Comprehensive Predictor 2023

Respuesta es Lithium toxicity and seizure actvity Pregunta2 A nurse is preparing to iniate intravenous fluids via pump for a client. which of the following actons should the nurse take? Obtain A surge protector that can accommodate the pump and several other appliances Pregunta 3 A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to assess the port? a. An Angio catheter b. A butterfly needle c. A noncoring needle d. A 25-gauge needle pregunta 4 . A nurse is conductng an inital assessment of a client and notces a discrepancy Between the clients current IV infusion and the informaton received during the shiM report. Which of the following actons should the nurse take? compare the current infusion with the prescripton and the clients medical record. Pregunta 5 For #6 I’m kind of iffy about the television because in mental health it says when a client has hallucinatons the tv or music helps during auditory hallucinatons it can assist in limitng the effect the hallucinatons have on the clients stress level. So, It may be as follows indicated, indicated, indicated, indicated, and the last one contraindicated. Pregunta 7 .A nurse is caring for a client who is near the end of life and is on complete bed rest . The client states that he needs to have a bowel movement and the nurse offers a bed pan. The client states “I've always used the bathroom” which of the following responses should the nurse make? a. Tell me what concerns you about the bedpan. b. make sure to use nearby furniture to support yourself when walking to the bathroom. c. I will have the physical therapist ambulate you to the bathroom. d. you have to use the bedpan for your own safety pregunta 8 Pregunta 9 9.A nurse is providing an in service about client evacuaton during the fire. Which of the following clients should the nurse instruct the staff to evacuate first? a client who uses a wheelchair and is confused a client who is bedridden and wears a hearing aid a client who is ambulatory and receiving oxygen a client who has a fracture and is in balance suspension tracton pregunta 10 Pregunta 11 . A nurse is assessing a client who has a possible right pneumothorax. Which of the following findings should the nurse expect? a.Reduce right sided breath sounds b.inter coastal retractons c.high pitched strider d.paradoxical chest movement pregunta 12 I say for this one it's 1,2,3 and 6 when I looked up in the ATI book it says Patients with COPD could be on 24L/m of oxygen via the nasal cannula, we always want to continue to assess the clients breath sounds, chest percussions and vibration is needed to help move the secretions, and diaphragmatic breathing is needed as well. ATI MEDSURG PG.138 Pregunta 13 A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure? A. Trendelenburg B. Prone C. Right lateral D. High-fowlers Pregunta 14 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 has a history of asthma b. The client takes furosemide twice daily c. The client has a history of alcohol use disorder d. The client takes vitamin C daily pregunta 15 15. A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications? a. Ranitidine b. Vitamin B 12 PATIENTS WITH TOTAL GASTRECTOMY LACKS VIT B12 NEED TO SUPPLEMENT c. Metoclopramide d. Vitamin K pregunta 16 . A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? a. Initiate seclusion protocol. c. Tell the client, “you seem to be very upset.” Pregunta 17 . A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching? take your temperature immediately after waking and before getting out of bed. Pregunta 18 A nurse is reading a tuberculin skin test for a client who received a protein derivative test 72 hours ago. Which of the following findings indicate a positive test? An induration measuring 10mm . pregunta 19 A nurse is providing teaching about home safety to adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include? Mark the edges of the doorway to the house with tape Pregunta 20 . a nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect? a. crackles in the lungs b. decreased thirst c. poor skin turgor d. tachycardia pregunta 21 . A nurse is assessing a client who received hydromorphone 4mg IV 15 min ago. the client has a respiratory rate of 10/min. the nurse should prepare to administer which of the following medications? naloxone pregunta 22 . A nurse is 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. Administer analgesics on a scheduled basis for the first 24 hr c. Give cromolyn nebulized solution every 8 hr d. Apply a warm compress to the operative site every 4 hr pregunta 23 . A nurse is caring for a client whose child died from cancer. The client states “it's hard to go on without him”. which of the following questions should the nurse ask the client first? a. What has helped you through difficult times in the past? b. Has anyone in your family committed suicide? c. Is there anyone you would like involved in your care? d. Are you thinking about ending your life? Pregunta 24 . A nurse is teaching a client about advanced directives. Which of the following statements by the client indicate an understanding of the teaching? a. A living will is a document that includes my wishes about health care decisions. b. My provider will make my health care decisions if I complete advanced directives. c. advanced directives outline who inherits my material possessions in the event of my death. d. my partner needs to be present as a witness when I sign my living will pregunta 25 . A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency Pregunta 26 . 