ATI Capstone Comprehensive Exam B

Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

Ask another nurse to witness the disposal of the new patch.

Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8

Withhold the heparin infusion

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina

Floating dark spots

infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider

Irritability when being held. signifies increased ICP

Assessing a newborn heart rate follow actions the nurse should take

Auscultate the apical pulse and count beats for at least 1 min.

Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool

Insert a lubricated gloved finger and advance along the rectal wall.

Dietary teaching for a new prescription of phenelzine

Broccoli, Yogurt, Cream Cheese

Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse document in the client's medical record?

Time the medication was given

Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first?

A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain. Can indicate peritonitis from a ruptured appendix.

Community health nurse providing teaching on home safety for older adults

Have grab bars installed around your bathtub and toilet.

School age child with scald burns on both hands and wrists suspected abuse

Contact child protective services.

Client who has acute blood loss following trauma refuses potentially life saving blood transfusion

Explore the client's reasons fro refusing the treatment

Discussing common prenatal discomfort 20 weeks gestational

I will wear a supportive bra overnight

Discharge instructions to client to received home oxygen therapy

Wear clothing made with cotton fabrics while oxygen is in use.

Preparing an educational session about advocacy to a group of nurses

Advocacy is a leadership role that helps others to self actualize

Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and decreased urinary output

Irrigate the catheter with 0.9% sodium chloride irrigation

Child with sickle cell anemia and is having a vaso-occlusive crisis

Infuse IV fluids

Client teaching about the basal body temp method for birth control

Your body temperature might decrease slightly just prior to ovulation

Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent

Proceed with provision of medical care

Client who has fluid volume overload. Which tasks can nurse delegate to UAP

Measure the client's daily weight

Checking for Chvostek's sign

The nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia.

Reviewing urinalysis report of client with acute glomerulonephritis expected findings

Protein

Newly admitted child. Which of the following actions should the nurse include in the plan

Administer high dose antibiotic therapy

Client with cancer deciding between two treatment plans

tell me more about your understanding of the options.

Caring for a client receiving hemodalysis with AV fistula

Auscultate the affected extremity for a bruit

Oncology unit nurse is administering doxorubicin to breast cancer patient

Inspect the client's mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding

Hospice nurse consulting about receiving home services

We can expect the hospice nurse to provide support for us after our mother's death

Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure about this now I'm afraid it's too risky

You have the right to refuse to have the ECT even after you have agreed to it

Discharge instructions about newborn care to a client 2 days postpartum

I will cover my baby's body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose.

Assigning task roles for group of clients in community mental health clinic. Which should be assigned to group functioning the orienter

Noting the progress of the group toward assigned goals

Nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster

A client who has cellulitis and is receiving oral antibiotics every 8 hours.

Developing a client education program about osteoporosis for older adult clients

Sedentary lifestyle

Charge is providing educational session about infection control for a group of staff on isolation precautions

A client who requires airborne precautions should be placed in a negative pressure airflow room

Preparing to assist with a thoracentesis for a client who has pleurisy

Instruct the client to avoid deep breathing during the procedure

Caring for a school age child taking valporic acid. Diagnostic tests

Serum liver enzyme levels

Inpatient mental health unit is monitoring a visit between client with aggressive behavior and the client's partner

The client is pacing around the chair in which his partner is sitting.

Home health nurse evaluating a school age child with cystic fibrosis initiates a request for high frequency chest compression vest

My child has only a small amount of mucus after percussion therapy

Planning care for a client with left sided weakness following a stroke

Support the client's left arm on a pillow while sitting

caring for a client who has schizophrenia who recently started risperidone

Implement fall precautions for the client

Caring for a child with a fever and fluid filled vesicles on trunk and extremities. Identify priority

Initiate transmission based precautions

Assessing client for compartment syndrome expected findings

Edema

Just received change of shift report on 4 clients. Which should the nurse assess first

A client who is postop with abdominal distention and no bowel sounds

Assessing a client after administering epinephrine for anaphylactic reactions. Identify adverse effect of this med

Report of Chest pain

Provide teaching to client 24 wks gestation scheduled for glucose tolerance test

You will need to fast the night before the test.

Assessing older adult client with pneumonia

acute confusion

Teaching for client about right to confidentiality

You can provide a list of family members who can receive information about the diagnosis.

Caring for a client reporting nausea and vomiting the past 2 days

Urine specific gravity 1.052

Caring for a client postop after receiving moderate conscious sedation suddenly becomes restless and reports feeling lightheaded

Check the client's oxygen saturation level

Assessing client who is 11 wks gestation and reports drinking ginger tea. signs of it's effectiveness

The client reports a decrease in episodes of nausea

Teaching a client who newly diagnosed with DM. Instructions on manifestations of hypoglycemia

Irritability

caring for a client with DVT

Instruct the client to elevate the affected extremity when sitting

Providing info to a client immediately before Romberg test

I will be checking you once with your eyes open and once with them closed

Providing teaching to parents of child with autism spectrum disorder

Use a reward system to modify the child's behavior

Teaching a client undergoing ECT about adverse effects

Short term memory loss

Caring for a client with active TB about disease transmission

Have the client wear a surgical mask while being transported outside the room.

