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Questions and Answers
Which nutrient should the nurse instruct the client to decrease in his diet?
Which action by the nurse manager demonstrates a democratic leadership style?
Which finding should the nurse expect when assessing a client with COPD?
Which client action indicates understanding of teaching for a client with peripheral arterial disease?
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Which action should the nurse plan to take to prevent the transmission of TB?
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Which response should the nurse make to a client grieving the loss of a partner?
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Which patient should the nurse recommend for treatment first?
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Which information should the nurse include in report when transferring a patient from ICU?
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Which patient should the nurse assess first after receiving the change of shift report?
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Which finding should the nurse report to the provider when assessing a newborn?
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Which activity is the nurse's priority when providing discharge teaching for a client with type 1 DM?
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Which instructions should the nurse include in discharge teaching for parents of a preschool-age child taking amoxicillin/clavulanate suspension? (Select all that apply)
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Which action should the nurse manager take first regarding staffing weekend shifts?
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Which action should the nurse take for a toddler with a blood lead level of 3?
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Which alterations in speech is a client with bipolar disorder using?
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Which step of the time management process should the nurse manager include as a priority?
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Which response should the nurse make to a client considering kidney donation?
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Which action should the nurse plan to take when administering an IM injection to an obese client?
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Which action should the nurse take for a client with schizophrenia receiving risperidone?
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Which procedure should the nurse follow to ensure proper client identification before a blood transfusion?
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Which statement should the charge nurse make to address a nurse violating break time policies?
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Which client should the nurse recommend for discharge to make room for critically injured clients?
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Which finding indicates the client's use of ginger tea is effective at 11 weeks gestation?
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How much mannitol should the nurse administer if the patient weighs 198 lb and the order is 0.2 g/kg IV bolus?
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Which action should the nurse take for a post-op patient after receiving moderate sedation who suddenly becomes restless?
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A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate?
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A nurse is caring for a patient who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
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A nurse enters a patient's room and sees smoke coming from a small fire in the trash can. Which of the following actions should the nurse take first?
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A community health nurse is providing teaching about home safety with a group of older adult patients. Which of the following statements should the nurse make?
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A nurse is developing a patient education program about osteoporosis for older adult patients. The nurse should include which of the following variables as a risk factor for osteoporosis?
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A nurse has received change of shift report on 4 assigned patients. For which of the following patients should the nurse intervene to prevent a potential food and medication interaction?
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An antepartum nurse is caring for 4 patients. For which of the following patients should the nurse initiate seizure precautions?
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A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After the nurse opens the packet containing the new pouch, the patient declines to accept it. Which of the following actions should the nurse take?
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A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the patient that which of the following findings is an adverse effect of this medication?
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A nurse is providing teaching to a patient who speaks a different language than the nurse about an upcoming diagnostic procedure. Which of the following actions should the nurse take?
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A nurse is caring for a client who has DVT. Which of the following actions should the nurse take?
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A nurse is developing a discharge plan for a school-age child who has thrombocytopenia. The nurse should instruct the child to avoid which of the following?
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A nurse is caring for a child who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following lab results indicates that the treatment regimen is effective?
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A nurse in an ED is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?
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A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.
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A nurse is caring for a client who has COPD and becomes extremely short of breath. Which of the following interventions by the nurse requires completion of an incident report?
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A nurse is caring for a patient who has hyperthyroidism. Which of the following findings should the nurse expect?
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A nurse educator is teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following examples should the nurse include as a reportable incident and an indication for completing a report?
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A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect in the client's urine?
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A nurse is assessing a patient who received 2 units of packed RBCs 48 hours ago. Which of the following findings should indicate to the nurse that the therapy is effective?
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A nurse in an ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the patient's family to obtain consent. Which of the following actions should the nurse take?
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A nurse is caring for a child who has sickle cell anemia and is having a vaso-occlusive crisis. Which of the following interventions should the nurse implement first?
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A nurse is providing teaching about advance directives to a middle adult patient. Which of the following patient responses indicates an understanding of the teaching?
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A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?
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A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding?
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A nurse is providing info to a patient immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
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A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
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A nurse is admitting a patient who has pneumonia. The nurse should initiate which of the following isolation precautions for the patient?
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A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
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A nurse is providing discharge instructions about newborn care to a patient who is 2 days postpartum. Which of the following statements indicates to the nurse that the patient understands the teaching?
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A nurse is caring for a client who has cancer and is deciding between two treatment plans. The patient asks the nurse for assistance in making a decision. Which of the following responses should the nurse make?
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A nurse is preparing for a patient for a paracentesis. Which of the following actions should the nurse take?