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? b. Shuffling gait pregunta27 A charge nurse is monitoring A newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). which of the following statements by the newly licensed nurse indicates an understanding of the procedure? a. I will hang a new bag of TPN and IV tubing every 24 hours. b. I will obtain the client's weight every other day. c. I will monitor the client's blood glucose level every eight hours. d. I will increase the rate of the TPN infusion to ensure the correct amount is given pregunta 28 A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis Pregunta29 . A nurse is assessing a client who has historic personality disorder. Which of the following manifestations should the nurse expect? a. Suspicious of others b. Callousness c. self-centered behavior d. violates others rights pregunta30 .A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take? a. Prepare to assist with intubation b. obtain a throat culture c. suction the child's oropharynx d. prepare a cool mist tent pregunta 31 OK so with number 31 I want to select the urine protein, fetal actvity, blood pressure, and report of a headache. But I am stuck between urine protein and gravita parity because I've heard that you're not supposed to have excess protein in the urine during pregnancy because it can be a sign of preeclampsia, but then she did have a preterm labor before making me want to put the gravida/parity. IDK im going with 1,2,3,and 6 Pregunta 32 Preeclampsia: Blood pressure HELLP: HGB, ALT, PLATELET COUNT Pregunta 33 SAME PATIENT FROM #31 ITS SEIZURES AND CERVICAL INSUFFICIENCY Pregunta 34 This is the same patent with preeclampsia/EECLAMPSIA so the optons 1, 2(I'm not 100% sure in the ATI book 198 and the pink book it says to encourage bed rest on leM side not maintain bedrest), 3, 4, 5, and 6. Vaginal examinaton every 12 hours is incorrect the next queston is going to be contnuous care for the client and it says to do contnuous external fetal monitoring Pregunta 35 Pregunta 36 Pregunta 37 . A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Zinc b. Calcium c. Folate d. Iron pregunta38 . A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider? Dyspnea Pregunta39 . A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions? shrugs his shoulders pregunta 40 . A nurse is preparing to admit a six-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take? Assign the child to a negative air pressure room( airborne) Pregunta 41 . A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include? A. Avoid preparing medications for more than two clients at one time. B. Inform clients about the action of the medication prior to administration. C. Read medication labels at least two times prior to administration. D. Complete an incident report if a client vomits after taking a medication. Pregunta 42 . A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Delegate tasks to the AP. b. Determine goals of the day (I put this one -Jackie) c. Schedule daily activities. d. Develop an hourly time frame for tasks. Pregunta 43 A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take? a. Cleanse the tip of the penis in a side to side motion b. Pick up the catheter 13 cm (5 in) from its tip c. Perform the cleansing procedure with a fresh swab two times d. Lift the penis so that it is perpendicular to the client’s body pregunta 44 A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. Protect IV bag from exposure to light. D. Attach an inline filter to the IV tubing. Pregunta 45 A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. Protect IV bag from exposure to light. D. Attach an inline filter to the IV tubing. Pregunta 46 A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states, “Providing constant care is very stressful and is affecting all areas of my life. Which of the following actions should the nurse take? C. Assist the caregiver to arrange a daycare program for the client. Pregunta 47 .A nurse and an assistive personnel are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse? A client who has a prescription for compression stockings and did not receive them Pregunta 48 A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements? Keep a calorie count for foods and beverages Pregunta 49 A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take? Provide the client with cold foods rather than hot foods Pregunta 50 . A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client? a. Canned barley soup b. Potato pancakes. Remember they can’t have gluten c. Wheat crackers d. White flour tortillas pregunta 51 . A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? A. Obtain the specimen immediately upon the client waking up. B. Wait 1 day to collect the specimen if the client cannot provide sputum. C. Ask the client to provide 15 to 20 ml of sputum in the container. D. Wear sterile gloves to collect specimen from the client. Pregunta 52 . A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include? a. Return in two weeks for a follow up MRI - MRI should be avoided b. Expect to have a rapid pulse rate for the first few weeks ?? c. Resume tub baths and swimming after 24hr d. Wear loose fitting clothing (I put this one -Jackie) pregunta 53 . A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take? a. Place the clients head of bed flat b. apply heat to the client's abdomen c. keep the client on NPO status d. administer A laxative to the client pregunta 54 A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first? a. Encourage the family to assign specific tasks to individual family members. b. Determine the roles of individual family members. c. Assist the family to establish a daily routine d. Refer the family to a grief support group. Pregunta 55 A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine which of the following