ATI COMPREHENSIVE RETAKE 2019 with NGN-With 100% verified solutions.docx | Exams Nursing | Docsity (2024)

Download ATI COMPREHENSIVE RETAKE 2019 with NGN-With 100% verified solutions.docx and more Exams Nursing in PDF only on Docsity! ATI COMPREHENSIVE RETAKE 2019 with NGN- With 100% verified solutions A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints (15-30min). 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. D. Document the client’s condition every 15 minutes. 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 b. Give cromolyn nebulizer solution every 6 hr c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr d. Administer analgesics on a scheduled basis for the first 24 hr 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 d. A client who has a hip fracture and a new onset of tachypnea A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Shave hairy areas of skin prior to application 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 d. Remove the previous patch and place it in a tissue b. Wear gloves to apply the patch to the client’s skin 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 a. A client who was just given a glass of orange juice for a low blood glucose level 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 a. A history of gastroesophageal reflux disease 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 a. Serum glucose level- increased 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 d. Absent gag reflex a. Increase in frequency of swallowing 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 b. Monitor the child’s cardiac status 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 c. Use of tobacco decreases the level of athletic ability 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 d. Platelet count c. Serum potassium 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.” a. “I will let the client know that I am available as the interpreter.” A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A two-day old newborn who has a respiratory rate of 70 b. A 16-hour old new newborn who has yet to pass meconium c. A 2-day old newborn who has a small amount of blood tinged vagin*l discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl a. A two-day old newborn who has a respiratory rate of 70 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? a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity 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 b. A client who has fractured left tibia and pallor in the affected extremity 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 c. Sedation d. Shuffling gait d. Shuffling gait 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? a. Clean the base of the cord with hydrogen peroxide daily b. The cord stump will fall off in 5 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off d. Keep the cord stump dry until it falls off 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 b. Potato pancakes c. Wheat crackers d. Canned barley soup b. Potato pancakes 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 c. Disorganized speech d. Hypochondriasis c. Disorganized speech 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 client’s legs b. Place a towel roll under the client’s neck c. Apply an orthotic to the client’s foot d. Position a pillow under the client's knees c. Apply an orthotic to the client’s foot 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 c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. a. You may breastfeed unless your nipples are cracked or bleeding. 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 client’s information? Exhibit. a. Level of consciousness. b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds a. Level of consciousness. 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 c. Administer oral acetaminophen d. Initiate seizure precautions d. Initiate seizure precautions A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include? a. Document the client's conditions every 15 minutes 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 a. Document the client's conditions every 15 minutes 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? a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid d. Initiating IV fluid 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 would not worry about that. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have questions about your mom dying. Let’s talk about it. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. E. You sound like you have questions about your mom dying. Let’s talk about it. 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 b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 d. A client who is taking warfarin and has INR of 1.8 A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone a. Clarify the source of the referral 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? a. You have the right to decide who receives information 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 a. You have the right to decide who receives information 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. a. 7.5% b. 15% c. 8.1% d. 13.3% a. 7.5% A nurse is caring for a client who is 4hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a-Perform fundal massage b-Pour water from a squeeze bottle over the client’s perineal area. c-Insert an indwelling urinary catheter. d-Apply cold therapy to the client’s perineal area. b-Pour water from a squeeze bottle over the client’s perineal area. 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? a. Avoid hot tub while wearing the patch 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. a. Avoid hot tub while wearing the patch A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan. 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 c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke c. Applying a condom catheter for a client who has a spinal cord injury 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” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain b. “I will avoid food and beverages that contain caffeine” 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 c. Provide humidification of the room air A nurse is caring for four clients. Which of the following tasks can the nurse delegate to 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 b. Perform chest compressions during cardiac resuscitation 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. The client has a history of asthma 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 b. Weight loss c. Urinary retention d. Hypertension c. Urinary retention 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 b. Hypertension c. Fibromyalgia d. Fibrocystic breast condition b. Hypertension 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) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments 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? a. “You should not have this procedure if you are allergic to iodine.” 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.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” 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 b. Start a 24-hr urine collection c. Give aspirin to reduce pain d. Encourage ambulation a. Initiate IV fluid replacement 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? a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion b. Set the IV infusion pump to administer the blood over 6 hr. c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- d. Administer the blood via a 21-gauge IV needle c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- 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 b. Explain the risks of leaving 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.” b. “I think the baby should be sleeping through the night by now. a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls b. administering potassium via IV bolus c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication b. administering potassium via IV bolus 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 d. Use an albuterol inhaler d. Use an albuterol inhaler A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? a. Monitor the dorsalis pedis pulse every 15 minutes b. Maintain strict bedrest for first 12 hr c. Keep the client NPO for 24 hr d. Place the client in Fowler’s position a. Monitor the dorsalis pedis pulse every 15 minutes 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? a. Offer high-calorie, high protein snacks to the client 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 a. Offer high-calorie, high protein snacks to the client 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 c. Autonomy d. Justice c. Autonomy 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? A. Check the mouth for smooth and smoky breath 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. A. Check the mouth for smooth and smoky breath A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor? a. Hyponatremia b. Hyperkalemia c. Hypercalcemia d. hypoglycemia a. Hyponatremia 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 a. I will change my baby’s diaper at least every 4 hours 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 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 b. initiate a consultation with a speech 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% C. HbA1c 6.5% 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 B. Blood pressure 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 1hr 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 B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen 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 B. Communicate appropriate tasks to the APs with specific expectations C. Monitor progress of task completion with each AP D. Evaluate the APs’ performance of each task