Virtual ATI predictor Green Light Exam | Questions and Answers

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions - ANS D. Contractions A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1 hr if unable to fall asleep B. Take a 1 hr nap during the day C. Perform exercises prior to bedtime D. Eat a light snack before bedtime - ANS D. Eat a light snack before bedtime A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular tachycardia. Which of the following actions should the nurse take first after determining the client does not have a palpable pulse? A. Assess heart sounds B. Defibrillate C. Establish IV access D. Administer epinephrine - ANS B. Defibrillate A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data? A. Have the client's child translate B. Allow the client's partner to translate C. Request a female interpreter through the facility D. Ask a nursing student who speaks the same language as the client to translate - ANS C. Request a female interpreter through the facility A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling? a. Flushing b. Tachycardia c. Restlessness d. Shivering - ANS d. Shivering A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Exhibit) A. Position the client with the affected extremity lower than the heart B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin C. Administer acetaminophen D. Massage the affected extremity every 4 hr - ANS B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietitian? A. An older adult client who has a BMI of 24 B. A client who has a nonhealing leg ulcer C. An older adult client who has presbyopia D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4) - ANS B. A client who has a nonhealing leg ulcer 8. A nurse is providing discharge teaching to a client who has a chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Eat 1 g/kg of protein per day b. Take magnesium hydroxide for indigestion c. Drink at least 3 L of fluid daily- Consume foods high in potassium- restrict - ANS a. Eat 1 g/kg of protein per day A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? A. Sitting in a high-Fowler's position during the feeding B. A history of gastroesophageal reflux disease C. Receiving a high osmolarity formula D. A residual of 65 mL 1 hr postprandial? - ANS B. A history of gastroesophageal reflux disease ?A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client that she will undergo which of the following screening tests at 16 weeks of gestation? A. Chorionic villus sampling- as early as 8 weeks B. Cervical cultures for chlamydia- 1st appointment. C. Nonstress test -28 weeks D. Maternal serum alpha-fetoprotein- 16 to 18 weeks - ANS D. Maternal serum alpha-fetoprotein- 16 to 18 weeks A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? A. Decreased serum calcium levels- increased serum calcium B. Increased blood pressure- hypotension C. Swollen area on calf D. Urinary frequency- - ANS C. Swollen area on calf 12. A nurse in acute care mental health facility is participating in a medication-education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? A .The leader encourages group members to remain silent until questions are called for B. The leader lecture about medication adverse effects to the group members c. The leader allows the group to discuss whatever they would like to regarding their medications d. The leader has group members vote on what they would like to learn about during the session - ANS d. The leader has group members vote on what they would like to learn about during the session A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A "You can add the medication to a half-cup of your child's favorite juice." B "Repeat the dose if your child vomits within 1 hour after taking medication." X C "Limit your child's potassium intake while she is taking this medication." D "Have your child drink a small glass of water after swallowing the medication." - ANS D "Have your child drink a small glass of water after swallowing the medication." A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid? A. Grapefruit B. Spinach C. Cottage cheese- cream cheese ok. D. Smoked salmon - ANS D. Smoked salmon A nurse is planning care for a client who has COPD and weighs 99 lb. The provider has prescribed a diet of a 1.5 g protein/kg/day. How many grams of protein per day should the nurse include in the client's dietary plan? (Round to the nearest whole number - ANS a. 68 A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client's TV privileges if he does not attend group therapy X C. Encourage the client to take frequent rest periods D. Place the client in seclusion when he exhibits signs of anxiety X - ANS C. Encourage the client to take frequent rest periods A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session? a Encourage clients to establish a timeline for their own grieving process b. Initiate a discussion with clients about ways to cope with changes in family dynamics c Discourage clients from sharing negative aspects of their relationship with the deceased persons d Assist clients in identifying ways suicide could have been prevented - ANS b. Initiate a discussion with clients about ways to cope with