Assess 1 wk old for palmer grasp reflex

By touching the palms of the infant's hands near the base of the digits causing the flexion of the fingers

Conducting a mental status examination on newly admitted client. Priority assesment

Ideals of self harm

Caring for a client with a prescription of chlorpromazine indications of effectiveness

Decreased hallucinations

Assessing a client whose partneer recently died. States I don't know what to do without my partner. Life is not worth living

You seem to be having a difficulty time right now

Developing discharge plan for school age child with thrombocytopenia. What should the child avoid

Blowing the nose it increases the risk for bleeding or hemorrhaging.

Reviewing lab report for client in end stage kidney disease who received hemodialysis 24 hr ago. Findings to report to provider

sodium 148 mEq/

Caring for a client with a magnesium level of 2.5 mEq/l

Initiate continuous cardiac monitoring

Outpatient mental health clinic clients which of the following clients is effectively using sublimation as a defense mechanism

A client who channels her energy into a new hobby following the loss of her job

Caring for a group of clients which one should the nurse see first

An older adult client who is anxious and attempting to pull out his IV line

Preparing to teach about dietary management to a client with Crohn's disease with a enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in his diet

Firber

Caring for a client who is in resuscitation phase of burn injury

Hyponatremia

Teaching self administration of insulin to a client with short acting and intermediate acting insulin

Pinches the skin prior to injecting the insulin

Teaching a client 26 wks gestation about a glucose tolerance test.

avoid caffeine

Caring for a client who has hyperthyroidism

Tremors

Caring for a newborn with herpes simplex virus which precautions should be initiated

Contact

Postpartum nurse is caring for 4 clients which one should be on seizure precautions.

A client who is as 33 wks of gestation and has severe gestational hypertension

Assessing an adolescnet who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Assess for adverse effects

Have you had any stomach pain or bloody stools

Caring for older adult who is experiencing chronic anorexia and receiving tube feedings. Lab values that indicate additional nutrients are needed

Albumin 2.8 g/dL

Teaching to school age child with asthma using albuterol dose inhaler instructions

Take the medication 15 min before playing sports

Assessing a client with decreased visual acuity due to cataracts. Identify physiological changes

Increased opacity of the lens

Mental health clinic caring for clients. Which of the following clients is using dissociation as a defense mechanism?

A client who was abused as a child describes the abuse as if it happened to someone else

Assessing a 2 wk old newborn with a birth weight of 3.64 kg being breastfed. Indicators of effective breastfeeding

The newborn has 6 to 8 wet diapers per day

Preparing to administer a blood transfusion to a client . Ensure proper client identification

Verify the client and blood product information with another licensed nurse

Reviewing client's right with the nurses on the unit. Informed consent promotes which of the following ethical principles

Autonomy

Teaching about lithium to client who has bipolar disorder

Notify your provider if your experience increarsed thirst

Change of shift report informs of newly admitted client with disoriented and combative during the night. Actions the day shift nurse should take

Move the client to a room near the nurses' station.

Caring for an 18-month old toddler who has a blood lead level of 3mcb/dL. Which of the following actions should the nurse take

Recommend re-screening in 1 year

Assessing a client who has bipolar. Which of the following alterations in speech is the client using

Flight of Ideas

Working in ED triaging 4 clients. Which of the following clients should the nurse recommend for treatment first?

A middle aged adult client who has unstable vital signs

Admission assessment on a client who had a recent positive pregnancy test. First day of her last menstrual period was May 8 . Nagel's rule EDB

February 15

Assessing a client who received 2 units of packed RBCs 48 hr ago. Findings that indicate the therapy is effective?

Hemoglobin 14.9 g/dL

Caring for a client who recently signed informed consent to donate a kidney to her sibling in ERF. States "I don't want my brother to die, but what if I need this kidney one day?"

You afraid that you other kidney will fail at some point after the organ donation

A nurse is preparing to administer an IM injection to a client who is obese

Use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels.

Providing education to the parent of school age child with asthma. Indicates understanding?

I will make sure my child receives a yearly influenza vaccination

Admitting a client who has pneumonia. Should initiate which type of isolation precautions?

Droplet

Assessing a client who has COPD

pH 7.31. Respiratory acidosis is an expected finding for a client who has COPD

Providing teaching for teaching for a client who has a fracture of the right fibula with a short leg cast in place. Client is non weight bearing for 6 weeks.

Use a three-point gait

Caring for a child who has hypotonic dehydration and is receiving an oral re-hydration solution. Lab results indicates treatment effective

Serum sodium 136 mEq/L

Assessing a client who has pulmonary edema. Finding to expect

Pink, frothy sputum-due to fluid leaking across the pulmonary capillaries and into the lung tissue.

Received change of shift report on 4 clients. Which one should the nurse intervene to prevent food and medication interaction?

A client who is receiving a MAOI and is requesting a cheeseburger for dinner. -Contains tyramine can cause hypertension

Assessing a client following vaginal delivery and notes heavy lochia and a boggy fundus. Which med should be administered

Oxytocin

Caring for a client with a new diagnosis of terminal cancer. Client states he would like to go home to be with family and loved ones.

Make a referral for social services

Caring for a client who is taking valproic acid for seizure control. Adverse effect to monitor and report

Jaundice-clients are at risk for liver damage.

Manager planning to use a democratic leadership style. Which of the actions demonstrates democratic leadership style?

Seeks input from the other nurses

Assessing a client with history of seeking counseling for relationship problems. Shows the nurse multiple superficial self-inflicted lacerations on her forearms. This behavior should be identified as a characteristic of which personality disorder

Borderline-emotionally unstable, have troubled interpersonal relationships and often engage in harmful behaviors such as cutting, substance use and suicidal thoughts.