returns as promised? ANS: Fidelity 148.A nurse is reinforcing teaching with an older adult client who has of the following instructions should the nurse include? ANS: Apply capsaicin cream 4 times daily 149.A nurse in a provider's office is reinforcing teaching with a client who is to follow a 2000mg sodium restricted diet. Which of the following client food selections indicates an understanding of the teaching? ANS: Canned peaches150.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 understanding of the teaching? ANS: "I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant." 151.A nurse is reinforcing teaching about managing manifestations of anxiety with a client who has generalized anxiety disorder. Which of the following information should the nurse include? ANS: Say the word "stop" when upsetting thoughts occur. 152.A nurse is collecting data from a client following a lumbar puncture. For which of the following adverse effects should the nurse monitor? ANS: Headache 153.A nurse is preparing to insert an indwelling catheter for a female adult client.Which of the following actions should the nurse take? (Select all that apply.) ANS: Cleanse the clients labia and meatus using a front to back motion Use the nondominant hand to expose the clients urinary meatus Advance the catheter 5-7 in into the client's urinary meatus Ask the client to bear down while inserting the catheter 154.A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which of the following actions should the nurse take? ANS: Select a site in the antecubital fossa 155. A nurse is assisting with an educational program about car restraint safety for a group of parents. Which of the following statements by a parent indicates an understanding of the instructions? My 12 year old child should place the shoulder lap belt low across his hips 156. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching?Drink high protein and high calorie nutritional supplements 157. A nurse is contributing to a teaching plan for a group of male adolescents about the adverse effects of anabolic steroid use. Which of the following manifestations should the nurse include? Reduced height potential 158. A nurse is planning to administer nystatin oral suspension to a client who has oral candidiasis. Which of the following instructions should the nurse give to the client? Hold the medication in your mouth for several minutes prior to swallowing 159. A nurse is preparing to care for the assigned clients on her upcoming shift. Which of the following time management strategies should the nurse plan to use? prepare a priority list of client needs for the shift 160. A nurse is preparing to witness a client who is scheduled for surgery sign an informed consent. Which of the following actions should the nurse take? Ask the client if he understands the procedure 161. A nurse is assisting with the care of a client who is 2 days post op following a total knee arthroplasty. Which of the following tasks should the nurse assign to an assistive personnel? reapply antiembolic stockings to the client following a shower 162. a nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this method of pain control? i should report leaking at the insertion site to the anesthesiologist 163 .a nurse is assisting with a community education program for parents of preschoolers about recommended activities to promote physical development. Which of the following statements should the nurse make? you should provide unorganized play activities for your child each day 164 a nurse is caring for a client who has just been diagnosed with a terminal illness. the client states, i have nothing to live for. I just cannot go on. Which of the following responses should the nurse make? It sounds like you feel there is no hope. Are you thinking about harming yourself?165 A nurse is contributing to the plan of care for a client who has a nasogastric tube and is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan? measure the pH of gastric tube aspirate prior to administering nutrition 166.A nurse is caring for a client who is at 34 weeks of gestation and has mild preeclampsia. Which of the following findings indicates a progression from mild to severe preeclampsia? Client reports blurred vision 167.A nurse is reinforcing teaching with a client who has a new prescription for metronidazole. the nurse should instruct the client to expert which of the following adverse effects while taking this medication? reddish-brown urine 168A home health nurse is collecting data from an older adult client who has generalized anxiety disorder. The client lives at home with her partner and a sibling. Which of the following responses by the client's partner is

Meer zien Lees minder
Instelling
Vak

Voorbeeld van de inhoud

ATI PN COMPREHENSIVE
PREDICTOR FORM A,B AND C
LATESTEXAM 2023 100%
VERIFIED SOLUTION WITH
165 QUESTIONS AND
ANSWERS

, ATI PN COMPREHENSIVE PREDICTOR FORM A |
QUESTIONS AND ANSWERS| LATEST
1. A nurse is reviewing the techniques for transferring a client from a bed to a chair with a
group of assistive personnel (AP). Which of the following instructions should the nurse
include?
ANS: Use lower-body strength
RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client to
reduce stress on the back

2. A nurse is participating in a quality improvement study about the effectiveness of
client pain management in the unit. Which of the following strategies should the nurse
use to collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered and 1
hr after administration
RATIONALE: The nurse should collect data from clients' charts about pain ratings before and after
pain management interventions

3. A nurse is reinforcing teaching about confidentiality with a client who has a new
diagnosis of HIV. Which of the following information should the nurse include in the
teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team who
provides direct care for the client, just like any other diagnoses

4. A nurse is planning care for a client who has a history of seizures. Which of the
following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RATIONALE: The nurse should place suction equipment in the room of a client who has a history of
seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the
client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a
patent airway




5. A nurse in a provider's office is reviewing the medical record of a client who requests a
prescription for an oral contraceptive. Which of the following findings should the nurse
identify as a contraindication for oral contraceptive use?
ANS: Coronary artery disease

,RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because it
increases the client's risk for myocardial infarction. Other contraindications for receiving oral
contraceptives include gallbladder disease, breast cancer, and hypertension\

6. A nurse is assisting with the care of a school-age child immediately following surgery. The
child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following
findings should the nurse report to the provider?
ANS: 250 mL of sanguineous drainage over the last 3 hr
RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage
occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging.
Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse
should report this finding to the provider immediately

7. A nurse is collecting data from a client who is at 30 weeks of gestation and has
gestational diabetes. Which of the following findings should the nurse report to the
provider as an indication of hyperglycemia?
ANS: Polyuria
RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia and report
this finding to the provider

8. A nurse is discussing home safety with a group of clients who have type 1 diabetes
mellitus. Which of the following client statements indicates an understanding of the
teaching?
ANS: "I will dispose of my needles in a plastic laundry detergent container."
RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof container,
such as a plastic laundry detergent container.