changes in family A nurse manager observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following actions should the nurse manager take first? a Instruct the nurses to close the client's computer record b Request the nurses present an in-service on client confidentiality c. Advise the nurses to read the facility's confidentiality policyd. d. Place documentation of the nurses' actions in the personnel file - ANS a Instruct the nurses to close the client's computer record A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. Heart rate 58/min b. Fasting blood glucose 100 mg/dL c. Hgb 14 g/dL d. WBC count 2,900/mm3- also agranulocytosis same thing or soar throat. - ANS d. WBC count 2,900/mm3- also agranulocytosis same thing or soar throat. A nurse is caring for several clients on a medical-surgical unit. For which of the following nurses activities is it required that the nurse use sterile gloves? a. Inserting an NG tube b. Administering total parenteral nutrition through a central venous access device c. Initiating IV access d. Performing tracheostomy care - ANS d. Performing tracheostomy care A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse give? a. Influenza b. Measles, mumps and rubella c. Human papilloma virus d. Varicella - ANS a. Influenza A nurse is inserting an indwelling catheter for a male client. Which of the following actions should the nurse take? a. Perform the cleansing procedure with a fresh swab two times b. Lift the penis so that it is perpendicular to the client's body c. Cleanse the tip of the penis in a side-to-side motion d. Pick up the catheter 13 cm (5 cm) from its tip - ANS b. Lift the penis so that it is perpendicular to the client's body A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? a Bleeding gums- low platelet b Faintness upon rising c Swelling of the face d Urinary frequency - ANS c. Swelling of the face A nurse has received change-of-shift report for a group of clients. Which of the following actions should the nurse take to manage time effectively? a. Document client care at the end of the shift b. Make the client to-do list for the day c. Skip breaks until the client tasks are completed d. Focus on several client tasks at a time - ANS b. Make the client to-do list for the day A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Minimize noise in the newborn's environment b. Administer naloxone to the newborn c. Swaddle the newborn with his legs extended d. Maintain eye contact with the newborn during feedings - ANS a. Minimize noise in the newborn's environment A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? A. The anterior fontanel is open b. The posterior fontanel is open c. Both fontanels are the same size d. Both fontanels show molding - ANS A. The anterior fontanel is open A nurse is caring for client who has acute diverticulitis. Which of the following diets should the nurse recommend to the client? Diverticulosis- High fiber a. High residue b. Lactose-free c. Gluten-free d. Low-fiber - ANS d. Low-fiber A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse include in the plan of care? A. Administer low-dose heparin B. Place the client on a full liquid diet C. Use an incentive spirometer every 3 hr D. Maintain the client on bed rest - ANS A. Administer low-dose heparin A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching? A. Burp the infant frequently during feedings B. Position the nipple at the front of the infant's mouth C. Hold the infant in a supine position D. Use feeding devices without nipples - ANS A. Burp the infant frequently during feedings A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? A. A client who depressive disorder and requires assistance with ADLs B. A client who has obsessive-compulsive disorder and is upset about a change in a daily routine C. A client who is taking clozapine to treat schizophrenia and reports sore throat D. A client who has narcissistic personally disorder and is mocking other during group therapy - ANS C. A client who is taking clozapine to treat schizophrenia and reports sore throat 31. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? A. Develop an hourly time frame for tasks B . Schedule daily activities C. Determine goals of the day D. Delegate tasks to the AP - ANS C. Determine goals of the day A nurse is performing an admission assessment for a client who is in the manic phase of bipolar disorder. Which of the following behaviors should the nurse expect? A. Performance of ritualistic behaviors- ocd B. Suspiciousness and distrust- schizo C. Distractibility and poor judgment D. Reports of physical discomfort -anxiety - ANS C. Distractibility and poor judgment A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? A Weak femoral pulses?- they get upper extremity yper, lower extremity hypo B Frequent nosebleeds- yes C Upper extremity hypotension D Increased intracranial pressure - ANS A Weak femoral pulses?