ATI NCLEX RN PROCTORED COMPREHENSIVE FOR FINAL EXAM WITH NGN

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take a. Ensure the state health department has been notified b. Administer antitoxin c. Educate the family to avoid sharing personal belongings d. Assess for skin necrosis - a. Ensure the state health department has been notified A nurse is caring for a client who has been admitted to the hospital. (NGN) – - Provide frequent rest periods - Restrict client sodium intake - Advise client to avoid using soap and alcohol-based lotions - Instruct the client to avoid blowing their nose forcefully - Assess the client's lv of orientation A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? a. Administered an antiemetic medication b. Evaluate functioning of the suction device c. Provide oral hygrine care d. Replace the NG tube - b. Evaluate functioning of the suction device While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion device. Which of the following actions should the nurse take first a. Initiate a requisition for a replacement CPM device b. Report the defect to the equipment maintenance staff c. Remove the device from the room d. Ensure the device inspection sticker is current - c. Remove the device from the room A nurse is setting up a sterile field to perform would irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution a. Remove the cap and place it sterile-side up on a clean surface b. Pace sterile gauze over areas of spilled c. Hold the bottle in the center of the sterile field when pouring the solution d. Hold the irrigation solution bottle with the label facing away from the palm of the hand - a. Remove the cap and place it sterile-side up on a clean surface A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan a. Wear loose-fitting underwear b. Take a bubble bath after intercourse c. Drink four 240 ml (8 oz) glasses of water each day d. Void every 5-6 hr during the day - a. Wear loose-fitting underwear A nurse is caring for a newborn. Fiil in the blank (NGN) The client at risk for developing _____ and _____ a. Hypoglycemia b. Bronchopulmonary dysplasia c. Transient tachypnea of the newborn d. Tachycardia - Tachypnea of the newborn and hypoglycemia. A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider? a. Pale and a 24-hr fluid deficit of 30 mL b. Sunken fontanels and dry mucous membranes c. Decrease appetite and irritability d. Temperature 38 C and pulse rate of 124/min - b. Sunken fontanels and dry mucous membranes A nurse is conducting health promotion education regarding contraindication to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse includes in the teaching? a. Hypertension b. Fibromyalgia c. Renal calculi d. Fibrocystic breast diseases - a. Hypertension A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? a. I can continue to take St. john wort while taking this medication b. I know it will be a couple of weeks before the medication helps me feel better c. I expect this medication to raise my blood pressure d. I should take this medication on an empty stomach - b. I know it will be a couple of weeks before the medication helps me feel better A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture a. Position a pillow under the client's knee b. Place a towel roll under the client's neck c. Align a trochanter wedge between the client's legs d. Apply an orthotic to the client's foot - c. Align a trochanter wedge between the client's legs A nurse is assessing a client who is post-op following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/h. Which of the following should the nurse anticipate? a. Initiate continuous bladder irrigation b. Administer fluid bolus c. Clamp the catheter tubing for 30 min d. Obtain a urine specimen for culture and sensitivity - d. Obtain a urine specimen for culture and sensitivity A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following should the nurse report to obtain the prescription for warfarin a. Fibrinogen lv b. aPTT c. INR d. Platelet count - c. INR A nurse is assessing a client ho is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following is the signs of pseudo parkinsonism a. Serpentine limb movement b. Shuffling gait c. Nonreactive pupils d. Smacking lips - b. Shuffling gait A nurse care for client with expressive aphasia and right hemiparesis after a stroke. What is the best way to promotes communication among staff caring for the client? a. Posting swallow precautions at the head of client's bed b. Noting changes in the treatment plan in the client's medical record c. Recording the clients progress in the nurse's note d. Have interdisciplinary team meetings for the client on a regular basis - d. Have interdisciplinary team meetings for the client on a regular basis A nurse is caring for a 2 yo toddler. Which food choice should the nurse recommended to promote independence in eating? a. Banana slices b. Grapes c. Hot dog d. Popcorn - a. Banana slices A nurse on med-surge unit got notified that a mass casualty event has occurred. Which action should the nurse take? a. Act as a liaison between the facility and media b. Recommend to the provider specific acute care clients for discharge c. Determine the medical needs of incoming clients through the emergency department d. Call in additional med-surge unit nursing care staff - c. Determine the medical needs of incoming clients through the emergency department A nurse has received report for 4 clients. Who should the nurse see first? a. A client who is scheduled for a procedure in 1 hr b. A client who received a pain med 30 min ago fir post-op pain c. A client who has just given a glass of orange juice for a low blood glucose lv d. A client who has 100 ml of fluid remain in his IV bag - c. A client who has just given a glass of orange juice for a low blood glucose lv A nurse is performing postmortem care prior to the client's family visit. Which action should the nurse take? a. Cross patient's arms across their chest b. Hold client's eyes shut for a few seconds c. Place client in a high fowler's position d. Removed the client's dentures from their mouth - b. Hold client's eyes shut for a few seconds A nurse admitting a schizophrenic client. Client state: "I'm hearing voices". Which responses is the priority for the nurse to state? a. What are the voices telling you? b. I realize the voices are real to you, but I don't hear anything c. Have you taken your med today? d. How long have you been hearing the voices? - a. What are the voices telling you? A nurse is administered furosemide IV bolus to a client who has fluid volume excess. Which finding is an indication that the med has been effective? a. Increase blood pressure b. Weight loss c. Decrease inflammation d. Decrease pain - b. Weight loss A nurse caring for client who need trach suctioning. Identify the sequence of how should the nurse sucks – 1. Turn on the suction and set the pressure 2. Don sterile gloves 3. Insert the catheter during the client inspiration 4. Apply suction while rotating the catheter 5. Rinse the catheter to remove secretions