laboratory values should the nurse monitor? a. Liver function tests b. kidney function tests c. hemoglobin and hematocrit pregunta 56 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 the virus b. I can visit my nephew who has chickenpox 5 days after the sores have crusted pregunta 57 . A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? a. Encourage physical activity prior to bedtime b. Replace the carpet with hardwood floors c. Wear clothing with zippers instead of buttons d. Place locks at the top of exterior doors (medsurg pg. 46: installing door locks that cannot be easily opened) pregunta 58 . A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take? A. Keep visitors at least 6 feet (1.8 m) away from the client. B. Place the client’s soiled bed linens in a biohazard bag outside the client’s room. C. Wear an isolation gown when caring for the client. D. Discard the radioactive source in the client’s trash can. Pregunta 59 The nurse is discussing discharge plans with an older adult client who lives alone and has left sided weakness following a stroke which of the following information is the priority for the nurse to discuss? . Transport the client to another area of the nursing unit (1) Activate the facility’s fire alarm system (2) . Close all nearby windows and doors (3) . Use the unit’s fire extinguisher to attempt to put out the fire (4) Pregunta 60 The nurse is discussing discharge plans with an older adult client who lives alone and has left sided weakness following a stroke which of the following information is the priority for the nurse to discuss? a. Reviewing information about support groups for individual who have had a stroke b. obtaining an alert system to get help in case of a fall c. providing information about available transportation resources d. choosing an agency to provide home physical therapy pregunta 61 Pregunta 62 Psychosis: Hallucinatons, lack of sleep, disorginized thought process Mania: pressured speech, spending, hallucinatons, lack of sleep (DOUBLE CHECK) Pregunta 63 Pregunta 64 . An%cipated: avoid napping, weigh the client, high calorie is all for mania. Pregunta 65 Pregunta 66 Pregunta 67 . A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make? 1. When using implanted contraceptive methods, condoms should also be used to protect against STDs 2. Use of petroleum based lubricant with a condom increases the condom’s effectiveness 3. Ensure that the condom fits snugly over the tip of the penis 4. Condoms are equally effective for birth control with or without the use of vaginal spermicides Pregunta 68 . a nurse is assessing the fontanels of 8 month old infant. which of the following findings should the nurse recognize as an expected finding? The anterior fontanel is open Pregunta 69 . a nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use? Axillary Pregunta 70 For #70 the BP seemed fine to me so I say breathsounds, wbc, temp Pregunta 71 . A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority? a. Xerostomia b. Client reports a pain level of 6 on a scale from 0 to 10 c. Excoriation of the skin on the neck and chest d. Dysphagia pregunta 72 A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago. Which of the following manifestations indicates that the client might be experiencing hypoglycemia? Confusion Pregunta 73 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. Administering potassium via IV bolus Pregunta 74 . A nurse is admitting a client to a med-surg unit. When performing medication reconciliation for the client. Which of the following actions should the nurse take? a. Compare new prescription with the list of medications the clients reports. Pregunta 75 . 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. Complete oral hygiene b. Take pancrelipase c. Use an albuterol inhaler d. Eat a meal pregunta 76 . a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A.“Let’s talk about how you can change your response to stress.” B. “We should establish our roles in the initial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” Pregunta 77 . A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (select all that apply) a. Addressing client needs when providing resources * b. Making decisions about health care on client’s behalf c. Promoting health care access* d. Encouraging clients to seek further information from the provider * e. Honoring family requests to withhold medical information *(I put this one -Jackie) pregunta 78 A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. which of the following interventions should the nurse include in the plan of care? Provide a tracheostomy tray at the bedside Pregunta 79 . A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care? A. Wash the penis from the scrotum to the tip using a spiral motion B. Discard the washcloth after cleansing the urethral meatus C. Don sterile gloves to prevent infection D. Use water with no soap to prevent skin irritation Pregunta 80 . A nurse is reviewing the medical history of a client who asked about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication. Thrombonphlebitis Pregunta 81 A nurse is caring for a client who is experiencing aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? a. posting swallowing precautions at the head of the clients bed b. noting changes in the clients treatment plan are noted in the clients medical record c. having interdisciplinary team meeting for the client on a regular basis pregunta 82 A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? (medsurg pg. 164) a. Administer nitroglycerin 0.4 mg SL 30 min before the procedure b. Draw blood specimens for culture and sensitivity c. Transport the client to radiology for a CT scan d. Obtain CBC with differential pregunta 83 . A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take? a. Report the infection to the state department of health b. Schedule the client for retesting in 1 week c. Administer ceftriaxone via intermittent IV bolus d. Instruct the client to abstain from abstain from sexual intercorse for 1 month pregunta 84 A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? A client who is taking clozapine to treat schizophrenia and reports of sore throat Pregunta 85 . 