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A nurse is caring for a patient who is receiving positive end expiratory pressure (PEEP) via mechanical ventilator. The nurse should monitor the patient for which of the following adverse effects of PEEP?
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A nurse is assessing an infant who has hydrocephalus and is 6 hours post-op following placement of a VP shunt. Which of the following findings should the nurse report to the provider?
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A nurse is performing an admission assessment on a patient who had a recent positive pregnancy test. The first day of her last menstrual period was May 8. According to Nägele's rule, which of the following dates should the nurse document as the patient's estimated date of birth?
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A nurse at a mental health clinic is caring for four patients. The nurse should recognize that which of the following patients is using dissociation as a defense mechanism?
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A nurse is providing teaching about lithium to a patient who has bipolar disorder. Which of the following statements should the nurse include in the teaching?
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A nurse is assessing a patient who has depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of this medication?
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Which of the following interventions should the nurse use to maintain surgical aseptic technique?
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Which of the following actions should the nurse take for a patient who has a colostomy?
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The nurse should identify that the patient with pH of 7.20, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L has which of the following acid-base imbalances?
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Which of the following interventions should the nurse include in the patient's care plan who is receiving hemodialysis with an AV fistula?
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Which of the following findings indicated that the patient is experiencing fluid overload?
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Which of the following pieces of information should the nurse include when teaching about the basal body temperature method of birth control?
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Which finding should the nurse identify as a potential indication of sexual abuse in a preschooler?
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Which of the following instructions should the nurse include for a patient who is scheduled for a 3-hour oral glucose tolerance test?
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Which action should the day shift nurse take after a night nurse reports that a newly admitted patient was disoriented and combative?
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Which statement should the nurse make to inform a patient about their right to confidentiality?
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Which lab test should the nurse review prior to adjusting the patient's heparin infusion?
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Which observation should the nurse identify as an indication for potential violence in a patient with a history of aggressive behavior?
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Which action should the nurse take when digitally evacuating stool for a patient with fecal impaction?
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Which action should the nurse take to address the family's concerns about transferring a patient who has had a stroke to a rehab facility?
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Which finding should the nurse expect when assessing a patient who has pulmonary edema?
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Which finding should the nurse expect in a patient who is in the resuscitation phase of burn injury?
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Based on the lab values aPTT 98 seconds and INR 1.8 for a patient receiving heparin and warfarin, which action should the nurse take?
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Which finding should the nurse inform a client is an adverse effect of ECT?
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Which intervention should the nurse implement to prevent heat loss by conduction in a newborn immediately after delivery?
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Which situation should the nurse intervene while observing an LPN and an AP move a client up in bed?
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Which finding should indicate to the nurse that the client is experiencing an adverse reaction to propranolol?
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Which action indicates an understanding of the teaching for self-administration of insulin for a patient with a new prescription for short-acting and intermediate-acting insulin?
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Which manifestation of hypoglycemia should the nurse instruct the patient with a new diagnosis of type 1 diabetes mellitus to monitor for?
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Which instruction should the nurse include for a school-age child with asthma about using albuterol?
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Which information about advocacy should a nurse manager include in an education session?
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Which finding should the nurse identify as an indication that chlorpromazine is effective?
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Which task should the nurse delegate to the AP when caring for a patient who has fluid volume overload?
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Which action should the nurse take regarding the continuous passive motion machine following a total knee arthroplasty?
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Which child should the nurse assess first after receiving a report on 4 children?
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What response should the nurse make to a patient with major depressive disorder who expresses fear about the risks of ECT?
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Which action should the nurse take while performing gastric lavage for a patient with an NG tube in place?
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Which statement by the family indicates understanding of home hospice care?
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Which instruction should the nurse give to a child during a visual acuity test using the Snellen letter chart?
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Which statement by a patient with stage 4 breast cancer shows a constructive use of a defense mechanism?
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What action should the nurse take for a patient with a new diagnosis of terminal cancer who wishes to go home?
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Which behavior indicates that a client is bonding with her newborn 2 days postpartum?
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Which finding should the nurse expect when assessing a client for compartment syndrome?
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Study Notes
Infection Control
- For a newborn with herpes simplex virus (HSV), initiate contact isolation precautions to prevent virus transmission.
Medication Safety
- Monitor clients on valproic acid for jaundice, a possible adverse effect.
Emergency Response
- In the event of a small fire, the first action is to remove the client from the room for safety.
Home Safety for Older Adults
- Advise older adults to install grab bars around bathtubs and toilets to prevent falls.