- they get upper extremity yper, lower extremity hypo A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. "The client might act seductively"- histrionic B. "The client is overly concerned about minor details"- ocd C. "The client exhibits impulsive behavior" D. "The client is exceptionally clingy to others"- dependent - ANS C. "The client exhibits impulsive behavior A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? TIDLING IN WATER SEAL AND CONTINUOUS IN SUCTION CHAMBER OKAY! WATER SEAL BUBBLING IS AIR LEAK. A. There is a loop of tubing below the drainage system B. The system is working properly C. The lung has re-expanded D. The tubing is partially obstructed by clots - ANS B. The system is working properly A nurse in an emergency department is caring for a client who is experiencing stimulant withdrawal. Which of the following findings should the nurse expect? A. Runny nose B. Decreased appetite -Increased appetite C. Muscle spasms D. Fatigue, agitated anxiety, increased appetite - ANS D. Fatigue, agitated anxiety, increased appetite A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? A. A history of being in prison B. Experiencing delusions C. Male gender D. Previous violent behavior - ANS D. Previous violent behavior A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? A. Instruct the client to lift her chin when swallowing X B. Talk to the client during feeding X C. Discourage the client from coughing during feedings D. Sit at or below the client's eye level during feedings - ANS D. Sit at or below the client's eye level during feedings 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 expect this medication to raise my blood pressure" B. "I should take this medication on an empty stomach" C. "I can continue to take St. John's wort while taking this medication" d "I know it will be a couple of weeks before the medication helps me feel better" - ANS D. "I know it will be a couple of weeks before the medication helps me feel better" A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care? A. Ambulate the client before each meal B. Offer the client three large meals each day X C. Administer a bronchodilator after meals D. Limit fluid intake with meals YES drinking before and after can bloat you - ANS D. Limit fluid intake with meals YES drinking before and after can bloat you A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Exhibit) A. Encourage the client to verbalize feelings * B. Assess for hopelessness C. Implement seizure precautions for the client D. Administer ondansetron to the client for nausea Obtain the client's weight - ANS A. Encourage the client to verbalize feelings * A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? A. A client who lives with family members and begins to take more responsibility of self-care B. A client who reports being given sedative medications by family members C. A client who is taking warfarin and has several small bruises on her shins and hands D. A client who schedules multiple visits with his provider every month - ANS B. A client who reports being given sedative medications by family members A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care? ALTEPLASE TREATS STROKES, HEART ATTACKS AND CLOTS. A. Administer medications intramuscularly X- it is IV B. Provide a diet low in protein X- why C. Observe for bruising of the skin- check for bleeding D. Monitor vital signs every hour for the first 4 hr- X every 15 min for the first hour - ANS C. Observe for bruising of the skin- check for bleeding A nurse is caring for a client who is postoperative following an appendectomy and is receiving gentamicin. Which of the following assessment findings should the nurse identify as an adverse effect of this medication? A. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity B. Respiratory rate 22/min C. 2+ pitting edema of the ankles D. Hgb 8.7 g/dL - ANS A. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity A nurse in an acute care facility is caring for a client who is homeless and has a decubitus ulcer. Which of the following actions should the nurse take as a client advocate? A. Gather dressing supplies for the client's discharge B. Provide client teaching about nutrition C. Consult with the facility's quality improvement team D. Contact the facility's case management department? - ANS D. Contact the facility's case management department? A nurse is caring for client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? A. Discard the open can of formula after 36 hr- B. Administer feedings at a slower rate---can give d10W. C. Flush the tube with 10 mL of water after feedings D. Provide chilled formula- room temperature - ANS B. Administer feedings at a slower rate---can give d10W. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? A. Withhold the medication if the client does not appear to be in pain B. Withhold the medication if the client has a fever C. Document administration of the medication upon removal from the medication dispensing system d. Count the current number of unit doses available in the medication dispensing system - ANS d. Count the current number of unit doses available in the medication dispensing system A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. Herpes zoster b. Hypertension c. Obesity d. Hypothyroidism - ANS a. Herpes zoster A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Temperature 37.6 C (99.7 F) B. Urinary output 20 mL/hr C. Blood pressure 100/70 mm Hg D. Serious drainage on abdominal dressing - ANS B. Urinary output 20 mL/hr A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury? A. Place the bedside table at the foot of the bed B. Keep the television on during the night C. Assist the client to the toilet frequently D. Raise the side rails up when the client is in bed - ANS C. Assist the client to the toilet frequently A certified IV nurse is providing education about peripherally inserted central catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Use a vein in the middle of the lower arm to insert a PICC"- above elbow, below shoulder B. "Flush a PICC using a 3-mililiter syringe"- 10 mL C. "Informed consent is required prior to a PICC placement" D. "Position the client's arm in adduction for PICC placement" - ANS C. "Informed consent is required prior to a PICC placement" A nurse is teaching self-administration of insulin glargine to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this insulin before meals" B. "I will not mix this insulin with other types of insulin" C. "I will rotate the injection sites between my arm and my thigh" (abdomen) D. "I will shake the vial to mix the insulin" (you must roll) - ANS B. "I will not mix this insulin with other types of insulin" A nurse is caring for a client who is immunocompromised. Which of the following antiseptic solutions should the nurse use to perform hand hygiene? A. Isopropyl alcohol B. Bleach C. Chlorhexidine D. Povidone-iodine - ANS C. Chlorhexidine A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? (exhibit) a. Place the client on a cooling blanket B. Obtain arterial blood gas levels C. Elevate the head of the client's bed to 30 D. Administer an analgesic - ANS B. Obtain arterial blood gas levels A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? A. "This test should be performed after your baby is 24 hours old" B. "A nurse will draw blood from your baby's inner elbow" C. "Your baby will be given 2 ounces of water to drink prior to the test" D. "This test will be repeated when your baby is 2 months old" - ANS A. "This test should be performed after your baby is 24 hours old" A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted" B. "I can clean my cat's litter box during my pregnancy" C. "I should take antibiotics when I have a virus" D. "I should wash my hands for 10 seconds with hot water after working in the garden" - ANS A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted" A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? A. Primary glaucoma B. Amputation C. Hypertension D. Osteoarthritis - ANS C. Hypertension A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? A. Replace the carpet with hardwood floors B. Place locks at the tops of exterior doors C. Wear clothing with zippers instead of buttons? D. Encourage physical activity prior to bedtime - ANS B. Place locks at the tops of exterior doors A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personal (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of of the following torts? a. Malpractice b. Negligence c. Assaultd. Battery - ANS c. ASSAULT A nurse is reviewing a client's laboratory results prior to surgery. Which of the following findings should the nurse report to the provider? A. Bicarbonate 26 mEq/L--- 22-28 norm calcium 8-10 b. Chloride 100 mEq/L -- norm is 96-106 c. Potassium 3.8 mEq/L norm 3.5-5 d. Sodium 160 mEq/L - norm is 135-145 - ANS d. Sodium 160 mEq/L - norm is 135-145 A charge nurse is evaluating a newly licensed nurse's understanding of advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of advance directives? A. "I'll refer clients who do not have advance directives for legal assistance" B. "I have to witness a client's signature on his advance directives" C. "I have to document whether or not a client has prepared his advance directives" "D. I'll encourage clients to follow their provider's wishes for end-of-life care" - ANS C. "I have to document whether or not a client has prepared his advance directives" A clinic nurse is assessing an 8-year-old child during an annual physical examination. Which of the following findings indicates the need for intervention by the nurse? A. The client eats at least one snack daily B. The client's height has increased by 6.35 cm (2.5 in) 2 inches/year C. The client's weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs D. The client drinks 3 cups of 1% milk per day - ANS C. The client's weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? A. Presence of a bloody show B. Intermittent, painless contractions C. Slow change in dilation and effacement D. Contraction intensity increased by ambulation - ANS B. Intermittent, painless contractions A nurse is caring for a client who has a urinary tract infection and has been taking cefaclor. Which of the following serum laboratory results indicates the medication is effective? A. Creatinine 2.3 mg/dL B. BUN 32 mg/dL C. Eosinophils 3.9% D. WBC 9,200 mm3 - ANS D. WBC 9,200 mm3 A charge nurse is mentoring a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates the need for intervention by the charge nurse? A. Uses an IV infusion pump to administer total parenteral nutrition to a client B. Inserts