ATI COMPREHENSIVE 2019 C
ATI COMPREHENSIVE 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
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
d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first.
13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?
a. “Can you tell me who visited you today?”
b. “What high school did you graduate from
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7%
15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client’s seizure disorder is no longer under control
d. The client is having adverse effects due to combination antimicrobial therapy
16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing→ may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC
17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?
a. “I will let the client know that I am available as the interpreter.”
b. “I will receive a small fee for interpreting for this client.”
c. “I am glad I’m available today, but when I’m not, you can use a family member.”
d. “I will let the client know that an interpreter is unavailable during the night shift.”
21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider?
b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool
c, A 2 day old newborn who has a small amount of blood tinged vaginal discharge
d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia
a. A client who is 1 hr postoperative and has hypoactive bowel sounds
c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
d. A client who has a elevated AST level following administration of azithromycin
23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider?
a. Weight gain
b. Dry mouth→ anticholinergic effects
c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening
24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? P . 177 ch 26
a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths
b. The cord stump will fall off in 5 days- about 10 - 14 days
c. Contact the provider if the cord stump turns black
Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is
expected to turn black and dry.
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
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
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
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.
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
42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care?
a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal)
b. A client who is scheduled for colonoscopy and taking sodium phosphate
d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin)
43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?
b. Implement the nursing process
c. Schedule a time for the home visit
d. Contact the family by phone
!
44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?
b. Your partner can be a great source of support for you at this time
c. Is there a reason you don’t want your partner to know about your procedure?
d. The provider will be tactful when talking to your partner
45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage?
b. 15%
c. 8.1%
d. 13.3%
46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement?
a. Perform fundal massage ( massage if fundus is boggy)
c. Insert an indwelling urinary catheter.
d. Apply cold therapy to the client’s perineal area.( warm)
47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?
b. Apply patch to your forearm
c. Avoid high-fiber foods while taking this medication
d. Remove the patch for 8 hours every day to reduce the risk for tolerance.
51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps)
a. Transport the client to another area of the nursing unit (1)
b. Activate the facility’s fire alarm system (2)
c. Close all nearby windows and doors (3)
d. Use the unit’s fire extinguisher to attempt to put out the fire (4)
52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?
b. Rapid speech -severe
c. Feelings of dread
d. Purposeless activity
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
d. The client takes furosemide twice daily
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?
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
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.”
75. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored?
b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus)
c. Uterine atony( fundus not firm which means possible hemorrhage)
d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly)
76. A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ?
a. Polyuria- oliguria
b. Hypotension- hypertension
d. Weight loss - weight gain
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
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%
107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching?
A. Client can expect to have feeling of hopelessness
B. Client might feel guilt over some aspect of their loss
C. Client will experience anhedonia
D. Client will experience low self-esteem
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
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.
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
C. Examine for leakage at thes site of the procedure
D. Confirm that the client is able to urinate
126. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
A. Swaddle the newborn with this leg extended.
B. Maintain eye contact with the newborn during feedings.
C. Minimize noise in the newborn environment
D. Administer naloxone to the newborn
? Reduce environmental stimuli (decrease lights, lower noise level).
127. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness?
A. Participate in community drills and mock events.
B. Vaccinate susceptible children and adults against smallpox
C. Assess types, levels and scopes of disasters.
D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First
128. A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect?
A. Ritualistic behavior (OCD)
B. Exhibits separation anxiety (Dependent)
C. Preoccupied with aging
D. Suspicious of others. (Paranoid)
129. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
A. Withdraw the client's TV privileges if he does not attend group therapy
B. Place the client in seclusion when exhibits signs of anxiety
C. Encourage the client to take frequent rest periods.
D. Encourage the client to spend time in the day room
133. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?
a. Seizure disorder
b. Polycystic ovary syndrome
c. Renal insufficiency
d. Gluten intolerance
134. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
a. Contractions -
b. Vomiting
c. Hypertension
d. Epigastric pain -google
135. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first?
a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site
b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120
c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate
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
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 ? 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?
b. Tachypnea( bradypnea, less than 12/min)
c. Pruritus( sign of allergic reaction)
d. Polyuria (oliguria, less than 30 ml/hr)
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
154. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first?
A. Inform the provider of the time of the last dose of pain medication.
B. Document the sequence of events as they occur.
C. Provide non-pharmacological pain management interventions.
D. Instruct the client about the steps of the procedure.
155. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
A. The client was intubated without complications.
B. The estimated blood loss was 250 milliliters.
C. There was a total of 10 sponges used during the procedures.
D. The client is a member of the board of directors.
156. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
A. “You can add the medication to a half-cup of your child’s favorite juice.”
B. “Repeat the dose if your child vomits within 1 hour after taking the medication.”
C. “Limit your child’s potassium intake while she is taking this medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
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
b. Dependant Edema- fluid volume excess
c. Decreased Hematocrit - fluid volume excess d/t super diltion
d. Neck vein distention - fluid volume excess
180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?
a. “How long have you been hearing the voices?”
b. “What are the voices telling you?”
c. “Have you taken your medication today?”
“I realize the voices are real to you, but I don’t hear anything.”-
-
Rating:
/5
Solution: ATI COMPREHENSIVE 2019 C