ATI PN EXIT EXAM 2021

ATI PN EXIT EXAM 2021 • A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? o The client wants to talk a ...

ATI PN EXIT EXAM 2021 • A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? o The client wants to talk about the diagnosis with nursing staff o The client has a decreased energy level o The client makes funeral arrangements o The client requests a second opinion • A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply) o Allows the nurse to touch him on the arm o Plays with toys in the examining room o c. Answers questions asked by the nurse o d. Makes eye contact with the nurse • Sits on his parent’s lap when the nurse enters the room • A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first? o A client who has bipolar disorder and is displaying flights of ideas o A client who has ADHD and has an inability to concentrate o A client who has schizophrenia and is having command hallucinations o A client who has depressive disorder and is withdrawn • A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, “ I can’t seem to do anything right. What should I do?” Which of the following responses should the nurse make? o “I’ll take him back to the nursery, so you can get some rest.” o “Babies need to cry soon after they are born to develop their lungs.” o “Let me show you how to swaddle and cuddle him, then you try.” o “If I turn him on his side, maybe he’ll go back to sleep.” • A nurse is using a glucometer to measure a client’s capillary blood glucose level, Which of the following actions should the nurse take? o Test the first drop of blood that forms after the puncture o Wear sterile gloves o Keep the finger in a dependent position o Select the central tip of the finger • A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel? o Docusate sodium o Ranitidine o Vitamin D3 o Naproxen • A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client’s foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first? o Administer opioid pain medication o Apply an ice pack to the affected extremity o Check for pain with passive movement of the affected extremity o Elevate the affected extremity with several pillows • A nurse in a provider’s office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? o Decreased hemoglobin o Somnolence o Bradycardia o Decreased blood pressure • A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the st • aff can medicate a client against his will, without a court hearing, in which of the following situations? o A client who has a serious mental illness o A client who is having difficulty making decisions about his treatment o A client for whom the benefits of the medication outweigh the risks o A client who is attempting to hurt himself or others • A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? o “Monitor for muscle weakness while taking the medication.” o “Rotate injection sites when administering the medication.” o “Withhold the medication if your pulse rate is above 100 beats per minute.” o “Increase your intake of dietary fiber to increase absorption.” • A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client’s medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? o A nurse from another unit after a client commits suicide o A social worker who is assigned to an involuntary committed school-age client o A client’s partner after the client reports intimate partner abuse o A client’s employer who is concerned about safety due to substance use • A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider? o Hgb 13.2 g/dL o Urine protein 3 plus o Fasting blood glucose 72 mg/dL o BUN 15 mg/dL • A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse’s priority, requiring immediate intervention? o Pain rating of 9 on a scale from 0 to 10 o Blood pressure 160/90 mm Hg o Oxygen saturation 89% o Abdominal dressing with a moderate amount of bright red drainage • A nurse in a provider’s office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately? o A 2 kg (4.4 lb) weight gain o Blurred vision o Potassium 3.6 mEq/L o Resumption of cigarette smoking • A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first? o Place the client on bed rest o Obtain the clients ABG levels o Prepare the client for a ventilation-perfusion scan o Elevate the head of the client’s bed • A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management? o Urine ketones o Glucose tolerance test o Glycosylated hemoglobin o Fasting blood glucose • A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene? o Requests a client to assist with distributing lunch trays o Tells a client he will lose his phone privileges if he does not take his medication o Encourages a client to participate in a recreational therapy group o Places mechanical restraints on a client who is hitting another staff member • A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client’s room? o Oral suction equipment o Wrist restraints o Tongue depressor o Tracheostomy tray • A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching? o Maintain a verbal no-harm contract with the client o Assume responsibility for making the client’s decisions o Encourage the client to be assertive o Limit the client’s social interactions • A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate? o “You should avoid crossing your legs for 3 months.” o “You should avoid putting a pillow between your legs when in bed.” o “You should avoid exercising for the next 6 weeks.” o “You should avoid lying on your right side.” • • A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching? o Drink 240 mL ( 8 oz) of water with each meal o Eat a small meal every 2 to 3 hr o Avoid eating dairy products o Choose foods that are high in fat • A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching? o “I have to remain upright