Nursing Care for Various Health Conditions | Exams Nursing | Docsity (2024)

Download Nursing Care for Various Health Conditions and more Exams Nursing in PDF only on Docsity! ATI comprehensive practice B, ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2024 A, RN 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? - Correct answer -hemoglobin 14.9 g/dL a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first? - Correct answer -a middle adult client who has unstable vital signs 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? - Correct answer -measure the client's daily weight 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? - Correct answer -18 g 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? - Correct answer -Moving the leg away from the midline of the body (off to the side, not to the front) a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect? - Correct answer -tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect? - Correct answer -nuchal rigidity also weight loss a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? - Correct answer -auscultate the apical pulse at least 1 min 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? - Correct answer -instruct the client to avoid coughing during the procedure 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? - Correct answer -the child exhibits discomfort while walking 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? - Correct answer -irrigate the catheter with 0.9% sodium chloride irrigation a nurse is assessing a client who has COPD. which of the following findings should the nurse expect? - Correct answer -pH 7.31 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? - Correct answer - abdominal bloating increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary frequency of urgency 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? - Correct answer -Have the client wear a surgical mask while being transported outside the room a nurse is caring for a group of clients. which of the following clients should the nurse attend to first? - Correct answer -an older adult client who is anxious and attempting to pull out an IV line 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? - Correct answer -The LPN and the AP grasp the client under his arms to lift him up in bed a nurse is preparing to administer insulin to a client via a pen device. which of the following actions should the nurse take? - Correct answer -hold the insulin pen device perpendicular to the client's skin to inject the medication a nurse is caring for a client who has immunosuppression and a continuous IV infusion. which of the following actions should the nurse take? - Correct answer -monitor the client's mouth every 8 hours 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? - Correct answer -"I can designate my partner as my health care surrogate" a nurse is assessing a client following a vagin*l delivery and notes heavy lochia and a boggy fundus. which of the following medications should the nurse expect to administer? - Correct answer -oxytocin 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? - Correct answer -seeks input from the other nurses 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? - Correct answer -noting the progress of the group toward assigned goals 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? - Correct answer - Administer high dose antibiotic therapy cystic fibrosis kid with lung infection 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? - Correct answer -use a protective cover on the scale when weighing the infant a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the nurse's priority? - Correct answer -assist with deep breathing and coughing 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? - Correct answer -a client who channels their energy into a new hobby following the loss of their job 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? - Correct answer -aspirate contents from the tube and verify the pH level an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions? - Correct answer -a client who is at 33 weeks of gestation and has severe gestational hypertension 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? - Correct answer -Agency for healthcare research and quality a nurse is assessing a newborn following a vagin*l delivery. which of the following findings should the nurse report to the provider? - Correct answer - Nasal flaring 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? - Correct answer -ask the partner to list specific concerns a nurse is providing information to a client immediately before his scheduled Romberg test. which of the following statements should the nurse make? - Correct answer -"I will be checking you once with your eyes open and once with them closed" 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? - Correct answer -"I will wear a supportive bra overnight" 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? - Correct answer -jaundice 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 - Correct 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" 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? - Correct answer -ideas of self-harm 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 - Correct answer -13 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? - Correct answer - irritability 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? - Correct answer -short term memory loss 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? - Correct answer -"I would like to talk to you about the unit polices regarding break time" 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? - Correct answer -urine specific gravity 1.052 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? - Correct answer -albumin 2.8g/dL should be 3.5 to 5.0 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? - Correct 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 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 - Correct answer -broccoli yogurt cream cheese a nurse is assessing a client for compartment syndrome. which of the following findings should the nurse expect? - Correct answer -edema 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? - Correct answer -ensure that the client understands the medication regimen a nurse is assessing a client who has a chest tube. which of the following findings should the nurse expect? - Correct answer -occlusive