ATI RN Comprehensive Online Practice 2024 A

A nurse is caring for a client in the emergency department (ED). 0600: Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke this morning on the living room floor trembling and flushed; remembers having intense dreams and was afraid they had a seizure so they called a family member to bring them to the ED. Client reports their average alcohol intake has been "two or three beers" after work each day and "more on the weekends" for the past 6 months. Client reports headache, nausea, agitation, and is noted to be diaphoretic. 0800: Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic. History and Physical: Alcohol use disorder Delirium tremens Nicotine use disorder Hypertension, diet and exercise controlled. Vital Signs 0 - a. Initiate seizure precautions c. Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) d. Administer chlordiazepoxide e. Maintain a low-stimulation environment f. Administer thiamine an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed. for which of the following situations should the nurse intervene? - The LPN and the AP grasp the client under their arms to lift him up in bed. This can result in shoulder dislocation or other injury to the client. 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? - Support the client's left arm on a pillow while sitting. Prevents the extremity from hanging freely because this can cause shoulder subluxation. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? - Allow for frequent rest periods throughout the day. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? - Move the client to a quiet place away from others. A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? - "I will provide you with information about medical treatment to include in your living will." A nurse is assess a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? - Stroke the infant's cheek A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? - Rapid decrease in blood pressure 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 an adverse reaction to propranolol? - Wheezing A client who is 24 hours postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? - Ask the client to rate their pain level A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? - Substernal pain A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? - Gather more information about the staff nurse's actions A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? - Notify the incident commander A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? - Apply a cold pack to the client's ankle for 30 min every hour A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? - Rapid speech A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? - Edema The nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? - Tension pneumothorax An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? - Insertion of a nasogastric tube A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? - Check the client's oxygen saturation level A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? - Hematuria A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? - Decreased lung expansion A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? - "I will wear a supportive bra overnight." A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? - Latex allergy A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? - Fiber A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? - Ask the nurse about their knowledge of the procedure A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? - "I will bend at my knees when picking an object up off the floor." A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? - The time of the client's last dose of pain medication A nurse in an outpatient mental health clinic is working with a client who has post- traumatic stress disorder (PTSD) and asks the nurse to recommend a non pharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? - Guided imagery A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum- assisted births? - Cervical laceration 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? - Check the insulin dose with another licensed nurse A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? - Mannitol A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include? - Empty the appliance when it is one-third to one-half full A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? - A client who channels their energy into a new hobby following the loss of their job A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? - "You will receive fingersticks for blood glucose testing." A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual maltreatment? - The child exhibits discomfort while walking A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? - Maintain hydration with liberal fluid intake A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? - "We can expect the hospice nurse to provide support for us after our mother's death." The nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? - aPTT A nurse is caring for a client who has a potassium level of 3 mEq/L (3.5 to 5 mEq/L). Which of the following manifestations should the nurse monitor? - Decreased deep tendon reflexes A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. - Inspection Auscultation Percussion Palpation A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? - Aspirate contents from the tube and verify the pH level A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? - Nystagmus A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take? - Ask another nurse to witness the disposal of the new patch A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical sterile technique? - Maintain sterile objects within the line of vision An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? - Places a pillow under the client's right arm A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? - Avoid venipuncture when possible A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make? - "Tell me more about your understanding of the options." 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? - 45 seconds A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? - "I should pull the top of the ear upward and back while installing the medication." A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? - An adolescent client who has food borne botulism a nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. which of the following observations should the nurse identify as an indication for potential violence? - The client is pacing around the chair in which their partner is sitting A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? - Decreased hallucinations A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? - Fever unresponsive to antipyretics A nurse administers an incorrect dose of a medication to a client. The nurse recognizes the error immediately and completes an indecent report. Which of the following facts related to the indecent should the nurse document in the client's medical record? - Time the medication was given 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 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 A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? - Tells the hospital chaplain a client's diagnosis A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication? - Dry mouth History and Physical 8-year-old male admitted with cystic fibrosis Reports shortness of breath Wheezing throughout lung fields Productive cough with thick sputum Graphic Record Heart rate 108/min Respiratory rate 26/min Temperature 37.2 C Blood pressure 100/62 mm Hg Oxygen saturation 92% Diagnostic Results Sputum culture: Burkholderia cepacia A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? - Administer high-dose antibiotic therapy A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? - Increased opacity of the lens A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take? - Withhold the heparin infusion A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? - Abdominal bloating A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? - Initiate oral rehydration therapy for the toddler A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement? - Contact A nurse is assessing an in fact who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider? - Irritability when being held A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication? - Reduce environmental stimuli A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? - Amount of vaginal bleeding A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? - "Secure the retainer clip at the level of your baby's armpits." 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." A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? - Elevate the affected leg A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? - Headaches