ATI Comprehensive Practice B

24 July 2022
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question
A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective?
answer
hemoglobin 14.9 g/dL
question
a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first?
answer
a middle adult client who has unstable vital signs
question
a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse delegate to an assistive personnel?
answer
measure the client's daily weight
question
a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer?
answer
18 g
question
a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint?
answer
Moving the leg away from the midline of the body (off to the side, not to the front)
question
a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect?
answer
tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema
question
a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect?
answer
nuchal rigidity also weight loss
question
a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take?
answer
auscultate the apical pulse at least 1 min
question
a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to perform which of the following actions?
answer
instruct the client to avoid coughing during the procedure
question
a nurse is 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 abuse?
answer
the child exhibits discomfort while walking
question
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?
answer
fiber - reduce diarrhea and inflammation
question
a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following a total knee arthroplasty. which of the following actions should the nurse take?
answer
Turn off the CPM machine during mealtime promote client comfort and dietary intake
question
a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?
answer
radial vein of the inner arm
question
a nurse is developing a client education program about osteoporosis for older adult clients. the nurse should include which of the following variables as a risk factor for osteoporosis?
answer
sedentary lifestyle also, small framed body with a thin build, estrogen deficiency
question
a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk and extremities. which of the following interventions should the nurse identify as the priority?
answer
initiate transmission based precautions
question
a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the following actions should the nurse take first?
answer
change the position of the client
question
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?
answer
empty the appliance when it is one third to one half full
question
a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?
answer
sodium 148 mEq/L
question
a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive personnel?
answer
Arrange the lunch tray for a client who has a hip fracture
question
a nurse is preparing a client for a paracentesis. which of the following actions should the nurse take?
answer
instruct the client to void
question
a nurse has received change of shift report on four assigned clients. for which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
answer
a client who is receiving an MAOI and is requesting a cheeseburger for dinner
question
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?
answer
allow for frequent rest periods throughout the day
question
a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary output. which of the following actions should the nurse take?
answer
irrigate the catheter with 0.9% sodium chloride irrigation
question
a nurse is assessing a client who has COPD. which of the following findings should the nurse expect?
answer
pH 7.31
question
a nurse in a community center is providing an educational session to a group of client about ovarian cancer. which of the following manifestations of ovarian cancer should the nurse include in the teaching?
answer
abdominal bloating increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary frequency of urgency
question
a nurse is caring for a client who has active tuberculosis TB. which of the following actions should the nurse plan to take to prevent the transmission of the disease?
answer
Have the client wear a surgical mask while being transported outside the room
question
a nurse is caring for a group of clients. which of the following clients should the nurse attend to first?
answer
an older adult client who is anxious and attempting to pull out an IV line
question
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?
answer
The LPN and the AP grasp the client under his arms to lift him up in bed
question
a nurse is preparing to administer insulin to a client via a pen device. which of the following actions should the nurse take?
answer
hold the insulin pen device perpendicular to the client's skin to inject the medication
question
a nurse is caring for a client who has immunosuppression and a continuous IV infusion. which of the following actions should the nurse take?
answer
monitor the client's mouth every 8 hours
question
a nurse is providing teaching about advance directives to a middle adult client. which of the following client responses indicates an understanding of the teaching?
answer
"I can designate my partner as my health care surrogate"
question
a nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. which of the following medications should the nurse expect to administer?
answer
oxytocin
question
a nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?
answer
seeks input from the other nurses
question
a nurse is assigning task roles for a group of clients in a community mental health clinic. which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?
answer
noting the progress of the group toward assigned goals
question
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?
answer
Administer high dose antibiotic therapy cystic fibrosis kid with lung infection
question
a nurse is caring for a newborn immediately after delivery. which of the following interventions should the nurse implement to prevent heat loss by conduction?
answer
use a protective cover on the scale when weighing the infant
question
a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the nurse's priority?
answer
assist with deep breathing and coughing
question
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?
answer
a client who channels their energy into a new hobby following the loss of their job
question
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?