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 diabetes mellitus and a hemoglobin A1C of 6.8% b. A client who has sinus arrhythmia and is receiving cardiac monitoring c. A client who has a hip replacement and a new onset of tachypnea pregunta 86 . A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism? There were layoffs at my company, so I journal about what I accomplished during my career. Pregunta 87 Positive Brudzinski and kernigs sign, initiate seizure precaution(meningitis) Pregunta 88 . A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? b. The system is working properly pregunta 89 . A nurse is teaching a group of school aged children about healthy snack options. Which of the following snacks should the nurse include? a. cheesecake b. air popped popcorn c. milkshake made with whole milk d. baked potato chips pregunta 90 . A nurse is teaching a client who is pregnant and has genital herpes simplex virus. which of the following statements should the nurse include in a teaching? You will need to have a cesarean birth if there are any visible lesions. Pregunta 91 Pregunta 92 For #92 For fracture all checked are correct, Sprain I believe it's ecchymosis, pain level, and sensation. if you look in the ATI Med surge book on page 477 you will see. I didn't see anything for edema for a sprain. and for dislocation I want to say pain, edema, and ecchymosis. let me know what you think Pregunta 93 Pregunta 94 . Limp immobiliza%on and pain medica%on Pregunta 95 Pregunta 96 Pregunta 97 A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take? Remove the protective gown while in the client's room Pregunta 98 A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take? Remove the protective gown while in the client's room Pregunta 99 A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strips shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? a. Ventricular asystole b. Second-degree heart block c. Sinus Tachycard d. Atrial fibrillation (I put this one -Jackie) me too!!!!! A fib has no p waves and HIGH HEART RATE Pregunta 100 Pregunta 101 . A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client . Which of the following actions should the nurse take first? Review the client's allergy history Pregunta 102 . The nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility b. Increased BP c. Urinary frequency d. Swollen area on calf pregunta 103 A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. Add medication directly to enteral feeding b. Dissolve the medication together c. Use a syringe to allow the medications to flow by gravity d. Flush the NG tube with 5 ml wáter pregunta 104 . 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 pregunta 105 . A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? “Drink 2 liters of warm water per day”. Pregunta 106 . A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis? ’ A. Raise the head of the client s bed to a high-fowlers position. B. Elevate the clients effected leg on a pillow when in bed. C. Position the clients knees slightly higher than the hips when up in a chair D. Keep an abduction pillow between the clients legs. Pregunta 107 . A nurses planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care? a. Observe for bruising of the skin b. Provide a diet low in protein c. Monitor v/s every hour for the first 4 hr. d. Administer medications intramuscularly pregunta 108 A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home. which of the following actions should the nurse take? Place the oxygen tank away from curtains or drapes Pregunta 109 . A nurse manager is addressing reports of conflict within a nursing unit. The nurse should identify which of the following situations as an example of interpersonal conflict? A nurse submits A complaint about another departments handoff reporting. (with interpersonal conflict it's when two people can't see eye to eye) Pregunta 110 A school nurse is performing scoliosis screening. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis? Uneven shoulder and pelvic heights Pregunta 111 . A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery. Which of the following actions should the nurse take to promote learning? a. Speak loudly when addressing the client b. connect new information with the client's past experiences c. present the information to the client using abstract concepts d. use a 12 point font when printing written material for the client pregunta 112 A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? Document the client’s condition every 15 min Pregunta 113 . 