for 1 hour after taking the medication.” o “I should take this medication in the morning and at night.” o “I should expect my tongue to turn black after I take this medication.” o “I have to take this medication on an empty stomach.” • A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include? o Airborne o Droplet o Protective o Contact • A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? o “Self administer oxygen through your nasal cannula at 6 milliliters per minute during meals.” o “Perform pulmonary hygiene 1 hour before meals.” o “Drink at least 240 milliliters of water during each meal.” o “Lie down for 30 minutes after eating.” • A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? o Decreased sodium excretion o Improved absorption of vitamins B and C o Improved respiratory function o Reduced fat in the stools • A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? o “Why do you feel the staff is the FBI?” o “What makes you think the staff is following you?” o “The psychiatric staff is not FBI. They are here to help you.” o “This must be very frightening for you. Let’s talk more about it.” • A nurse is assisting in the care of a client who has a fractured femur and is in Buck’s traction, which of the following actions should the nurse take? o Clean the pin insertion sites on a daily basis o Ensure that the weights are hanging freely o Apply a 9 kg (20 lb) weight to the traction o Remove the weights while the client is eating • A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings? o Calcium level 8.0 mg/dL o Peripheral vascular disease o Taking anticoagulant medication o IV access on the same extremity • A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma? Lady with eyes closed with nodule on eyelid • A nurse is assisting with the admission of a client who has Vancomycin- resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client? o Contact precautions o Droplet precautions o Airborne precautions o Protective precautions • A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take? o Use a 12 point font size o Present information from complex to simple o Explain medical terminology using basic, one-syllable words o Write the information at an 8th-grade reading level • A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse’s priority? o “I’m angry with my girlfriend about an argument we had last night.” o “I have anxiety when I’m in a large group.” o “I’m not sleeping much because of all the homework I have.” o “I would rather be alone than with my friends.” • A nurse is placing a dressing over a stage 1 pressure ulcer on a client’s heel, which of the following types of wound dressing should the nurse use? o Gauze packing o Calcium alginate o Transparent film o Adhesive strips • A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client’s current blood pressure is 114/55 mm Hg. Which of the following actions should the nurse take? o Request a prescription for a different pain medication for the client o Administer the medication to the client o Place the client on strict bedrest o Repeat the client's blood pressure measurement • A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plans? (Select all that apply) o Set a specific time frame for meeting performance goals b. Ask the nurse supervisor to review the plan • Base performance goals on peer comments • Request clients complete an evaluation about the AP’s quality of care • Include the performance standard that the AP should meet o nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? Cleanse the neck by rubbing with a washcloth Limit fluid intake to 750 mL per day Eat three large meals each day Avoid exposing the neck to the cold • A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement? o Create a schedule with an assistive personnel to do hourly rounding for the client o Apply rubber-soled slippers before ambulation o Move the bedside table with the client’s personal items close to the bed o Determine the client's ability to use the call light • A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? o “You cannot drink fluids for 4 hours after the procedure.” o “You will need to urinate before the procedure.” o “You will have a leg bag to collect the urine.” o “You will feel pressure when I inflate the catheter balloon.” • A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take? o Meet with the client’s family to discuss treatment options o Perform a mental status examination to establish the client’s competency o Ask the client if he has any financial concerns o Talk with the nurse about the need to support the client’s decision • A nurse is reinforcing teaching about breastfeeding with a client who gave birth 2 days ago. Which of the following information should the nurse include? o Allow the newborn to nurse for no more than 10 min on each breast o Store expressed breast milk in the refrigerator for up to 72 hr o Feed the newborn 8 to 12 times every 24 hr o Supplement feedings with 30 mL (1 oz) of water four times per day • A nurse is assisting with the admission of a school-aged child. Which of the following actions should the nurse plan to take? (Exhibit) o Initiate contact precautions for the child o Place the child on bed rest for 24 to 48 hr o Restrict the child's intake of foods containing vitamin k o Keep the child on NPO status for 8 hr • A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? o Keep the client’s daily protein intake below 0.8 g/kg o Position the client supine with his legs elevated o Measure the client’s abdominal girth daily o Restrict the clients sodium intake to 3 g per day • A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurence of diarrhea? o Apple juice o Ice cream o Coffee o Yogurt • • A nurse is assisting with the care of a client who has increased intracranial pressure