answer
aspirate contents from the tube and verify the pH level
question
an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions?
answer
a client who is at 33 weeks of gestation and has severe gestational hypertension
question
a nurse is providing discharge teaching to a client who is to receive home oxygen therapy. which of the following instructions should the nurse include in the teaching?
answer
wear clothing made with cotton fabrics while oxygen is in use use water soluble lubricant not petroleum based lubricant
question
a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place a new prescription for crutches. The client is non weight bearing for 6 weeks. which of the following instructions should the nurse include in the teaching?
answer
use a three point gait
question
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?
answer
The time of the client's last dose of pain medication
question
a nurse is assessing an infant 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?
answer
irritability when being held - increased intracranial pressure
question
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?
answer
decreased hallucinations
question
a nurse is providing teaching about lithium to a client who has bipolar disorder. which of the following statements should the nurse include in the teaching?
answer
"Notify your provider if you experience increased thirst"
question
a nurse is caring for a client who has a fecal impaction. which of the following actions should the nurse take when digitally evacuating the stool?
answer
insert a lubricated gloved finger and advance along the rectal wall
question
a nurse is planning to delegate client care tasks to an assistive personnel AP. which of the following tasks should the nurse plan to delegate to the AP?
answer
perform gastrostomy feedings through a client's established gastrostomy tube
question
a nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. which of the following methods should the nurse include in the teaching?
answer
delegate non nursing tasks to ancillary staff
question
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?
answer
The client is pacing around the chair in which their partner is sitting
question
a nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy. The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." which of the following responses should the nurse make?
answer
"You have the right to change your mind about this procedure at any time"
question
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?
answer
Agency for healthcare research and quality
question
a nurse is assessing a newborn following a vaginal delivery. which of the following findings should the nurse report to the provider?
answer
Nasal flaring
question
A charge nurse is speaking with the partner of a client. the partner states that the client is not receiving adequate care. which of the following actions should the charge nurse take first to resolve the situation?
answer
ask the partner to list specific concerns
question
a nurse is providing information to a client immediately before his scheduled Romberg test. which of the following statements should the nurse make?
answer
"I will be checking you once with your eyes open and once with them closed"
question
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?
answer
"I will wear a supportive bra overnight"
question
a nurse is caring for a client who is taking valproic acid for seizure control. for which of the following adverse effects should the nurse monitor and report?
answer
jaundice
question
a nurse is providing discharge instructions about newborn care to a client who is postpartum. which of the following statements indicates to the nurse that the client understands the teaching? select all
answer
"I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth then in her nose"
question
A nurse on a mental health unit is conducting a mental status examination MSE on a newly admitted client. which of the following components of the MSE is the priority for the nurse to assess?
answer
ideas of self-harm
question
a nurse is preparing to administer lactated ringers 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round to nearest whole number
answer
13
question
a nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. the nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
answer
irritability
question
a nurse is providing teaching to a client who is scheduled for electroconvulsive therapy ECT. The nurse should inform the client that which of the following findings is an adverse effect of ECT?
answer
short term memory loss
question
a charge nurse notices that one of the nurses on the shift frequently violates unit polices by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
answer
"I would like to talk to you about the unit polices regarding break time"
question
A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. which of the following findings should the nurse expect?
answer
urine specific gravity 1.052
question
a nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. which of the following laboratory values indicates that the client needs additional nutrients added to the feedings?
answer
albumin 2.8g/dL should be 3.5 to 5.0
question
A nurse is conducting group therapy with clients who have breast cancer. the nurse should recognize which of the following statements by a client as an example of altruism?
answer
"I told my doctor that I would like to start a support group for other women who are sick in my community" - reaching out and helping others
question
a nurse is providing dietary teaching to a client who has a new prescription for phenelzine. which of the following food recommendations should the nurse make? select all
answer
broccoli yogurt cream cheese
question
a nurse is assessing a client for compartment syndrome. which of the following findings should the nurse expect?
answer
edema
question
a nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?
answer
ensure that the client understands the medication regimen
question
a nurse at an urgent care clinic assessing a client who reports impaired vision in one eye. which of the following reports by the client should indicate to the nurse that the client has a detached retina?