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? The estimated blood loss was 250 ml Pregunta 114 A nurse in a long term care facility is admitting a client with dementia. Which of the following actions should the nurse take to reduce the risk for client injury? a. Keep the television on during the night b. Place the bedside table at the foot of the bed c. Raise the side rails up when the client is in bed d. Assist the client to the toilet frequently pregunta 115 . A nursing in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take? Document the clients behavior every 15 minutes Pregunta 116 A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 (low INR clotting) D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L Pregunta 117 117.A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hours ago. The nurse notes pink tinged urine and the drainage bag. Which of the following actions should the nurse take? Maintain the irrigation solution rate (ati turp pg 440 medsurge book) Pregunta 118 The charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A client who was one day postoperative following a vertebroplasty Pregunta 119 A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test? a. PT and INR b. 12 lead ECG c. Chest X-ray pregunta 120 . A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect? A. Stridor B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain (I put this one -Jackie) C. Friction rub D. Bradycardia Preguna 121 For #121 I say duration of contractions and characteristics of the amniotic fluid Pregunta 122 Pregunta 123 Pregunta 124 This one I'm a liole stuck on. I want to say everything is an%cipated and nothing is contraindicated. The only thing I'm a liole hesitant about is the lactated ringers I'm not surewhy Pregunta 125 Pregunta 126 Check this one as well , i want to say highlight everything except for the temperature. Pregunta 127 . A nurse is preparing to administer dopamine hydrochloride 4mcg/kg/min via con>nuous infusion. Available is dopamine hydrochloride in a solu>on of 800 milligrams in a 250ML bag. The client weighs 80 kilograms. The nurse should set the IV infusion to deliver how many ml/hr? 6ml Pregunta 128 . A nurse is consul>ng A pharmacological reference about medica>on compa>bility prior to administering warfarin to a client. Which of the following medica>ons should the nurse iden>fy as being incompa>ble with warfarin? Naproxen Pregunta 129 . A charge nurse is observing A newly licensed nurse provide care for a client who is postopera>ve. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse iden>fy as having occurred? assault pregunta 130 . a nurse is caring for a client who is in ac>ve labor the nurse should no>fy the provider for which of the following findings? a. Baseline fetal heart rate 115/min b. Three uterine contrac>ons within 10 minutes c. prolonged decelera>ons d. moderate variability in the fetal heart rate pregunta 131 . A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs. which of the following ac>ons should the nurse plan to take? Use a solu>on 0.9% sodium chloride to flush the transfusion tubing Pregunta 132 A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next. A. Administer flumazenil to the client. Pregunta 133 . A nurse is assessing a client following an esophagogastroduodenoscopy. Which of the following findings should the nurse report to the provider? Abdominal pain All the others like belching, flatulence, and sore throat are normal findings Pregunta 134 .A nurse is reviewing the medica>on administra>on record of a client. Which of the following prescrip>ons should the nurse clarify? Digoxen 250 PO daily Pregunta 135 . A nurse is crea>ng a plan of care for a client who has paranoid personality disorder and refuses to take their medica>on. Which of the following interven>ons should the nurse include in the plan? Speak in a neutral tone when addressing the client Pregunta 136 . A nurse is preparing to insert an IV catheter for a client. Which of the following ac>ons should the nurse plan to take? A. Elevate the clients arm prior to insertion. B. Select a site on the clients dominant arm. C. Apply a tourniquet below the venipuncture site. D. Choose a vein that is palpable and straight. Pregunta 137 A nurse in an outpa>ent mental health clinic is assessing an adolescent client . The nurse should expect the adolescent to be in which of the following of erikson stages of psychosocial development . iden>ty versus role confusion pregunta 138 A nurse is teaching a client about a variety of stress management techniques. Which of the following instruc>ons by the nurse is appropriate? Tighten your muscles before relaxing them when using muscle relaxa>on techniques Pregunta 139 . A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistant personnel telling the client “if you don't eat I'll put restraints on your wrists and feed you”. The nurse should intervene and explain to the AP that this statement cons>tutes which of the following torts? Assault Pregunta 140 A nurse is preparing to remove an IV catheter from the arm of a client who has phlebi>s at a peripheral IV site. Which of the following ac>ons should the nurse plan to take? b. Place Pregunta 141 A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take? a) Determine if the AP has the skills to perform the test. b) Help the AP performed the blood glucose test c) Assign the AP to ask the client is taking his diabetic medication today d) Have AP check the medical record for prior blood glucose test results pregunta 142 A nurse is caring for a client who is one hour postpartum and unable to urinate. Which of the following ac>ons should the nurse take? Place the clients hand in warm water Pregunta 143 . A nurse is assessing a child who has bacterial pneumonia. Which of the following manifesta>ons should the nurse expect? Fever Pregunta 144 . A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following ac>ons should the nurse take when working with the interpreter? speak in a normal voice at a natural pace. Pregunta 145 . a charge nurse is teaching a new staff member 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? previous violent behavior pregunta 146 . an occupa>onal health nurse is providing teaching to a group of factory workers about proper li`ing techniques . Which of the following statements should the nurse make? Bend at the waist