following a closed head injury. Which of the following actions should the nurse take? o Monitor the client’s temperature every 4 hr o Wake the client every 6 to 8 hr o Elevate the head of the bed to 30 degrees o Place the client in lateral sim’s position • A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client’s plan of care? o Administer diuretics o Limit fluid intake o Apply support stockings o Place on bedrest • A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend? o Remind the client of the day and time often o Alternate daily caregivers o Avoid discussing the client’s fears o Offer the client several choices at mealtimes • A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include? o Potatoes o Oranges o Grapes o Corn • A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching? o “You should have a sputum examination every 4 weeks.” o “You should obtain a chest x-ray every 3 months.” o “You should schedule a tuberculin skin test every 6 months.” o “You should stop taking your antituberculin medication after 2 weeks.” • A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? o Explain that nonreactivity might require immediate medication administration o Tell the client the test should take about 10 min o Remind the client to press the button when she feels fetal movement o Assist the client into a supine position • A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include? o Encourage socialization during meal times o Elevate the head of the clients bed to 30 degrees o Tilt the client’s head forward during meals o Provide three large meals per day • A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider? o Leukorrhea o Epistaxis o Fatigue o Persistent headache • A nurse is talking with the partner of a client who recently died, which of the following statements should the nurse make? o “I will call the chaplain to speak to you.” o “It seems bad right now, but things will get better over time.” o “Tell me what I can do for you at this time.” o “I think you should attend a grief support group.” • A nurse is assisting with the admission of a client who states, “The last time I was in the hospital, the nurses took forever to answer my call light.” Which of the following is an appropriate response by the nurse? o “That must have been a difficult experience for you.” o “It will not happen this time because we have more staff.” o “I am sure no one meant to ignore you.” o “Let’s discuss what brought you to the hospital this time.” • A nurse in a provider’s office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? o Neisseria gonorrhoeae o Sarcoptes scabiei o Human papillomavirus o Impetigo contagiosa • A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? o Hematuria o Nuchal rigidity o Jaundice o 2 plus pedal edema • A nurse is reviewing laboratory findings for four clients. Which of the following laboratory values is an expected finding for a client who has end stage kidney disease? o Creatinine 15 mg/dL o Potassium 4.0 mEq/L o BUN 15 mg/dL o Phosphorus 4.0 mg/dL • A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider? o Obtain an aPTT level o Change the medication to heparin IV o Administer protamine sulfate o Reduce the dosage of the medication • A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess? o Urine output of 360 mL/12 hr o Blood pressure of 100/74 mm Hg o Distended neck veins o Decreased bowel sounds • A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching? o “You should place the diaper over the strap of the harness.” o “You can apply lotion under the straps of the harness.” o “The harness can be removed for sleeping each night.” o “The harness can promote hip joint development.” • A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error? o Provider’s progress notes o Nursing care plan o Incident report o Controlled substance inventory record • A nurse is preparing a sterile field to perform a dressing change for a client’s leg wound, which of the following actions should the nurse take? o Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field o Hold the irrigation solution bottle 5 cm (2 in) above the sterile container o Place the irrigation solution bottle cap on the sterile field o Open the outer wrapper of the sterile package toward her body • A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following? o Boundary crossing o Countertransference o Veracity o Promoting trust • A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client? o Contact precautions o Airborne precautions o Droplet precautions o Protective environment • A nurse is documenting client care in the nurses notes and notices that a space was left blank. Which of the following actions should the nurse take? o Draw a horizontal line through the space and sign at the end of the line o Leave the space as it is within the entry o Place the date at the beginning of the space, followed by double lines o Black out the line with a felt-tip pen • A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client’s overhead table following a blood spill? o Chlorhexidine o Bleach o Hydrogen peroxide o Isopropyl alcohol • A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the following findings should the nurse identify as a safety risk? o The client's daughter fills the medication organizer once weekly o The client’s electrical wires are run under carpeting o The client has a smoke detector in his bedroom o The client has a raised toilet seat in his bathroom • A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching? o “A family member must witness your signature on the informed consent form.” o “We require informed consent for all routine treatments.” o “You can sign the informed consent form after the provider explains the pros and cons of the procedure.” o “We can accept verbal consent unless