9. A nurse is caring for a client who has Alzheimer's disease. Which of the following
actions should the nurse take?
ANS: Encourage the client to reminisce about the past
RATIONALE: The client who has Alzheimer's disease has progressive loss of short-term memory
and might not be able to recall recent happenings and events. This can lead to increased
frustration. However, remote memory remains in place for a longer period of time and can elicit
feelings of happiness

10. A nurse is monitoring a client who is receiving telemetry. Which of the following ECG
findings should the nurse report to the provider?
ANS: PR interval 0.24 seconds
RATIONALE: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval
indicates a heart block; therefore, the nurse should report this finding provider
11. A nurse on a medical unit is reviewing a client's medical record. Which of the
following procedures should the nurse identify requires the client to sign a separate
informed consent form?
ANS: Lumbar puncture

, RATIONALE: The nurse should identify that a client needs to provide consent for general treatment,
as well as a separate written, informed consent for any treatment that has an element of risk, such
as a lumbar puncture

12. A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift.
Which of the following clients should the LPN ask the charge nurse to reassign to a
registered nurse (RN)?
ANS: A client who has a new colostomy and requires the development of a teaching plan
RATIONALE: Developing a client teaching plan is not within the scope of practice for an LPN. The
nurse should contact the nursing supervisor to inform them of the client's need for a teaching plan
regarding the new colostomy and request that this client is reassigned to an RN. The scope of
practice of an LPN does allow the nurse to reinforce teaching once the plan has been established

13. 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 one of
the following interprofessional team members?
ANS: Occupational therapist
RATIONALE: The nurse should identify the need for a referral to an occupational therapist to teach
the client how to use special eating utensils

14. A nurse is preparing to perform blood glucose monitoring for a client who has type
1diabetes Mellitus. Which of the following actions should the nurse take first?
ANS: Hold the finger for testing in a dependent position
RATIONALE: Evidence-based practice indicates that the nurse should first position the testing site
to enhance blood flow, which improves the ability to collect an adequate specimen

15. A home health nurse is reinforcing teaching with a client about the use of elastic
stockings to decrease peripheral edema. Which of the following instructions should the
nurse include?
ANS: Apply the stockings in the morning
RATIONALE: The nurse should instruct the client to apply the elastic stockings in the morning and
remove them at the end of the day before bedtime



16. A nurse in a provider's office is reviewing pediculosis capitis management and
prevention strategies with the parent of a school-age child. Which of the following
strategies should the nurse include?
(Select all that apply.)
ANS:
Store the child's clothing in a separate cubicle when at school. Boil
brushes and combs in water for 10 min.
Dry bed linens and clothing in a hot dryer for at least 20 min.
RATIONALE:

Geschreven voor

Vak

Documentinformatie

Geüpload op
1 april 2023
Aantal pagina's
83
Geschreven in
2022/2023
Type
Tentamen (uitwerkingen)
Bevat
Vragen en antwoorden

Onderwerpen

$20.99
Krijg toegang tot het volledige document:

Verkeerd document? Gratis ruilen Binnen 14 dagen na aankoop en voor het downloaden kun je een ander document kiezen. Je kunt het bedrag gewoon opnieuw besteden.
Geschreven door studenten die geslaagd zijn
Direct beschikbaar na je betaling
Online lezen of als PDF

Maak kennis met de verkoper
Seller avatar
ExceLgrades

Maak kennis met de verkoper

Seller avatar
ExceLgrades Chamberlain college
Volgen Je moet ingelogd zijn om studenten of vakken te kunnen volgen
Verkocht
3
Lid sinds
3 jaar
Aantal volgers
3
Documenten
204
Laatst verkocht
1 jaar geleden

0.0

0 beoordelingen

5
0
4
0
3
0
2
0
1
0

Recent door jou bekeken

Waarom studenten kiezen voor Stuvia

Gemaakt door medestudenten, geverifieerd door reviews

Kwaliteit die je kunt vertrouwen: geschreven door studenten die slaagden en beoordeeld door anderen die dit document gebruikten.

Niet tevreden? Kies een ander document

Geen zorgen! Je kunt voor hetzelfde geld direct een ander document kiezen dat beter past bij wat je zoekt.

Betaal zoals je wilt, start meteen met leren

Geen abonnement, geen verplichtingen. Betaal zoals je gewend bent via iDeal of creditcard en download je PDF-document meteen.

Student with book image

“Gekocht, gedownload en geslaagd. Zo makkelijk kan het dus zijn.”

Alisha Student

Bezig met je bronvermelding?

Maak nauwkeurige citaten in APA, MLA en Harvard met onze gratis bronnengenerator.

Bezig met je bronvermelding?

Veelgestelde vragen