RN ATI Capstone Comprehensive Predictor Form C 2022-2023 | Study notes Nursing | Docsity (2024)

Download RN ATI Capstone Comprehensive Predictor Form C 2022-2023 and more Study notes Nursing in PDF only on Docsity! RN ATI Capstone Comprehensive Predictor Form C 1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client’s peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client’s condition every 15 minutes 2. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hr (for asthma) c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr 3. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) b. Wear gloves to apply the patch to the client’s skin c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hr (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain 6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial 7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an increase in which of the following laboratory values? a. Serum glucose level- increased b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased . 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. 9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level 11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas c. Wheat crackers d. Canned barley soup 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood d. Hypochondriasis ( anxiety disorder) 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the clients legs b. Place a towel roll under the clients neck d. Position a pillow under the client's knees 28. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution 29. A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → 30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED a. Hgb 12.8 g/dl - 12- 16 b. Potassium 4.2 meq/l 3.5 - 5.0 meq c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl c. Serum creatinine 0.8 mg/dl b. Prealbumin 10 mcg/dl (normal: 16-40) b. Potato pancakes c. Disorganized speech c. Apply an orthotic to the clients foot d. Calcium 9.5 mg/dl 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs 33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? p . 88 ch 13 maternity b. Stop the oxytocin infusion c. Perform a vagin*l examination d. Initiate an amnioinfusion 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 35. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. a. A client who is postoperative following a bowel resection with an NGT set to continuous suction a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMED a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range a. You may breastfeed unless your nipples are cracked or bleeding. b. Compare the current infusion with the prescription in the client's medication record. 37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. b. Skin turgor d. Bowel sounds 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? P. 482 ch 75 CONFIRMED a. Providing pain management b. Offering emotional support c. Preventing infection 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. D. Tell her not to worry. She still has plenty of time left. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? a. Document the client's conditions every 15 minutes c. Deep-tendon reflexes d. Initiate seizure precautions d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing B. C. Let's talk about your mom’s cancer and how things will progress from here. Tell me how you are feeling about your mom dying. 54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds 55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) d. Connect abuse survivors with legal counsel (3rd) 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia- d. Reviewing active range-of-motion exercise with a client who had a stroke 57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication- b. Perform chest compressions during cardiac resuscitation- c. Perform a dressing change for a new amputee- d. Apply a transdermal nicotine patch- *60. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily c. Teach parenting skills to families at risk for abuse c. Applying a condom catheter for a client who has a spinal cord injury b. “I will avoid food and beverages that contain caffeine” d. Weak femoral pulses 61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss d. Hypertension- orthostatic hypotension it will cause instead 62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma c. Fibromyalgia d. Fibrocystic breast condition 63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) e. Cost of the procedure 64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? a. Initiate IV fluid replacement- a. b. c. d. Explain the procedure Expected outcome of the procedure Potential complications Possible alternative treatments a. “You should not have this procedure if you are allergic to iodine.” c. Urinary retention- b. Hypertension B b. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's disease d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? B a. . C and D not shown 68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion- assess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr d. Administer the blood via a 21-gauge IV needle 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: 70. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. “I try to respond to the baby quickly .” b. “I think the baby should be sleeping through the night by now. c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.” c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Take pancrelipase b. Complete oral hygiene c. Eat a meal 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P . 164 ch 27 medsurge b. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usally are up to 4 hours. c. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the procedure , and npo b4 the procedure is uP to 8 hours. d. Place the client in Fowler’s position- supine they must be 84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? a. Non maleficence b. Veracity a. Monitor the dorsalis pedis pulse every 15 minutes → circulation a. Offer high-calorie, high protein snacks to the client d. Use an albuterol inhaler c. Autonomy d. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. 87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? b. Hyperkalemia- c. Hypercalcemia d. hypoglycemia 88. a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) 140??(not sure) pounds 1 lb per week x 25 week= 25 lbs 75 x 2.2= 165 lbs 165 lbs-25 lbs=140 lbs or 63.6 kg (64 kg) 89. a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will change my baby’s diaper at least every 4 hours b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change Teach the parents to keep the area clean. 90. a home health nurse is caring for an adult client who reports, “I keep coughing when I try to swallow my food, but not at other times.” Which of the following actions should the nurse take? a. encourage the client to increase fluid intake b. initiate a consultation with a speech→ language pathologist; swallow eval A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body a. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow c. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. 91. A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% 92. A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication? A. BUN B. Blood pressure C. Respiratory rate D. aPTT 93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? A. Encouraging the client to use jet therapy on her lower back for 1 hr B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen C. Using effleurage on a client’s lower abdomen D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30 min 94. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 D. Evaluate the APs’ performance of each task 4 95. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I should take antibiotics when I have a virus.” B. “I should wash my hands for 10 seconds with hot water after working in the garden.” C. “I can clean my cat’s litter box during my pregnancy.” D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 96. A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take? A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site. 109. A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics- C. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen D. Bounding pulse 111. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occur. . 112. A nurse is caring for a client who has end stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension b. Primary glaucoma c. Osteoarthritis d. Amputation 113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. b. Request non gas forming foods from the dietary department c. Limit the client’s food consumption between meals. d. Arrange for a low protein diet. HIGH PROTEIN. 114. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department? a. Candidiasis b. Herpes simplex virus c. Human papillomavirus d. Chlamydia 115. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? a. Place a cardiac monitor on the client b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hr urine collection . 116. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks. -Avoid vigorous activities. b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds. c. I can resume activities, such as sewing. d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level. 117. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose 118. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching ? a. Take magnesium hydroxide for indigestion -not for pts with CKD or dialysis. b. Eat 1g/kg of protein per day c. Drink at least 3L of fluid daily -too much fluid d. Consume foods high in potassium -low potassium diet 119. A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology- b. Take the vital signs of the clients on the side of the unit c. Tell me the standing weight of the client in room 102 before breakfast d. The client in room 109 has spilled his water pitcher Rationale: right direction/communication. Leadership. 120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site b. Blood pressure 92/68 mm Hg - c. Urine output 35mL/hr d. Pedal pulse of +1 bilaterally 121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward . 122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot B. Kick a ball forward C. Climb Stairs with alternate feet D. Ride a tricycle 123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. Im sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. ● Facilitating conti ● Improving efficiency of care and utilization of resources 124. A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures 125. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. B. Check the client's serum albumin levels 136. A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after i first feel the urge to urinate 137. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? a. I need to have an enema before the test b. I should urinate before the test c. I will lie on my left side during the test d. I will drink an oral glucose solution during the test 138. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect? a. Memory loss b. Slurred speech c. Elevated temperature d. hypotension ● Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension 139. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules 140. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Consume food high in bran fiber c. Sweeten foods with fructose corn syrup d. Increase intake of milk product ● Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids 141. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client’s condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client’s condition. d. I will determine which muscles to contract by stopping and starting my stream of urine 142. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client’s extremities. d. Place the clients right hand in supination position. 143. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. “I will decrease my protein intake during the third trimester”( increase protein for basic growth) b. “I will need to increase my insulin doses later in my pregnancy” c. “I will increase my carbs at breakfast and limit them the rest of the day” d. “I will decrease my calorie consumption during the first trimester”(increase calorie) 144. A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau’s sign b. Assess the client’s skin turgor c. Check the client’s motor strength d. Measure the client’s pupil size 145. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. “I should clean my stoma with warm water”( can use low ph soap and water) b. “ My stoma should be bright pink or red”(pink,red and moist) c. “I should change the stoma pouch every day” d. “I should cut my pouch opening ⅛ inch larger than my stoma”(allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. 146. A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hr) 147. A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 148. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “Your desire to be an organ donor must be documented in writing” b. “I cannot be a witness for your consent to donate” c. “You must be at least 21 years of age to become an organ donor” d. “Your name cannot be removed once you are listed on the organ donor list 149. A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr 150. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen 151. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension 152. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic 153. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension Rationale: a. The client was intubated without complication c. There was a total of 10 sponges used during the procedure - what kind d. The client is a member of the board of directors 157. A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension 158. A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge ? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range b. A client who has cancer with a sealed implant for radiation therapy - an implant is inside them, and its active c. A client who is 1 day postoperative following a vertebroplasty d. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for Hospital and that other Coumadin for home 159. A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery ? a. Fasting blood glucose 108 mg/ dl b. WBC 9,800 mm3 > 4,800 is normal c. Creatnine 0.9 mg/dl , < 1.0 is normal d. Potaissium 5.2 meq / L 3.5 - 5.0 = 160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching ? a. Engage the client in activities that increase sensory stimulation. b. Discourage physical activity during the day c. Establish a toileting schedule for the client d. Use clothing with buttons and zippers b. The estimated blood loss was 250 milliliters 161. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred Assess the situation first prior to trying to solve it. 162. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. 163. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding - not without crushing them first b. Dissolve the medications together- some medications can mix others can’t c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water- 10ml 164. The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor c. Seductive Behavior d. Lack of remorse 165. A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. I can use my ultrasound picture as a focal point during contractions 166. A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute - wnr c. 2 PVCs per minute d. Widened P wave 167. A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Increases the tpn infusion rate each hour until the prescribed rate is achieved 168. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? a. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your responsibility to contain it b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - no comparison 169. A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations -either or is fine b. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the right way c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear d. Count respirations for 1 minute if the rhythm is irregular 170. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff c. contact the laboratory manager regarding the situation - you are not high enough up the chain to do that d. Notify the facilities legal department - no need to go that far 171. A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin b. ST segment elevations_ Remember this could possibly lead to infarctions