the surgical procedure is an emergency.” • A nurse is reinforcing teaching with a client who has a trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching? o “You should expect your urine to turn brown.” o “You might develop constipation.” o “You will need to take the medication for 3 weeks.” o “You might have increased saliva production while taking this medication.” • A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, “I don't understand why this procedure is necessary.” Which of the following actions should the nurse take? o Remind the client about the specifics of the procedure o Explain to the client that the procedure will help treat his diagnosis o Ask the client to sign the consent form anyway o Notify the charge nurse about the situation • A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information? o “Advance directives include a living will” o “Federal legislation dictates the legal guidelines for advance directives.” o “My medical record should not include my advance directives.” o “Advance directives include instructions for resolving financial matters after my death.” • A nurse is collecting data from the caregiver of a client who has Alzheimer’s disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend? o Encourage the client to take frequent walks during the day o Give the client a barbiturate medication at bedtime o Allow the client to nap for at least 1 hr during the day o Put a simple lock on the clients bedroom door • A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply) o Check the clients capillary refill o Administer terbutaline 0.25 mg subcutaneous o Give the client 800 mg of ibuprofen o Massage the client's fundus o Assist the client to empty her bladder • A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage? o “Apply steady pressure with this tennis ball to her sacral area.” o “Assist her to breathe in deeply at the beginning of each contraction.” o “Gently stroke her abdomen during contractions.” o “Help her to focus on an object in the room.” • A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? o Massage the area around the clients coccyx o Limit the client’s fluid intake o Use a moisture barrier on the client’s skin o Clean the client’s skin with soap and hot water • A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client’s autonomy? o Be honest with the client about the prognosis o Allow the client to choose treatment times o Provide privacy during client care procedures o Administer pain medication on a routine schedule • A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? o Turns a nitrazine strip blue o Appears greenish-brown in color o Preceded by bloody mucus o Has a pH of 7 • A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? o Administer opioids to the adolescent on a schedule o Position the adolescent with his neck hyperextended o Keep the adolescent NPO o Inform the adolescent that he might experience a headache • A nurse is reinforcing teaching about advance directives with a client who has end- stage heart failure. Which of the following statements by the client indicates an understanding of the teaching? o “I am not allowed to change my mind once I sign this document.” o “My partner needs to be present when I sign this document.” o “I should discuss this document with my family after I sign it.” o “An attorney will need to notarize this document for it to be valid.” • A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take? o Clamp the urinary catheter tubing o Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation o Replace the indwelling urinary catheter with a smaller diameter catheter o Allow the tubing to hang below the drainage bag • A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? o Instruct the client to remain as still as possible during the recording o Assist the client to the orthopneic position o Tell the client to expect a mild stinging sensation o Attach a blood pressure cuff to the clients upper arm • A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching? o “You should increase fluid intake to relieve dysuria.” o “You will no longer be infectious once you have completed a course of antibiotics.” o “You should wear nylon underwear until the lesions have healed.” o “You should have the lesions drained as they appear.” • A nurse is preparing to empty a postoperative client’s closed-wound drainage system. Which of the following actions should the nurse plan to take? o Apply sterile gloves prior to handling the drainage system o Attach the drainage tube to low-intermittent suction o Cleanse the drainage port with soap and warm water o Compress the container before replacing the drainage plug • A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching? o Administer the medication when the toddler has an acute asthma attack o Mix the medication in juice prior to administration o Provide an additional dose of the medication prior to physical activity o Administer the medication to the toddler each evening • A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship? o Overcoming resistance o Promoting insight o Defining responsibilities o Examining one’s feelings • A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate? Lower left • A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? o Preoxygenates with 100% oxygen o Suctions for 30 seconds o Auscultates breath sounds o Applies suction during catheter removal • A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client? o Thrombocytopenia o Dry cough o Hypotension o Hyperglycemia • A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity? o Verify the client’s identity with a family member o Ask the client the name of the facility o Ask the client to state her first name o Verify the client’s identity using a photograph • A nurse in a provider’s