ATI RN Comprehensive Practice A 2023 Final Exam updated

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for high-frequency chest compression vest in response to which of the following parent statements? "My child doesn't like to sit still for nebulizer treatments." "I think that my child has been running a fever over the last couple of days." "My child has only a small amount of mucus after percussion therapy." "I am concerned about my child's future participation in team sports." - ANSWERS"My child has only a small amount of mucus after percussion therapy." A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? Obtain capillary blood glucose level every 2 hr. Check the neurovascular status of the client's lower extremities every hour. Apply a cold pack to the client's ankle for 30 min every hour. Maintain the affected ankle elevated and immobilized. - ANSWERSApply a cold pack to the client's ankle for 30 min every hour. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? Slightly blue hands and feet Respiratory rate 40/min Axillary temperature 36.2C (97.2F) Apical pulse 136/min - ANSWERSAxillary temperature 36.2C (97.2F) A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Drag 1 condition and 1 client finding to fill in the blank in the following sentence. The client is at risk for developing ____ due to ____. - ANSWERSThe client is at risk for developing HEMORRHAGIC STROKE due to AUTONOMIC DYSREFLEXIA. A nurse is caring for a school-age child. For each assessment finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process. - ANSWERSADHD- Hyperreactivity to sensory input, Interrupting others, Losing necessary things, Intellectual impairment ID- Impaired language skills, Intellectual impairment A nurse is caring for a newly admitted client. Select 2 findings that require immediate follow-up. - ANSWERSHemoglobin Platelet count A nurse is caring for a newborn. Complete the following sentence by using the list of options. The nurse should plan to first assess the newborn's ______followed by the newborn's_______. - ANSWERSThe nurse should plan to first assess the newborn's RESPIRATORY RATE followed by the newborn's HEART RATE. A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in the blank in the following sentence. The client is at risk for developing ____ as evidenced by _____. - ANSWERSThe client is at risk for developing SEIZURES as evidenced by BLOOD PRESSURE. A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Complete the diagram. - ANSWERSPotential condition: Varicose veins Actions to take: Elevate the extremity Apply graduated compression stockings Parameters to monitor: Edema of right lower extremity Pruritis of right lower extremity A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated. - ANSWERSAnticipated: Initiate suicide precautions Potassium 40 mEq PO daily Contraindicated: Low-sodium diet Fluoxetine 20 mg PO daily A nurse is caring for a client in the emergency department (ED). The nurse is planning care for the client. Select the 5 actions the nurse should plan to take. - ANSWERS-Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) -Initiate seizure precautions -Administer chlordiazepoxide -Administer thiamine -Maintain a low-stimulation environment A nurse is caring for a client in the inpatient psychiatric unit. Based on the assessment findings, which of the following actions should the nurse take? Select all that apply. - ANSWERS-Ensure the client does not have access to sharp objects -Observe the client swallow all prescribed medications -Assess the client's method of lethality -Provide one-on-one observation A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, peritonitis. Each finding may support more than one disease process. - ANSWERSBowel pattern: Crohns disease Weight: Crohns disease, Ulcerative colitis Heart rate: Peritonitis WBC: Crohns disease, Ulcerative colitis, Peritonitis Temperature: Crohns disease, Ulcerative colitis, Peritonitis Abdominal pain location: Crohns disease Albumin level: Crohns disease, Ulcerative colitis A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? Keep the client resting in bed. Ask the client to restate directions. Clear objects from the clients walking area. Evaluate the clients ability to swallow. - ANSWERSClear objects from the clients walking area. A client is caring for a client with bulimia nervosa. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing _____ and ______. - ANSWERSThe client is at risk for developing HYPONATREMIA and CARDIOVASCULAR ABNORMALITIES. A nurse is caring for a client who is receiving a transfusion of packed red blood cells (RBCs). The nurse should suspect a transfusion reaction based on which of the following assessment findings? Select all that apply. - ANSWERS-Back pain -Anxiety -Headache A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? Agency for Healthcare Research and Quality National Institutes of Health Department of Agriculture World Health Organization - ANSWERSAgency for Healthcare Research and Quality A nurse is caring for a client. Complete the diagram by dragging from the choices. - ANSWERSPotential Condition: Somatic symptom disorder Actions to take: Monitor the clients physical manifestations Assess the client for a secondary gain from illness Parameters to monitor: Vital signs Pain A nurse is assessing a client who is scheduled for surgery. Click to highlight the assessment findings that the nurse should notify the provider about prior to the procedure. - ANSWERS-Hemoglobin levels -Allergies -Family history A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the clients ability to be compliant? A detailed plan of care Absence of symptoms Dietary salt restriction Addition of new medication - ANSWERSAbsence of symptoms A nurse in a providers office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Complete the following sentence by using the lists of options. The client is at risk for developing _____ due to ______. - ANSWERSThe client is at risk for developing DELAYED WOUND HEALING due to GLUCOSE LEVEL. A nurse is providing discharge teaching a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? "I can resume my daily aspirin therapy" "I will contact my provider if my eye feels itchy" "I will bend at the knees when picking up an object up off the floor" "Its okay for me to pick up my grandchild, who weighs 20 pounds" - ANSWERS"I will bend at the knees when picking up an object up off the floor" A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure Floating dark spots Decreased central vision Double vision - ANSWERSDecreased central vision A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if cardiac arrest occurs. Which of the following statements should the nurse make? "You will need to draft a health care surrogate so a designee can make this decision for you" "I will make sure no one performs any lifesaving measures if your heart stops" "Your provider determines if you should have lifesaving measures if your heart stops" "I will provide you with information about medical treatment to include in your living will" - ANSWERS"I will provide you with information about medical treatment to include in your living will" A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Massage bony prominences on the clients left side Support the clients left arm on a pillow while sitting Position the bedside table on the clients left side Place the clients cane on their left side while ambulating - ANSWERSSupport the clients left arm on a pillow while sitting A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Teach the client reportable adverse effects from the medication Check the insulin dose with another licensed nurse Administer the insulin at a 90 degree angle Clean the insertion site - ANSWERSCheck the insulin dose with another licensed nurse A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT (30 to 40 seconds) values should the nurse expect? 11 seconds 22 seconds 30 seconds 45 seconds - ANSWERS45 seconds A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? "There's a protocol for reviewing your medical record, and I can initiate the process" "The medical record has a lot of medical terminology, and it might be difficult for you to understand" "You should really talk to your provider if you have any questions about your treatment" "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see" - ANSWERS"There's a protocol for reviewing your medical record, and I can initiate the process" A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses actions Advises the nurses that they are being insubordinate Tell the nurses to stop the discussion Document the incident in the clients medical record - ANSWERSTell the nurses to stop the discussion A nurse is caring for four clients. Which of the following tasks should the nurse delegate to the assistive personnel (AP)? Arrange the lunch tray for a client who as a hip fracture Measure the vital signs of a client who has just returned from the PACU Evaluate dietary intake for a client who has anorexia Assess I&O for a client who is receiving dialysis - ANSWERSArrange the lunch tray for a client who as a hip fracture A nurse is assessing for correct placement of a clients NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? Insert air in the tube and listen for gurgling sounds in the epigastric area Aspirate contents from the tube and verify the pH level Review the medical records for previous x-ray verification of placement Auscultate the lungs for adventitious breath sounds - ANSWERSAspirate contents from the tube and verify the pH level A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first? Observe the client and the situation Respect the clients personal space Give the client several clear options Select a quiet location to talk to the client while remaining visible to staff members - ANSWERSObserve the client and the situation A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing as adverse reaction to propranolol? Weight loss Wheezing Blood pressure 146/92 mm Hg Heart rate 110/min - ANSWERSWheezing A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the physiological changes is the cause for the clients visual loss? An increase in the intraocular pressure Deterioration of the macula Increased opacity of the lens Vitreous hemorrhage - ANSWERSIncreased opacity of the lens A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the clients medical record? Completion of incident report Time the medication was given Reason for the medical error Notification of the pharmacist - ANSWERSTime the medication was given