Osteoporosis Education
- A sedentary lifestyle is a significant risk factor for developing osteoporosis. Encourage weight-bearing exercises to strengthen bones.
Food and Medication Interactions
- Clients on MAOIs should avoid foods like cheeseburgers that contain tyramine to prevent severe hypertensive reactions.
Seizure Precautions
- Initiate seizure precautions for clients with severe gestational hypertension during pregnancy due to risks of seizures.
Medication Management
- If a client declines a new transdermal fentanyl patch, ensure proper disposal witnessed by another nurse to comply with safety protocols.
Understanding Adverse Effects
- Inform clients taking clonidine that dry mouth may occur as a common side effect.
Effective Communication with Diverse Patients
- Use pictures to explain diagnostic procedures to clients who speak a different language, enhancing understanding.
DVT Management
- Instruct clients with DVT to elevate the affected extremity to reduce swelling and promote venous return.
Thrombocytopenia Caution
- Advise children with thrombocytopenia to avoid blowing their nose to prevent bleeding.
Monitoring Treatment Efficacy
- A serum sodium level of 136 mEq/L indicates effective treatment in children with hypotonic dehydration.
Reporting Suspected Abuse
- If physical abuse is suspected, the nurse must contact child protective services for appropriate intervention.
Assessment Techniques
- During an abdominal assessment, follow the sequence: Inspection, Auscultation, Percussion, Palpation to ensure accurate findings.
Incident Reporting
- Any medication administered via the wrong route must be documented as an incident to ensure patient safety.
Urinalysis Findings
- For acute glomerulonephritis, expect to find protein in urine due to increased permeability of renal glomeruli.
Blood Transfusion Monitoring
- After packed RBC transfusion, an effective outcome is indicated by a hemoglobin level of 14.9 g/dL.
Emergency Care Protocol
- In emergencies where consent is unavailable, the nurse should proceed with medical care for the best interest of the patient.
Sickle Cell Crisis Management
- Prioritize IV fluid administration in managing a vaso-occlusive crisis to improve hydration and circulation.
Advance Directives Understanding
- Clients can designate their partner as their health care surrogate, which is vital for making health decisions.
Cataract-Related Visual Impairment
- Decreased visual acuity due to cataracts is caused by increased opacity of the lens, leading to light obstruction.
Effective Breastfeeding Indicator
- Newborns should produce six to eight wet diapers daily as a sign of effective breastfeeding.
Neurological Assessment Procedures
- During a Romberg test, the nurse will check the patient's balance with eyes both open and closed.
Understanding Asthma Management
- Parents should ensure their child with asthma receives a yearly influenza vaccination to prevent respiratory complications.
Isolation Precautions for Pneumonia
- Initiate droplet isolation precautions for clients diagnosed with pneumonia to prevent airborne transmission of pathogens.
Newborn Heart Rate Assessment
- Always auscultate the apical pulse for at least 1 minute when assessing a newborn's heart rate to ensure accuracy.
Safe Newborn Care Postpartum
- Wrap the newborn during hair washing to minimize heat loss; frequent washing can disrupt skin integrity.
Patient Decision-Making Support
- Encourage clients to share their understanding of treatment options when faced with difficult health decisions.
Paracentesis Preparation
- Instruct clients to void before a paracentesis to avoid puncturing the bladder during the procedure.
PEEP Monitoring
- Monitor clients on PEEP for signs of tension pneumothorax, a possible complication from mechanical ventilation.
Postoperative Hydrocephalus Care
- Report irritability when being held in a postoperative hydrocephalus patient as it may indicate increased intracranial pressure.
Nagele’s Rule for Due Date Calculation
- Apply Nagele’s rule: add 7 days and subtract 3 months from the last menstrual period for estimated due date; e.g., May 8 yields February 15.
Use of Defense Mechanisms
- Clients may exhibit dissociation by recalling past trauma as if it happened to someone else.
Lithium Education for Bipolar Disorder
- Advise patients to notify providers about increased thirst, a sign of potential lithium toxicity.
Adverse Effects of Amitriptyline
- Identify blurred vision as a common adverse effect of amitriptyline, which may impair functioning.
Sterile Technique in Dressings
- Maintain sterile objects within the line of vision during sterile dressing changes to prevent contamination.
Colostomy Care
- After cleansing the stoma site, secure the skin barrier over the stoma and hold it for 30 seconds for proper adhesion.
Acid-Base Balance Assessment
- A pH of 7.20 and elevated PaCO2 indicates respiratory acidosis, requiring careful respiratory monitoring.