office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider? o “I do not use fabric softener when I wash my clothing.” o “I limit my time spent out in the sunlight.” o “I remove old medication on my skin before applying a new dose.” o “I try not to look at the scales on my body.” • A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls? o Medication record o Admission face sheet o Pastoral care notes o Social activities report • A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? o Evaluate the need to suction the airway of a client who has a new tracheostomy o Inspect the incision of a client who is postoperative following a leg amputation o Feed a client who has difficulty swallowing liquids following a stroke o Complete post mortem care for a client who has died • A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report? o Hyperreflexia o Skin rash with fever o Tinnitus with ear pain o Diplopia • A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching? o “I will instruct the client to sit when putting on a pair of pants.” o “I will instruct the client to sit in a low-rise chair.” o “I will instruct the client to wear socks when ambulating to the bathroom at night.” o “I will instruct the client to bend at the waist when picking up an object.” • A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge? o A client who reports chest pain after ambulating o A client who has atrial fibrillation and an INR of 4 o A client who has a sodium level of 140 mEq/L after one episode of diarrhea o A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf • A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? o Obtain vital signs once per day o Administer liquid supplements o Weigh the client weekly o Discuss food topics during mealtime • A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o “I will delegate any tasks I do not have the skill to perform to assistive personnel.” o “I will be protected from liability if I am appointed with a resource nurse when I float.” o “I will document in the medical record the support nurse who assists with planning care for my clients.” o “I am not liable if I perform delegated functions when supervision is not provided.” • A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? o Serum creatinine 1.0 mg/dL o Urine specific gravity 1.020 o Urine output 12 mL/hr o BUN 18 mg/dL • A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? o Define the problem o Identify data collection methods o Perform chart audits o Review the facility’s policy and procedure manual • A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? o “Cover the electrical outlets with wet towels.” o “Turn on fans in the facility to circulate air.” o “Open the fireplace dampers in the day room.” o “Move clients to a room above ground with few windows.” • A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of the following actions should the nurse take? o Give IV fluids through the AV shunt o Obtain blood pressure from the right arm o Check a bruit over the shunt on a regular basis o Avoid range of motion in the right arm • A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client’s prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting? o Veracity o Autonomy o Justice o Beneficence • A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? o Dorsal recumbent o Left lateral o Semi-fowler’s o Supine • A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching? o “You should not palpate your child’s abdomen prior to surgery.” o “You should give your child captopril 200 mg PO daily.” o “Your child should have surgery in 7 to 10 days to remove the tumor.” o “Your child will not require further treatment after removal of the tumor.” • A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? o Place a pillow under the child's head o Restrain the child’s upper extremities o Place a padded tongue blade in the child’s mouth o Turn the child onto his back • A nurse is contributing to the plan of care for a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend? o Place the client in high-fowler’s position during feedings o Dilute the formula with water for the first 24 hr of therapy o Check the clients gastric residual 15 min after each feeding o Chill the formula before initiating feedings • A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client’s arms. This nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse’s priority action? o Provide information about moving to a shelter o Offer support and create a safe, trusting environment o Document the client’s injury and include a photograph o Determine if there is a gun in the client’s home • A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect? o Hypothermia o Somnolence o Muscle weakness o Hallucinations • A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? o I will report black stools to my doctor o I will mix the medication with water o I can prevent constipation if I drink more milk while taking this medication o I can prevent nausea if I take the medication on an empty stomach • A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? o Client report of burning with urination o Client report of uterine cramping o Boggy fundus 3 fingerbreadths above the umbilicus o Saturation of perineal pad in 15 min 114. • A nurse is attending an educational workshop about client confidentiality. Which of the following actions b y the nurse indicates an understanding of the teaching? o Changes her personal login password at random intervals o Gathers data from clients on other units who have the same diagnosis o Uses a personal digital assistant to record client information o Disables the use of the speed-dial function on fax machines • A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend a home health referral? o A young adult client who has a substance abuse disorder o An older adult client who has heart failure and lives alone o A middle adult client who had a mastectomy and requires chemotherapy o An adolescent client who has a tibia fracture and requires crutches • A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? o You can safely take this medication if you become pregnant o You can skip a dose of this medication if you are nauseated o You might experience swollen gums while taking this medication o You should expect to have blood work every 6 months while taking this medication • A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/ 5 mL. How many mL should the nurse administer?