answer
floating dark spots
question
a nurse on a medical surgical unit is assessing a client who has had a stroke. for which of the following findings should the nurse initiate a referral for occupational therapy?
answer
difficulty performing ADL's
question
a nurse is assessing a client following a colonoscopy. which of the following findings should indicate to the nurse that the client is hemorrhaging?
answer
rapid decrease in blood pressure
question
a nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end stage kidney disease. the donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day" which of the following responses should the nurse make?
answer
"You're afraid that your other kidney will fail at some point after the organ donation"
question
a nurse is assessing a client who has pulmonary edema. which of the following findings should the nurse expect?
answer
pink frothy sputum
question
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 client's medical record?
answer
time the medication was given
question
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?
answer
check the client's oxygen saturation level
question
a nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. the nurse suspects physical abuse. which of the following actions should the nurse take?
answer
contact child protective services
question
a nurse is caring for a 2 month old infant who has Hirschsprung disease HD. Which of the following areas should the nurse assess for manifestations of HD?
answer
C, the abdomen for distention and visible peristalsis
question
a nurse is admitting a client to the psychiatric unit after attempting suicide. the client states "My family does not care whether I live or die", which of the following responses should the nurse make?
answer
"how does this make you feel"
question
a nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. which of the following instructions should the nurse include in the teaching? select all
answer
"shake the medication bottle well before each dose is given" "store the medication in the refrigerator" "report diarrhea to the provider immediately"
question
a nurse on a medical surgical unit is caring for a client who has a new diagnosis of terminal cancer. the client tells the nurse that they would like to go home to be with family and loved ones. which of the following actions should the nurse take?
answer
make a referral for social services
question
a nurse is assessing a client who has a chest tube. which of the following findings should the nurse expect?
answer
occlusive dressing drainage should be less than 70 ml/hr continuous bubbling in the water seal chamber indicates an air leak
question
a nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. the clients family tells the nurse they are concerned about the level of care the client will receive. which of the following actions should the nurse take?
answer
facilitate an interdisciplinary conference at the new facility for the family
question
a nurse is assessing a client who has major depressive disorder and is taking amitriptyline. which of the following findings should the nurse identify as an adverse effect of the medication?
answer
blurred vision
question
a charge nurse is providing an educational session about infection control for a group of staff nurses. which of the following statements by one of the staff nurses indicates an understandings of isolation precautions?
answer
"A client who requires airborne precautions should be placed in a negative pressure airflow room"
question
a nurse is preparing to administer a blood transfusion to a client. which of the following procedures should the nurse follow to ensure proper client identification?
answer
verify the client and blood product information with another licensed nurse
question
a nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. the client shows the nurse multiple superficial self inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders.
answer
borderline - emotionally unstable, troubled interpersonal relationships, often engage ion harmful behaviors
question
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?
answer
apply a cold pack to the clients ankle for 30 min every hour - type 1 diabetes is a contraindication for cold therapy
question
a nurse is teaching about adverse effects with a client who is starting to take captopril. which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?
answer
cough - due to build up of bradykinin in the lungs
question
a nurse is reviewing the ABG values of a client. The client has a pH of 7.2, psco2 of 60 mm Hg, nd HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid base imbalances?
answer
respiratory acidosis
question
a nurse in a providers office is assessing an adolescent who has been taking ibuprofen for 6 months to treatjuvenile idiopathic arthritis. which of the following questions should the nurse ask to assess for adverse effect of this medication?
answer
"Have you had any stomach pain or bloody stools?
question
a nurse on a pediatric unit has received change of shift report for four children. which of the following children should the nurse assess first?
answer
a 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
question
a nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. which of the following actions should the nurse take?
answer
implement fall precautions for the client - orthostatic hypotension and dizziness
question
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?
answer
increased opacity of the lens
question
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 birth?
answer
cervical laceration
question
a nurse is updating the plan of care for a client who is 48 hr post operative following a laryngectomy and is unable to speak. which of the following actions should the nurse plan to take first?