when li`ing objects from the floor Pregunta 147 A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? A. Glargine insulin. B. Regular insulin. C. NPH insulin. D. Insulin aspart. Pregunta 148 . A nurse in an the emergency department is caring for a client who is ac>vely bleeding from a stab wound to the thigh. Which of the following ac>ons should the nurse take? Apply direct pressure to the wound with thick dressing material Pregunta 149 . a nurse is caring for a client who experience a trauma>c brain injury 72 hours ago. Which of the following findings should the nurse iden>fy as a poten>al indica>on of increased intracranial pressure? increasingly severe headache pregunta 150 . a nurse is assessing A 5 year old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse iden>fy as an indica>on that the medica>on is effec>ve? Heart rate 140/min B. Capillary refill 3 seconds C. Cessation of nocturnal enuresis (slows down the urine prevent bedwetting) D. Absence of hypoglycemic episodes Pregunta 151 . A nurse is caring for an infant who has coarcta>on of the aorta. Which of the following should the nurse iden>fy as an expected finding? Weak femoral pulses Pregunta 152 . a nurse is caring for a client who was at 33 weeks of gesta>on following an amniocentesis the nurse should monitor the client for which of the following complica>ons? contrac>ons pregunta 153 . a nurse is providing teaching to the parents of a newborn about newborn gene>c screening. Which of the following statements should the nurse include in the teaching? the test should be performed after your baby is 24 hours old pregunta 154 . a nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal absence syndrome. Which of the following actions should the nurse include in the plan? minimize noise in the newborns environment pregunta 155 155. the nurse is caring for a child who has cystic fibrosis and requires posterior drainage. Which of the following actions should the nurse take? Perform the procedure prior to meals Pregunta 156 a school nurse is teaching a parent about absence seizures . Which of the following information should the nurse include? This type of seizure can be mistaken for daydreaming Pregunta 157 a community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks? Ensuring that a client who is homeless receives preventative medical care Pregunta 158 . a nurse is planning care for a client who was receiving continuous internal tube feeding through an open system. Which of the following interventions should the nurse include in the plan of care? Placing a formula in the container to last 18 hours Pregunta 159 a nurse is caring for a client who asks for information regarding organ donation. Which of the following translate should the nurse make? Your desire to be an organ donor must be documented in writing Pregunta 160 . A nurses care for a client who has placenta previa which of the following findings should the nurse expect spotting pregunta 161 A charge nurse is concerned about a recent increase in facility acquired catheter infections. Which of the following actions should the nurse take? identify possible precipitating factors related to the infection pregunta 162 A nurse is assessing the grief response of a client whose child died six months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder? I am unable to fill any joy since my child died Pregunta 163 . a nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client which of the following findings should the nurse expect? Somnolence Pregunta 164 . Ok I want to say hot shower, flat or low heeled shoes, loose clothing, abdominal belt? Im iffy about but I know preg women that wears them for support, and avoid the fried foods. Pregunta 165 Pregunta 166 . A nurse in a prenatal clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. A transcutaneous electrical nerve stimulator will help with pelvic pressure b. I can use my ultrasound picture as a focal point during contractions pregunta 167 Pregunta 168 A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care? (ATI medsurg pg. 138) a. Offer the client three large meals each day (increased work of breathing increases caloric demands) b.limit fluid intake with meals ( yo respondi esta no se) c.ambulate the client before each meal d.administer a bronchodilator a`er meals pregunta 169 Pregunta 170 Pregunta 171 . The nurse is caring for a client who is in the active phase of Labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest? Provide information about the use of hydrotherapy during labor Pregunta 172 If we have this on the exam double check the drop down list to see what the other options are I am unable to see it so I don't know if this is correct. Pregunta 173 . A nurse is assessing a client who has bipolar disorder and is experiencing A depressive episode. Which of the following findings should the nurse expect? Move quickly from one idea to the next Pregunta 174 Pregunta 175 Pregunta 176 I don’t think the HR Pregunta 177 . A nurse is preparing a client for transfer to a long term care rehabilita>on facility following a below the knee amputa>on of the right leg. Which of the following ac>ons should the nurse take to protect the client's confiden>ality? Provide a verbal report of the client's condi>on to the paramedic performing the transfer Pregunta 178 A nurse is admi< ng an older adult client who was transferring from another facility. The nurse notes pressure ulcers on the clients Coccyx and abrasions around both wrists which of the following acGons should the nurse take to address suspicion of elder abuse? Privately interview the client about the injuries Pregunta 179 Pregunta 180 Pregunta 181 Esta me salio sin la columna del medio.