(Round answer to the nearest tenth.) • 7.5 mL • A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching? o I am having this test to check if my baby’s lungs are mature o The nurse will draw my blood after the procedure o I am having this test because my baby was nonstress test reactive during a o I will need to fast for 6 hours prior to the procedure • A nurse is discussing health practices with the mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping? o I apply petroleum jelly with garlic along my child’s wrist to treat infections o I insert needles into meridian lines of my child’s body to help with pain relief o I rub the edge of a coin lengthwise on my child’s back when he is sick o I sometimes place a bottle containing steam against my child’s skin • A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? o I should take a zinc supplement while taking this medication o This medication will dilate my eyes o I should check my heart rate while taking this medication o This medication will darken the color of my eyes • A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect? o Jugular vein distention o Moist mucous membranes o Weight loss of 10% o Capillary refill of 2 seconds • A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication? o Decreased liver function o Decreased kidney function o Increased metabolism o Decreased pulmonary function • A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral? o Social worker o Advanced practice nurse o Patient care technician o psychologist • A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergic reaction to this medication? o Arthralgia o Fever o Dyspnea o Nausea • A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician? o A client who has a body mass index of 32 o A client who has a sodium intake of 1200 mg/day o A client who has a total fat intake of 25% of daily calories o A client who has a serum albumin level of 4.5 g/dL • A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o Soiled dressings should be placed in a biohazard trash receptacle o Droplet precautions require that I wear a gown and gloves when providing care o Following a blood spill, I should use a bleach solution with a ratio of 1 to 20 o For a client who has Clostridium difficile, I will clean my hands with an alcohol-based rub • A nurse is preparing a vitamin K injection to give to a newborn. The newborn’s mother questions the purpose of this medication. Which of the following responses should the nurse make? o This medication will decrease the risk of hemorrhage in your newborn o This medication will increase the immunity of your newborn o This medication will increase the absorption of nutrients in the intestines o This medication will decrease the possibility of your newborn developing jaundice • A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? o Fruity breath odor o Elevated blood pressure o Clammy skin o Bounding pulse • A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take? o Cover the wound with a transparent film extending outward 5 cm (2 in) o Replace the wounds dressing every 12 hr o Use an adhesive remover to remove tape before reapplying a dressing o Pack the wound tightly with sterile gauze • A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent? o I should expect my periods to resume in 1 month o I am thankful I am done having children o I will have a large scar on my stomach after this procedure o I will no longer need a regular gynecological examination • A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? o Measure the duration of the seizure o Restrain the clients arms and legs to prevent injury o Lower the side rails of the bed when the seizure begins o Insert an oral airway into the clients mouth • A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, “We've been trying to get pregnant for several months, but now I'm not so sure I'm ready.” Which of the following responses should the nurse make? o I wouldn’t worry about it if I were you. You’ll be a good mother o You need to talk to a therapist about how you’re feeling o Why do you feel that way if you’ve been trying to get pregnant o Many women experience feelings of ambivalence during pregnancy • A nurse is caring for four clients. Which of the following situations require a signed consent form? o Performing a wound irrigation with an antibiotic solution o Giving a haemophilus influenzae B vaccine to an infant o Administering an iron injection Z-track method o Inserting a nasogastric tube • A nurse is receiving a report on four clients. The nurse should plan to collect data from which of the following clients first? o A preschooler who has epiglottis and is drooling o An adolescent who is postoperative and requesting pain medication o An infant who is dehydrated and has a heart rate of 160/min o A school-age child who has a broken ankle and reports pruritus under his cast • A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include? o The headaches should decrease as you get used to the medication o Swallow the tablet whole to minimize your headaches o You should take the medication on an empty stomach to prevent a headache o You can’t discontinue