dressing drainage should be less than 70 ml/hr continuous bubbling in the water seal chamber indicates an air leak 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? - Correct answer -facilitate an interdisciplinary conference at the new facility for the family 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? - Correct answer -blurred vision 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? - Correct answer - "A client who requires airborne precautions should be placed in a negative pressure airflow room" 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? - Correct answer -verify the client and blood product information with another licensed nurse 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. - Correct answer -borderline - emotionally unstable, troubled interpersonal relationships, often engage ion harmful behaviors 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? - Correct answer - apply a cold pack to the clients ankle for 30 min every hour - type 1 diabetes is a contraindication for cold therapy 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? - Correct answer - cough - due to build up of bradykinin in the lungs 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? - Correct answer - respiratory acidosis 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? - Correct answer -"Have you had any stomach pain or bloody stools? 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? - Correct answer -a 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain 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? - Correct answer -implement fall precautions for the client - orthostatic hypotension and dizziness 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? - Correct answer -increased opacity of the lens 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? - Correct answer -cervical laceration 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? - Correct answer -determine the clients reading skills 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 - Correct answer -serum sodium 138 mEq/L 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? - Correct answer -a client whose caregiver requests adult day care services PACE provides adult day care services along with in home assessments and supportive services 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? - Correct answer -a client who was abused as a child describes the abuse as if it happened to someone else a nurse is caring for a client who has active pulmonary tuberculosis. which of the following actions should the nurse take? - Correct answer -assign the client to a private room with negative air pressure 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? - Correct answer -you will need to fast the night before the test a blood sample is collected every hour 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? - Correct answer -"I will make sure my child receives a yearly influenza vaccination" 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? - Correct answer -aPTT - for those on heparin it should be 60-80 seconds 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? - Correct answer -wheezing a client is receiving IV fluids at 150 mL/hr. which of the following findings indicates that the client is experiencing fluid overload? - Correct answer - dyspnea 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? - Correct answer -"You seem to be having a difficult time right now" 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? - Correct answer -a client who has cellulitis and is receiving oral antibiotics every 8 hours 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? - Correct answer - February 15th (add 7 days to LMP and then subtract 3 months) 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? - Correct answer -use a reward system to modify the childs behavior 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? - Correct answer -recommend rescreening in 1 year - it is within the expected reference range 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? - Correct answer -"Tell me more about your understanding of the options" 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? - Correct answer -dry mouth 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? - Correct answer -support the client's left arm on a pillow while sitting 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? - Correct answer -explore the client's reasons for refusing treatment "We can expect the hospice nurse to provide support for us after our mother's death" 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? - Correct answer -report of chest pain 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? - Correct answer -tension pneumothorax 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? - Correct answer -autonomy 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? - Correct answer -starts a task then determines what supplies are needed 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? - Correct answer -advocacy is a leadership role that helps others to self actualize a nurse is admitting a client who has pneumonia. the nurse should initiate which of the following isolation precautions for the client? - Correct answer - droplet a nurse has just received change of shift report on four clients. which of the following clients should the nurse assess first? - Correct answer -a client who is postoperative with abdominal distention and no bowel sounds 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? - Correct answer -move the client to a room near the nurses station a nurse is reviewing the laboratory results of a toddler who has hemophilia A. which of the following aPTT values should the nurse expect? - Correct answer - 45 seconds a nurse is planning care for a client who has rheumatoid arthritis. which of the following interventions should the nurse include in the plan? - Correct answer - increase the client's dietary iron intake - promotes tissue repair 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? - Correct answer -strict adherence to routines 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 - Correct answer -place the client in a quiet environment 1 - Correct answer -1 PEPE TE SEES STEEP ESTE SEEPS SEEPS STEEL ESSE SEES SS SEE ESS SSEE ESS SSEE ESS SLEE ESS SSSE ESS SSSE ESS SLEE ESR1 - Correct answer -1 UPPST SEEPS SESE SSE SPSS S ESET SEEPS SSE PSSST SEES S SEES S SESS SESE SSS S SESS S SESS SESE ST