ATI PN Comprehensive Online Practice 2020 A 150 Q/A 1. A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actio ns should the nurse take? ANS: Assure the client that a family member will stay with the body after death RAT: The nurse should assure the client that a family member will remain with the body until burial 2. A nurse is caring for a client who is receiving telemetry. which of the following ECG findings should the nurse report to the charge nurse? PR interval 0.24 seconds. 3. A nurse in an urgent care clinic is collecting data from four clients. which of the following clients should the nurse recommend for treatment? a client who is experiencing shortness of breath after taking amoxicillin. 4. A nurse is assisting with the transfer of a client to a long term care facility. the nurse should review which of the following sections of the electronic medical record to locate information about the clients personal health insurance? admission sheet. 5. A nurse is reinforcing teaching with a client who is scheduled for a lumbar punture. which of the following statements should the nurse make? you should increase your fluid intake after this procedure. 6. A nurse is reinforcing teaching about puberty with a group of prepubescent female clients. Which of the following information should the nurse include in the teaching? you will likely gain weight before you start to get taller. 7. A nurse is assisting with a discussion about STI's with a group of adolescents at a health fair. which of the following statements should the nurse make? an infection with gonorrhea may result in infertility. 8. A nurse in a providers office is caring for client who is at 34 weeks of gestation. Which of the following instructions should the nurse anticipate providing to the client? monitor your blood pressure using your right arm daily. 9. A nurse is preparing to administer amoxicillin 875 mg PO every 12 hours. The amount available is amoxicillin oral suspension 400 mg/5mL. How many mL should the nurse administer per dose? 11. B. 21. 10.A nurse is collecting data from a client who has chronic hepatitis. In which of the following locations should the nurse expect the client to point to indicate hepatic tenderness? 11.A nurse is monitoring a client who is receiving lactated ringers 500 mL over 4 hr. the drop factor of the manual IV tubing is 10gtt/mL. The nurse should check that the manual IV infusion is delivered at how many gtt/min? 12.A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include? apply capsaicin cream four times a day. 13.A nurse is reviewing a client's medication record and notices that a double dose of oral digoxin was administered 1 hr ago. Which of the following actions should the nurse take first? ANS: Obtain a set of the client's vital signs RAT: The first action the nurse should take when using the nursing process is to collect data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the nurse can identify the need for intervention 14.A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A and is incontinent of stool. Which of the following infection control precautions should the nurse instruct the AP to use? ANS: Contact RAT: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to prevent the spread of infection. However, if the client who 15.A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the electronic health record to locate information about the client's personal health insurance? ANS: Admission sheet RAT: The nurse will find client data, such as date of birth, occupation, and the client's source of health insurance, on the client's admission sheet 16.A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider? ANS: Generalized petechiae RAT: Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of the newborns who has a nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the newborn's body can indicate infection or a decreased platelet count and should be reported to the provider 17.A nurse in a provider's office is obtaining the health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority for the nurse to ask? ANS: "Do you know if you're allergic to iodine?" RAT: The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies 18.A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider? ANS: INR 5.0 RAT: The international normalized ratio (INR) is a measurement of the body's blood clotting ability. A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value 19.A nurse is evaluating the safe use of electrical equipment by a newly hired assistive personnel (AP). Which of the following actions by the AP demonstrates an understanding of the proper use of electrical equipment? ANS: Grasps the plug of a device in the client's room to pull it straight out from the wall RAT: The nurse should recognize that by grasping the plug, rather than the cord, the AP is demonstrating an understanding of proper equipment use and preventing risk of injury from electronic equipment. 20.A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching? ANS: "I will soak my child's toothbrush in warm water to soften it before my child uses it." RAT: The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge-tipped disposable toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity 21.A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion? ANS: A client hits another client because they thought the other client was talking about them RAT: The nurse should request a prescription for seclusion for a client who hits another client to protect the client and others from physical injury 22.A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? ANS: Coronary artery disease RAT: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension 23.A nurse is assisting with the care of a school-age child immediately following surgery. The child weights 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider? ANS: 250 mL of sanguineous drainage over the last 3 hr RAT: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately 24.A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. Which of the following findings should the nurse report to the provider as an indication of hyperglycemia? ANS: Polyuria