an NG tube for a client using clean technique C. Crushes an SL tablet to administer into a client's feeding tube D. Stabilizes a client's indwelling urinary catheter with the nondominated hand prior to inflation of the balloon - ANS C. Crushes an SL tablet to administer into a client's feeding tube A nurse is reviewing laboratory results for a client who has a heart failure and notes a serum potassium level of 5.2 mEq/L. Which of the following medications should the nurse withhold? a. Furosemide b. Spironolactone c. Atorvastatin d. Metoprolol - ANS b. Spironolactone A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching? A. "Biofeedback stimulates certain pressure points to relax muscles" B. "Biofeedback improves energy flow through soft tissue manipulation to increase circulation" C. "Biofeedback requires concentration to control physiological responses" D. "Biofeedback uses herbs to reduce inflammation" - ANS C. "Biofeedback requires concentration to control physiological responses" A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching? A. "Give the child acetaminophen for pain following the procedure" B. "Ensure the child's hair is clean and without conditioner before the procedure" C. "Keep the child out of the sun for 4 hr following the procedure" D. "Make the child NPO before the procedure" - ANS B. "Ensure the child's hair is clean and without conditioner before the procedure" A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. "This type of seizure can be mistaken for daydreaming" B. "This type of seizure lasts 30 to 60 seconds" C. "The child usually has an aura prior to onset" D. "This type of seizure has a gradual onset" - ANS A. "This type of seizure can be mistaken for daydreaming" A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? A. "I will limit my alcohol use to one drink daily while taking disulfiram" X not within 12 hours B. "I will take my lithium on an empty stomach" X with food C. "I will take the sustained-release methylphenidate every morning" D. "I will avoid foods containing tyramine while taking fluoxetine" ssri X - ANS C. "I will take the sustained-release methylphenidate every morning" 72. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (Select all that apply) A. Foul perineal odor B. Lochia serosa C. Postpartum... if blues, then correct D. Fundus displaced to the right E. Fundus 4 cm (1.6 cm) below the umbilicus decends 1cm per day - ANS b, e, c? A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications a. Vitamin K b. Ranitidine c. Metoclopramide d. Vitamin B12- lifelong - ANS d. Vitamin B12- lifelong A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a Hold hand flat to perform percussions on the child- cup shape b Perform the procedure twice a day c Administer a bronchodilator after the procedure d Perform the procedure prior to meals * best time - ANS d Perform the procedure prior to meals * best time A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take? A. Contact the adolescent's parent for assistance B. Advise the adolescent to place the newborn for adoption C. Assist the adolescent in applying for Medicaid D. Refer the adolescent to a local mental health clinic - ANS C. Assist the adolescent in applying for Medicaid A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? A. Contact the family regarding the client's condition B. Notify risk management C. Privately interview the client about her condition D. Inform the transferring agency of the client's condition - ANS C. Privately interview the client about her condition A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a cerebrovascular accident. Which of the following actions by the nurse best promotes communications among staff caring for the client? A. Noting changes in the treatment plan in the client's medical record B. Recording the client's progress in the nurses' notes C. Posting swallowing precautions at the head of the client's bed D. Having interdisciplinary team meetings for the client on a regular basis - ANS D. Having interdisciplinary team meetings for the client on a regular basis 78. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? A. Empty the collected urine once every 24 hr B. Hang the drainage bag on a bed rail c. Provide perineal hygiene after defecation d. Change the indwelling catheter every 8 hr - ANS c. Provide perineal hygiene after defecation A nurse is assisting a client who has acute glomerulonephritis to choose menu items for breakfast. Which of the following food choices should the nurse recommend? a. Eggs- protein b. Banana- proteinX c. Smoked salmon- protein X d .Bagel - ANS d .Bagel A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Helping clients understand health screenings covered by their insurance plans b. Using an electronic messaging system to remind clients when to take medications c. Educating clients about contraindications to specific immunizations d. Providing clients with information about the benefits of exercise - ANS b. Using an electronic messaging system to remind clients when to take medications A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiating a referral to which of the following members of the interprofessional