ATI_Comp_B_2020

ATI_Comp_B_2020 (Complete) Terms in this set (150) A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After opening the packet with the new pouch, the patient refuses ...

ATI_Comp_B_2020 (Complete) Terms in this set (150) A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After opening the packet with the new pouch, the patient refuses to accept it. Which action should the nurse take? A) Withhold pain medications for 24 hr after the old patch is removed. B) Ask another nurse to witness the disposal of the new patch. C) Seal the patches in a plastic bag and place in the client's trash basket. D) Stick the two patches to each other and place them in the sharps bin. B) Ask another nurse to witness the disposal of the new patch. A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action should the nurse take? C) Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced or the infusion A) Prepare to administer vitamin K1. B) Prepare to administer alteplase. C) Withhold the heparin infusion. D) Withhold the next dose of warfarin. withheld until the aPTT returns to the therapeutic range. A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report from the patient should indicate to the nurse that the client has a detached retina? A) Halos around lights B) Floating dark spots C) Pain in the affected eye D) Cloudy vision B) Floating dark spots A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of a VP shunt. Which finding should the nurse report to the provider? A) Heart rate 122/min B) Irritability when being held C) Hypoactive bowel sounds B) Irritability when being held D) Urine specific gravity 1.018 A nurse is assessing a newborn's HR. Which action should the nurse take? A) Assess the apical pulse while the newborn is crying to detect cardiac problems. B) Palpate the radial pulse and determine the rate based on number of beats per minute. C) Listen to the apical pulse while palpating the radial pulse to detect variance. D) Auscultate the apical pulse and count beats for at least 1 min. D) Auscultate the apical pulse and count beats for at least 1 min. A nurse is caring for a client with a fecal impaction. Which action should the nurse take when digitally evacuating the stool? A) Place the client in the lithotomy position. B) Elicit a vagal response by performing gentle rectal stimulation. C) Administer oral bisacodyl 30 min prior to D) Insert a lubricated gloved finger and advance along the rectal wall. the procedure. D) Insert a lubricated gloved finger and advance along the rectal wall. A nurse is providing dietary teaching to a patient taking phenelzine. Which food recommendations should the nurse make? (Select all) A) Broccoli B) Yogurt C) Pepperoni pizza D) Cream cheese E) Bologna sandwich A) Broccoli B) Yogurt D) Cream cheese A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error immediately and completes an incident report. Which fact related to the incident should the nurse document in the client's medical record? A) Completion of the incident report B) Time the medication was given C) Reason for the medication error B) Time the medication was given D) Notification of the pharmacist A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess first? A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. A community health nurse is providing teaching about home safety with a group of D) "Have grab bars installed around your bathtub and toilet." elderly clients. Which statement should the nurse make? A) "Unplug your appliances by grasping the cord and pulling it straight from the outlet." B) "Set your water heater temperature at 130 degrees Fahrenheit." C) "Use throw rugs in high-traffic areas to partially cover wood floors." D) "Have grab bars installed around your bathtub and toilet." A nurse in the ED is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the nurse take? A) Discuss his suspicion of physical abuse with the provider. B) Confront the parents with his suspicion of physical abuse. C) Ask the hospital security to detain and question the parents. D) Contact child protective services. D) Contact child protective services. A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses a blood transfusion that could save his life. Which action should the nurse take first? A) Document the client's refusal in the medical record. B) Honor the client's decision to refuse the blood transfusion. C) Explore the client's reasons for refusing the treatment. D) Discuss the client's refusal with the provider. C) Explore the client's reasons for refusing the treatment. A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which statement by the client indicates an understanding of the teaching? A) "I will decrease my intake of high-fiber foods." B) "I will apply an anti- D) "I will wear a supportive bra overnight." inflammatory ointment if I develop a rash on my face." C) "I will sleep flat on my back if I develop back pain." D) "I will wear a supportive bra overnight." A nurse is providing discharge education to a patient who is to receive home oxygen therapy. Which instruction should the nurse include in the teaching? A) Check the functioning of oxygen equipment once each week. B) Wear clothing made with cotton fabrics while oxygen is in use. C) Apply petroleum- based lubricant to the nares as needed. D) Store full oxygen tanks on their side. B) Wear clothing made with cotton fabrics while oxygen is in use. The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes, because products containing oils are flammable when near oxygen. A nurse manager is preparing an education session about advocacy to a group of nurses. The nurse manager should include what information in the teaching? A) Advocacy is a leadership role that helps others to self-actualize. A) Advocacy is a leadership role that helps others to self- actualize. B) Subordinates are an advocate for the nurse manager. C) Advocacy is to encourage client dependence in decision making. D) Nurse managers should distrust people who speak out about harmful or inappropriate professional practices. A nurse is caring for a patient receiving continuous bladder irrigation following a transurethral resection of the prostate. The patient reports bladder spasms and the nurse observes a decreased urinary output. Which action should the nurse take? A) Increase tension on the urinary catheter. B) Irrigate the catheter with 0.9% sodium chloride irrigation. C) Assist the client to ambulate. D) Remove the urinary catheter immediately. B) Irrigate the catheter with 0.9% sodium chloride irrigation. Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear. A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? A) Collect a blood sample for laboratory tests. B) Administer medication for pain. C) Apply warm packs to affected areas. D) Infuse IV fluids. D) Infuse IV fluids. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to infuse IV fluids to promote hydration and circulation. Increased fluid reduces the tissue and organ ischemia caused by the clumping of the RBCs. A nurse is providing patient education about the basal body temperature method of birth control. What information should the nurse include in the teaching? A) "Your body temperature will drop approximately 1 degree 1 week after ovulation." B) "You should take your body temperature each evening prior to going to sleep." C) "Your body temperature might decrease slightly just C) "Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a drop in body temperature of approximately 0.25° C (0.5° F) commonly occurs immediately prior to ovulation. prior to ovulation." D) "Your body temperature is at its highest during menstruation." A nurse in the ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which action should the nurse take? A) Contact the facility's ethics committee. B) Obtain consent from the client's employer. C) Limit care to comfort measures. D) Proceed with provision of medical care. D) Proceed with provision of medical care. A nurse is caring for a client who has fluid volume overload. Which task should the nurse delegate to the AP? A) Palpate the degree of edema. B) Regulate IV pump fluid rate. C) Measure the client's C) Measure the client's daily weight. daily weight. D) Assess the client's vital signs. A nurse is assessing a patient with hypocalcemia. Which site should the nurse tap to elicit a positive Chvostek's sign? A) between the eyebrows B) under the eye C) cheek D) chin C) cheek A nurse is reviewing the urinalysis report of a client with acute glomerulonephritis. Which finding should the nurse expect in the client's urine? A) Uric acid crystals B) Protein C) WBCs D) Nitrates B) Protein Increased glomerular permeability allows protein to filter into the urine. Therefore, this is an expected finding in a client who has glomerulonephritis. A nurse is creating a plan for care of a newly admitted child. Which action should the nurse include in the plan? (Click exhibit) A) Initiate droplet D) Administer high dose antibiotic therapy. The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of isolation precautions. B) Keep the child on NPO status for 12 hr. C) Maintain the child on bed rest for 24 hr. D) Administer high dose antibiotic therapy. antibiotics to help fight aggressive infections such as Burkholderia cepacia. A nurse is caring for a client with cancer and is deciding between 2 treatment options. The client asks the nurse for assistance with the decision. Which response should the nurse make? A) "It's been difficult for everyone who has ever had to make this decision." B) "Tell me more about