answer
determine the clients reading skills
question
a nurse is caring for a school age child who has dehydration and is receiving an oral rehydration solution. which of the following laboratory results indicates that the treatment regimen is effective
answer
serum sodium 138 mEq/L
question
a school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. upon arrival at the playground, which of the following actions should the nurse take first?
answer
survey the scene for potential hazards to staff and children
question
a nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. the nurse is unable to locate members of the clients family to obtain consent. which of the following actions should the nurse take?
answer
proceed with provision of medical care
question
a nurse is caring for a school age child who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests?
answer
serum liver enzyme levels
question
a nurse manager is preparing to teach a group of newly licensed nurses about effective time management. which of the following steps of the time management process should the nurse manager include as the priority?
answer
making a list of activities to complete
question
a nurse is caring for a client who has pulmonary embolism. the client is receiving heparin via continuous IVinfusion at 1,200 units/hr and warfarin 5 mg PO daily. the morning laboratory values for the client are aPTT 98 seconds and INR 1.8. which of the following actions should the nurse take?
answer
withhold the heparin infusion
question
a nurse is providing teaching to a school age child who has asthma about using albuterol metered dose inhaler. which of the following instructions should the nurse include?
answer
take the medication 15 min before playing sports
question
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?
answer
"my child has only a small amount of mucus after percussion therapy"
question
a nurse is planning care for a client who is receiving chemotherapy and has neutropenia. which of the following interventions should the nurse include in the plan?
answer
avoid including raw fruits in the clients diet
question
a nurse is caring for a client who is in the fourth stage of labor and is reviewing oxytocin via continuous IV infusion. which of the following assessments is the nurse's priority?
answer
amount of vaginal bleeding
question
a nurse is caring for a client who is in the resuscitation phase of burn injury. which of the following findings should the nurse expect?
answer
hyponatremia hyperkalemia
question
a nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. which of the following information should the nurse include in the teaching?
answer
"I will need to measure your weight daily"
question
a nurse is assessing a client who has bipolar disorder. which of the following alterations in speech is the client using?
answer
flight of ideas - changing topics suddenly
question
a home health nurse is caring for a group of older adult clients. the nurse should initiate a referral to the program of all inclusive care for the elderly PACE for which of the following clients?
answer
a client whose caregiver requests adult day care services PACE provides adult day care services along with in home assessments and supportive services
question
a nurse at a mental health clinic is caring for four clients. the nurse should recognize that which of the following clients is using dissociation as a defense mechanism?
answer
a client who was abused as a child describes the abuse as if it happened to someone else
question
a nurse is caring for a client who has active pulmonary tuberculosis. which of the following actions should the nurse take?
answer
assign the client to a private room with negative air pressure
question
a nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3 hour oral glucose tolerance test. which of the following instructions should the nurse include in the teaching?
answer
you will need to fast the night before the test a blood sample is collected every hour
question
a nurse is providing education to the parent of a school age child who has asthma. which of the following statements by the parent indicates an understanding of the teaching?
answer
"I will make sure my child receives a yearly influenza vaccination"
question
a 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?
answer
aPTT - for those on heparin it should be 60-80 seconds
question
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?
answer
wheezing
question
a client is receiving IV fluids at 150 mL/hr. which of the following findings indicates that the client is experiencing fluid overload?
answer
dyspnea
question
a nurse is assessing a client whose partner recently died. the client states, "I don't know what to do without my partner. life is just not worth living" which of the following responses should the nurse make?
answer
"You seem to be having a difficult time right now"
question
a nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. which of the following clients should the nurse recommend for discharge?
answer
a client who has cellulitis and is receiving oral antibiotics every 8 hours
question
a nurse is performing an admission assessment on a client who had a recent positive pregnancy test. the first day of her last menstrual period LMP was May 8. according to Nagele's rules, which of the following dates should the nurse document as the clients estimated date of birth EDB?
answer
February 15th (add 7 days to LMP and then subtract 3 months)
question
a nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. which of the following instructions should the nurse include?