care team? A. Occupational therapist B. Respiratory therapist C. Social worker D. Speech-language pathologist - ANS D. Speech-language pathologist A nurse is performing a preoperative assessment for a client who reports having an allergy to several goods. Which of the following food allergies indicates a risk factor for a latex allergy? a. Peanuts b. Eggs c. Bananas d. Shrimp - ANS c. Bananas A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan care? A. Measure the arm circumference above the insertion site daily B. Schedule an MRI post procedure to verify placement (Xray) X C. Administer sedation for the procedure X - local anesthetic D. Use gauze to secure an arm board to involved extremity- used for midline - ANS A. Measure the arm circumference above the insertion site daily A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? PRIMARY FASTEST TYPE ON ITS OWN, SECONDARY REQUIRES GRANULATION TISSUES AND CREATES SCAR TISSUES, AND TETRIARY IS DELAYED WOUND CLOSURE. A. Approximated surgical incision B. Infected laceration- TERTIARY C. Stage II pressure ulcer -SECONDARY D. Partial-thickness burn- SECONDARY - ANS A. Approximated surgical incision A nurse is performing a change-of-shift assessment. Which of the following clients has the priority finding? A. A client who has a first-degree heart block and a heart rate of 62/min B. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor C. A client who has pneumonia with a productive cough and a fever of 38.8 C (101.8 F) D. A client who has type 2 diabetes mellitus and a blood glucose of 250 mg/dL - ANS B. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor A nurse on a medical-surgical unit delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP? a. Interpreting blood glucose values b. Performing postmortem care c. Explaining the steps for a 24-hr urine collection d. Assisting with low-carbohydrate diet selections - ANS b. Performing postmortem care A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make? A. "We can provide a copy of your records, but the therapist's notes aren't included" B. "I don't think you will benefit from reviewing your therapist's notes right now" C. "Why are you interested in seeing your therapist's notes?" D. "Are you not happy with your treatment?" - ANS A. "We can provide a copy of your records, but the therapist's notes aren't included" A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching? A. "I will wipe my nose instead of blowing it" B. "I will remove my shoes when I'm inside my house" C. "I will floss between my teeth every time I brush" D. "I will use an enema to manage my constipation" - ANS A. "I will wipe my nose instead of blowing it" A home care nurse is making follow-up visit with a client has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take? A. Store the oxygen tank wrench in a locked cabinet B. Have the client store smaller tanks under his bed C. Ensure that the client checks the gauge weekly D. Place the oxygen tank away from curtains or drapes - ANS D. Place the oxygen tank away from curtains or drapes A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? A. Renal calculi B. Fibrocystic breast disease? C. Fibromyalgia D. Hypertension - ANS D. Hypertension A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client? A. Hypokalemia B. Muscular depression C. Laryngeal stridor D. Hyperglycemia - ANS C. Laryngeal stridor A nurse is teaching a client who is to start a new prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? A. "Take with the protein snack" - limit protein B. "Report dark-colored urine"- this normal C. "Monitor for hyperglycemia" D. "Change positions slowly" ? - ANS D. "Change positions slowly" ? A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority? a. Constipation b. Sedation c. Euphoria d. Bradypnea - ANS d. Bradypnea A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about managing the disease. The nurse should emphasize the importance of which of the following factors to prevent a sickle cell crisis? A. Adequate hydration B. Calorie restriction C. Increased iron intake D. A low-protein diet - ANS A. Adequate hydration A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks? A. Accepting the decision of an older adult client to live alone in her home B. Ensuring that a client who is homeless receives preventive medical care- be fair C. Keeping a promise to visit with a client who is housebound after the delivery of care D. Being honest with the parents of a child about the need to report suspected abuse - ANS B. Ensuring that a client who is homeless receives preventive medical care- be fair 96. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? A. Changes in appetite B. Prescribed medications C. Swallowing ability D. Daily fluid intake - ANS C. Swallowing ability A nurse is caring for a client who has a new prescription for piperacillin/tazobactum 3.75 g intermittent IV bolus Q6H to infuse over 30 min. Available is piperacillin/tazobactum 3.75 g in 50 mL 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? a. 100 - ANS A nurse is assessing a client who has acute angle-closure glaucoma. Which of the following findings should the nurse expect? A. Increased light perception B. Reddened cornea C. Severe periocular pain D. Gray cast sclera - ANS C. Severe periocular pain A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client's laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? And A Dietitian B Infection control nurse C Nephrologist D. Cardiologist - ANS C Nephrologist A nurse is caring for a toddler who has retinoblastoma. Which of the following ngs should the nurse expect? AHyphema bOpacity of the lens c Nystagmus dWhite eye reflex - ANS dWhite eye reflex 101.a client who does not speak the same language as the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? a. Use gestures to convey meaning b. Speak directly to the client c. Pause in the middle of sentences d. Speak slowly when talking to the interpreter - ANS b. Speak directly to the client 102. A nurse is providing teaching about exercise to a client who is at 28 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching? a. "I can continue to do exercises that require the supine position" X b. "I should check my pulse rate once every hour while exercising" c. "I should increase my exercise level to prepare for labor" X d. "I should drink 16 to 24 ounces of water after I exercise" - ANS d. "I should drink 16 to 24 ounces of water after I exercise" A nurse is providing discharge teaching to the parents of toddler who has cystic fibrosis. What should nurse include? a."Use a nebulizer to administer a bronchodilator following airway clearance therapy" b."Restrict intake of foods that contain gluten" c.Perform chest percussion and postural drainage at least twice daily" d." "Administer pancreatic enzymes on an empty stomach"- X with meal - ANS c.Perform chest percussion and postural drainage at least twice daily" Plan of care for client who has preeclapsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Monitor the FHR via Doppler every 30 min b. Restrict the client's total fluid intake to 250 mL/hr c. Give the client protamine if signs of magnesium sulfate toxicity occur d Measure the client's urine output every hour - ANS d Measure the client's urine output every hour A nurse is planning discharge teaching for a client who is to start a new .prescription for metoprolol. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Tinnitus b. Polyuria c. Hyperglycemia d.Bradycardia - ANS d.Bradycardia A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the following instructions should the nurse include in the teaching? a. "Remove yellow exudate around the penis" b. "Wrap sterile gauze around the penis if bleeding occurs" c. "Use soap to cleanse the site" d, "Apply petroleum jelly to the glans with diaper changes" - ANS d, "Apply petroleum jelly to the glans with diaper changes" Care plan for bucks traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel? a. Remind the client to use the incentive spirometer b. Ask the client to describe her pain c. Observe the position of the suspended weight d. Check the client's pedal pulse on the right leg - ANS a. Remind the client to use the incentive spirometer A nurse is assessing the growth and development of a 3-year-old child. Which of the following questions should the nurse ask the parent to determine if the child exhibiting typical developmental expectations? a. "Can your child catch and throw a small ball?" b. "Can your child ride a tricycle?" c."Can your child name give colors?" d. "Can your child draw a stick figure?" - ANS b. "Can your child ride a tricycle?" A nurse is caring for a newborn whose mother was taking methadone during her ancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Bradycardia b. Acrocyanosis c. Hypertonicity d. Bulging fontanels - ANS c. Hypertonicity A charge nurse is admitting four clients to an acute care unit. Which of the following clients should the nurse place near the nurses' station? A. A client who is on fluid restriction B. A client who is in Buck's traction C A client who has orthostatic hypotension D A client who has an open wound - ANS C A client who has orthostatic hypotension A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test? a. Serum potassium b. 12-lead ECG c. PT and INR d. Chest x-ray - ANS b. 12-lead ECG A charge nurse on a medical- surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who has COPD and a respiratory rate of 44/min b. A client who has cancer with a sealed implant for radiation therapy c. A client who is receiving heparin for deep-vein thrombosis d. A client who is 1 day postoperative following a vertebroplasty - ANS d. A client who is 1 day postoperative following a vertebroplasty 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. Assess for skin necrosis b. Educate the family to avoid sharing personal belongings c. Ensure the state health department has been notified d. Administer antitoxin - ANS c. Ensure the state health department has been notified A nurse is reviewing annual educational requirements for fire safety. Identify the sequence the nurse should use when operating a fire estinguisher. a. Point the hose at the base of the fire b. Sweep the extinguisher from side to side c. Squeeze the handles together d. Unlock the handle by pulling on the pin - ANS