the medication until the headache goes away 137. • A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take? o Offer toileting every 6 hr o Encourage intake of caffeinated beverages o Limit fluid intake to 1500 mL a day o Check for residual urine after voiding • A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care? o Use a transcutaneous electrical nerve stimulator o Soak in a bathtub of hot water each night o Obtain a prescription for pramipexole o Lie on your left side with your top leg forward • A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following findings should the nurse include in the teaching as an adverse effect of this medication? o Increased salivation o Orthostatic hypotension o Alopecia o P ol y u ri a 1 4 1 . • A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care? o Suggest the client exercise before going to bed o Recommend the client spend time alone in his room o Encourage the client to use positive self talk o Offer the client low-protein snacks throughout the day • A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer? • 1.5 mL • A nurse is caring for a child who has terminated cancer. Which of the following responses by the child’s school-age brother should the nurse expect ? o Believes that his brother’s death will be reversible o Alternates himself from his peers o Believes his bad behavior is causing his brother’s death o Regresses to an earlier developmental level • A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal? o Lorazepam o Methimazole o Potassium o Naloxone • A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy? o 32 lb o 24 lb o 8 lb o 16 lb • A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure? o Paraesthesias o Tonic-clonic seizures o Disorientation o Sleep apnea • A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first? o Instruct the client about effective coping strategies o Suggest that the client assist with meal planning o Observe the client during and after meals o Refer the client to a support group for adolescents who have eating disorders • A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations? o Inform the client when beginning to observe the respirations o Count the client's respirations for 15 seconds o Place the client in a supine position o Observe the movements of the client’s chest wall • A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report? o Steps required for dressing change o Admission vital signs o Preferred bath time o Time of last pain medication • A nurse is reinforcing discharge teaching with a client who has a bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching? o I will plan to increase my intake of green, leafy vegetables o I should follow a gluten-free diet while taking this medication o I should take this medication on an empty stomach o I will plan to avoid grapefruit juice while taking this medication • An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict? o Grant the AP’s request to reassign the task o Ask the AP to discuss the issue in a private area o Perform the tasks personally rather than reassigning them o Reprimand the AP for failure to perform the tasks • A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching? o Engage in low-impact aerobic exercises o Apply ice to the inflamed joint o Sleep on a soft mattress o Use fingers to push off from the bed or chair • A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? o Collect a sterile specimen from the urinary drainage bag o Secure the tubing with adhesive tape to the lower abdomen o Instruct the client to hold the drainage bag at waist height when ambulating o Coil the tubing on the bed above the collection bag • A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence? o I am going to get a job to make some extra money o I plan to visit my friends while my husband is at work o I have decided to tell my husband I am leaving him o I just got accepted to our local college • A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect? o Tachypnea o Tachycardia o Hypotension o Hyperthermia • A charge nurse working in a long-term care facility overhears two AP’s in the nurses stations discussing a client who was just admitted. Which of the following actions should the charge nurse take? o Inform the client of the AP’s actions o Tell the APs to stop the conversation o Document the event in the client’s progress notes o Submit an incident report to the risk manager • A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements made by the client indicates an understanding of the teaching? o I do not need to sign a consent form before this procedure o I will feel a warming sensation after the injection of the dye o I can have a meal up to 2 hours before the procedure o I should limit my fluid intake for 2 days after the procedure • A nurse is assisting with the plan of care for a client who has end- stage amyotrophic lateral sclerosis and has developed pneumonia. Which of the following actions should the nurse take? o Initiate a referral to a speech therapist o Request a prescription for a glutamate antagonist o Verify the status of the client’s advance directive o Suggest a genetic counseling for the client’s family • A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching? o I can take my baby to the lobby to visit family o I will carry my baby to the nursery o I can remove my security band to give it to a family member o I will have an identification band that matches the one my baby wears • A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority action on which of the following actions? o Providing the client with information on community resources that will strengthen her coping skills o Identifying the client’s perception of the changes in her physical appearance o Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds o Encouraging the client to write about her feelings in a journal each day • A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse include in the teaching? o Increase dietary intake of canned vegetables o Limit caloric intake to 2500 calories per day o Restrict alcohol intake to 360 mL (12 oz) of wine per day o Walk for 30 min 5 days per week • A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect? o Reclusive o Perfectionistic o Submissive o Impulsive • A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? o Assign the client to a positive-airflow room o Have visitors remain at least 0.91 m (3 feet) away from the client o Administer aspirin if the client develops a fever o Initiate contact precautions for the client • A nurse is planning to administer four different medications to a client via gastrostomy tube. Which of the following actions should the nurse take? o Let timed-release medications dissolve for 30 min prior to administration o Mix crushed medications in 20 mL of water o Flush with 10 mL of tap water after administration o Allow separate medications to flow through the tube by gravity • A nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. Which of the following supplies should the nurse use while caring for this client? o Surgical mask o Gown o Sterile gloves o N95 respirator • A nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. Which of the following statements by the client indicates an understanding of the teaching? o I drink whole milk everyday o I may have four egg yolks per week o I make toast using enriched white bread o I have unsalted pretzels for a snack • A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian culture. Which of the following communication techniques by the nurse demonstrates cultural sensitivity? o Sitting closer than an arm’s length o Patting the clients shoulder for reassurance o Using social conversation to fill periods of silence o Holding eye contact for brief instances • A nurse is reinforcing teaching about safe food handling with a client who is recovering from food poisoning. Which of the following statements by the client indicates an understanding of the teaching? o I will set my refrigerator to 50 degrees fahrenheit o I will be sure to cook chicken to 180 degrees fahrenheit o It is safe to eat unpasteurized dairy products o It is safe to use uncooked ground beef that has been refrigerated for 4 days • A nurse is assisting with the discharge plan for a client who has burns on his arms and hands. Which of the following referrals should the nurse recommend to improve the client’s ADL’s? o Social worker o Occupational therapist o Case manager o Registered dietician • A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the clients vagina and vulva are a purplish color. The nurse should document this finding as which of the following? o Chadwick’s sign o Hegar's sign o Chloasma o Ballottement • A nurse should recognize that a client's right to confidentiality has been breached when which of the following occur? o A nurse tells the chaplain that her assigned client has a new diagnosis of cancer o A social worker reads a client's chart as a follow-up to a requested consultation o A facility risk manager includes information from a client's medical record in a written report o A newly licensed nurse discusses his clients postoperative complications during shift report • A nurse on a medical-surgery unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions? o A client who had a lobectomy and has a chest tube drainage system o A client who had a radical mastectomy 36 hr ago and has a surgical drain o A client who has cervical cancer and an internal radioactive implant o A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy • A nurse is reviewing laboratory values for a client who has respiratory acidosis. Which of the following arterial blood gas values should the nurse expect? o pH 7.45, PaCO2 35 mm Hg o pH 7.35, PaCO2 52 mm Hg o pH 7.28, PaCO2 28 mm Hg o pH 7.30, PaCO2 50 mm Hg • A nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room. Identify the sequence of actions the nurse should take. (Move steps in order) • Move the client to a safe location 2. Pull the nearest fire alarm • Shut all doors and window s 4. Attempt to extingui sh the fire • A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicate that the client is experiencing an adverse effect of the medication? o Lacrimation o Hypertension o Urinary retention o Tachycardia • A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the teaching? o Peanut butter o Dark chocolate o Cream of potato soup o Skim milk • A nurse is caring for a client who has a new mastectomy. Which of the following statements by the client should indicate to the nurse that the client is beginning to cope with the changes in her body image? o I am afraid to discuss my concerns with my husband o I am angry i had to lose my breast o I am worried i will never be able to take care of myself o I am not ready to change my own dressing • A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make? o Establish a daily exercise routine o Keep the telephone volume low while you are trying to fall asleep o Remain in bed until you fall asleep o Sleep longer hours on the weekend • A nurse is caring for an adolescent that states, “I joined the track and field team, so I won't argue with my brothers anymore.” The nurse should identify that the client is using which of the following defense mechanisms? o Regression o Repression o Denial o Sublimation • A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of this medication? o I will replace the patch every 12 hours o I will apply the patch in the same place every day o I will place the patch on a hairless area of skin o I will remove the patch if i develop a headache