answer
use a reward system to modify the childs behavior
question
a nurse in a providers office is caring for an 18 month old toddler who has a blood lead level of 3 mcg/dL. which of the following actions should the nurse take?
answer
recommend rescreening in 1 year - it is within the expected reference range
question
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?
answer
"Tell me more about your understanding of the options"
question
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?
answer
dry mouth
question
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?
answer
support the client's left arm on a pillow while sitting
question
a nurse is caring for a client who has acute blood loss following a trauma. the client refuses a blood transfusion that might potentially save their life. which of the following actions should the nurse take first?
answer
explore the client's reasons for refusing treatment
question
a nurse is performing an abdominal assessment on a client. identify the sequence of actions the nurse should take. (in order)
answer
Inspection auscultation percussion palpation
question
a nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome SIDS. Which of the following guardian statements indicates an understanding of the teaching
answer
"I will not allow anyone to smoke near my baby"
question
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 aseptic technique?
answer
maintain sterile objects within the line of vision
question
a nurse is caring for a client who has a magnesium level of 2.7 mEq/L. which of the following interventions should the nurse plan to take?
answer
initiate continuous cardiac monitoring - mag level is high
question
a nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. which of the following findings indicates the client's use of ginger tea is effective?
answer
the client reports a decrease in episodes of nausea
question
a nurse is caring for a client who has deep vein thrombosis. which of the following actions should the nurse take?
answer
instruct the client to elevate the affected extremity when sitting
question
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?
answer
ask another nurse to witness the disposal of the new patch
question
a nurse is assessing an older adult client who has pneumonia. which of the following findings should the nurse expect?
answer
acute confusion - along with fatigue, lethargy, and anorexia
question
a nurse is providing teaching about the basal body temperature method of birth control. which of the following information should the nurse include in the teaching?
answer
"your body temperature might decrease slightly just prior to ovulation" - decrease in body temperature of 1 degree commonly occurs immediately prior to ovulation
question
a nurse manager in a long term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. which of the following actions should the nurse manager take first?
answer
form a committee of staff members to investigate current staffing issues
question
a nurse is preparing to administer an IM injection to a client who is obese. which of the following actions should the nurse plan to take?
answer
use the ventrolateral site - it has a thick area of muscle and contains no large nerves or blood vessels
question
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?
answer
"We can expect the hospice nurse to provide support for us after our mother's death"
question
a nurse is assessing a client after administering epinephrine for an anaphylactic reaction. which of the following findings should the nurse identify as an adverse effect of this medication?
answer
report of chest pain
question
a nurse is caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. the nurse should monitor the client for which of the following adverse effects of PEEP?
answer
tension pneumothorax
question
a nurse manager is reviewing client's rights with the nurses on the unit. the nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
answer
autonomy
question
a nurse preceptor is evaluating the performance of a newly licensed nurse. which of the following actions by the newly licensed nurse requires intervention by the preceptor?
answer
starts a task then determines what supplies are needed
question
a nurse manager is preparing an educational session about advocacy to a group of nurses. the nurse manager should indicate which of the following information in the teaching?
answer
advocacy is a leadership role that helps others to self actualize
question
a nurse is admitting a client who has pneumonia. the nurse should initiate which of the following isolation precautions for the client?
answer
droplet
question
a nurse has just received change of shift report on four clients. which of the following clients should the nurse assess first?
answer
a client who is postoperative with abdominal distention and no bowel sounds
question
during a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. which of the following actions should the day shift nurse take?
answer
move the client to a room near the nurses station
question
a nurse is reviewing the laboratory results of a toddler who has hemophilia A. which of the following aPTT values should the nurse expect?
answer
45 seconds
question
a nurse is planning care for a client who has rheumatoid arthritis. which of the following interventions should the nurse include in the plan?
answer
increase the client's dietary iron intake - promotes tissue repair
question
a nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. which of the following manifestations should the nurse expect?
answer
strict adherence to routines
question
a nurse is caring for a client who had a stroke 6 hr ago. which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure? ICP
answer
place the client in a quiet environment