D,A,C,B A nurse is caring for a client who has a nasogastric tube. Which of the following actions should the nurse take to verify placement prior to each feeding. a. Auscultate air insertion into the tube b. Test the bilirubin level of gastric contents c. Palpate the abdomen for tube placement d.Test the pH of gastric contents - ANS d.Test the pH of gastric contents A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks gestation. Which of the following actions should the nurse take? a. performan leopold maneuvers prior to auscultating the fetal heart rate b. position the ultrasound stethoscope above the symphysis pubis to assess fetal heart rate c. measure the fundal height to determine the placement of the ultrasound stethescope d. place the client in a side lying position prior to assessing the fetal heart rate - ANS b. position the ultrasound stethoscope above the symphysis pubis to assess fetal heart rate While performing a routine assessment, a nurse notices fraying on the electrical cord of a client CPM device. Which of the following actions should the nurse take first. a. ensure the device inspection sticker is current b. report the defect to the equipment maintenance staff e the device from the room d. initiate a requisition for a replacement CPM device - ANS c. remove the device from the room A nurse is caring for a newly admitted client who has bacterial meningitis. Which following actions should the nurse take? a. Implement seizure precautions b. Monitor the client for hypoglycemia c.Perform range-of-motion exercises once per shift d. Place the client in high-Fowler's position - ANS a. Implement seizure precautions 19. A nurse is providing teaching to a client about the adverse effects sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth - ANS A. Excessive sweating A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? a. Contractions lasting 80 seconds- too long? b. Depending on frequency* c. FHR baseline 170/min normal 110-160 maybe this! * Early decelerations in the FHR d. Temperature 37.4 C (99.3 F) - ANS c. FHR baseline 170/min normal 110-160 maybe this! * Early decelerations in the FHR A nurse is preparing a client to undergo cardiac cauterization. Which of the following tasks should the nurse perform prior to the procedure? a. Draw blood specimens for culture and sensitivity b. Administer nitroglycerin 0.4 mg SL 30 min before the procedure c. Transport the client to radiology for a CT scan d. Obtain a CBC with differential? - ANS d. Obtain a CBC with differential? A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the followings actions should the nurse include in the plan? a. Ask the client directly what he is hearing b. Encourage the client to lie down in a quiet room c. Avoid eye contact with the client d. Refer to the hallucinations as if they are real - ANS a. Ask the client directly what he is hearing A nurse is reviewing the preadmission laboratory test results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? a. Sodium 142 b. Potassium 3.3 c. Blood Glucose 80 mg/dl d: pt 11.5 seconds - ANS b. Potassium 3.3 A nurse is in the emergency department is caring for client who has a new diagnosis of acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin. Which of the following findings should indicate to the nurse that the client is experiencing a satisfactory response to these interventions? a. The client's stool is guaiac positive b. S3 heart sounds are present c. The client's aPPT is two times the control d. Q wave is noted on the cardiac monitor tracing - ANS c. The client's aPPT is two times the control 125. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse? a. "I understand the voices are frightening you, but I do not hear any voices" b. "Do you recognize the voices as belonging to anyone you know?" c. "You shouldn't be afraid when you think the voices are telling you to hurt yourself" d. "That can't be true. The only voices in this room are yours and mine" - ANS a. "I understand the voices are frightening you, but I do not hear any voices" A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanation should the nurse provide? A. "Respite care includes volunteers who will perform household tasks" B."Respite care provides clinicians to work with you in caring for your husband" C. "Respite care offers financial resources to help care for your husband" D. "Respite care allows for time away from caring for your husband" - ANS D. "Respite care allows for time away from caring for your husband" A nurse working in the postpartum unit is reviewing a client's new prescription for methylergonovine. The nurse should recognize that which of the world following is a contraindication for this medication? a. hypertension b. confusion c. chlamydia d. polyuria - ANS a. hypertension A nurse is caring for a client who is in labor and has received an epidural. Which following actions should the nurse take? a. Decrease the maintenance infusion rate of IV fluid X more hypotension b. Have protamine sulfate available at the bedside- X Heparin c. Reposition the client side-to-side each hour d. Monitor the client hypertension X hypotension - ANS c. Reposition the client side-to-side each hour