AV Fistula Care in Hemodialysis
- Auscultate the affected extremity for a bruit every 4 hours to assess the function of the AV fistula.### Bradycardia, Dyspnea, and Poor Skin Turgor
- Bradycardia refers to an abnormally slow heart rate, typically below 60 beats per minute.
- Dyspnea is characterized by difficulty or labored breathing, often associated with conditions like asthma or pulmonary edema.
- Poor skin turgor is an indicator of dehydration, where skin loses elasticity and may remain tented when pinched.
Basal Body Temperature Method for Birth Control
- Body temperature typically decreases slightly just prior to ovulation, indicating fertility awareness.
- Regularly measuring body temperature can help identify ovulation when there's a rise in temperature post-ovulation.
Indicators of Potential Sexual Abuse in Children
- Discomfort when sitting may be a significant indicator of possible sexual abuse in children.
- Other factors like personal hygiene and the location of injuries must be evaluated within the context of the child's overall behavior and history.
Oral Glucose Tolerance Test Instructions
- Patients need to fast the night before undergoing a 3-hour oral glucose tolerance test to ensure accurate results.
- Blood samples are usually taken at regular intervals to monitor glucose levels effectively.
Managing Disoriented or Combative Patients
- When dealing with a disoriented and combative patient, it is crucial to move them closer to the nursing station for increased supervision and safety.
Patient Confidentiality Rights
- Patients have the right to designate family members who can receive their health information, emphasizing the importance of confidentiality in healthcare.
Heparin Infusion Monitoring
- The activated partial thromboplastin time (aPTT) test is critical for monitoring patients on heparin therapy to ensure therapeutic levels and prevent complications.
Monitoring for Potential Violence in Mental Health Settings
- Observing patients' behavior, such as pacing or restless actions, can indicate a risk for aggressive behavior or potential violence.
Digital Evacuation of Stool in Patients
- When performing a digital evacuation, a lubricated gloved finger should be inserted carefully to minimize discomfort and ensure safety.
Addressing Concerns About Rehabilitation Facility Care
- Facilitating an interdisciplinary conference can help alleviate family concerns regarding the level of care at a rehabilitation facility.
Signs of Pulmonary Edema
- Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid accumulation in the lungs.
Fluid Volume Overload Management
- Patients exhibiting symptoms of fluid volume overload may require daily weight monitoring as part of their ongoing care strategy.
Teaching on Side Effects of ECT
- Short-term memory loss is a known side effect of electroconvulsive therapy (ECT) that patients should be made aware of during counseling.
Preventing Heat Loss in Newborns
- Using protective covers on scales helps prevent heat loss by conduction during assessments of newborns.
Delegation in Nursing Tasks
- Non-invasive tasks, such as measuring daily weight or assisting with personal hygiene, can often be delegated to ancillary personnel.
Understanding Side Effects of Propranolol
- Coughing at night could signal an adverse reaction to propranolol, necessitating further assessment and possibly consultation with the prescribing provider.
Insulin Administration Techniques
- Pinching the skin before injecting insulin helps ensure the correct depth of penetration and minimizes discomfort during self-administration.
Hypoglycemia Manifestations in Type 1 Diabetes
- Irritability is a common sign of hypoglycemia that patients should monitor regularly to prevent severe consequences.
Using Albuterol MDI for Asthma
- Advising patients to use albuterol inhalers before physical activity can significantly help in managing asthma symptoms.
Advocacy in Nursing
- Advocacy empowers individuals to make informed decisions and supports patient rights and dignity in healthcare settings.
Effectiveness Indicators for Chlorpromazine
- A decrease in hallucinations indicates that chlorpromazine is effectively managing symptoms associated with severe psychiatric disorders.
Fluid Volume Overload Management
- Measuring daily weights is a vital task to monitor and manage fluid volume overload effectively.
Continuous Passive Motion Machine Use
- Turning off the CPM machine during mealtime allows for patient comfort and proper positioning for eating.
Pediatric Triage Considerations
- Assessing patients based on severity and necessity, the child with severe abdominal pain should be prioritized for immediate evaluation.
Advanced Directives and Autonomy
- Patients retain the right to refuse medical interventions, including ECT, even after giving informed consent.
Gastrointestinal Bleeding Management
- During gastric lavage, positioning the patient on the left side optimizes fluid flow and reduces the risk of aspiration.
Understanding Home Hospice Care
- Families should know that hospice care provides support even after a patient's passing, addressing emotional and logistical needs.
Visual Acuity Testing Instructions
- During visual acuity testing, children should be instructed to keep both eyes open for accurate assessment.
Defensive Mechanisms in Coping
- Initiating community support groups can be a positive coping mechanism for individuals facing severe health challenges, showcasing constructive use of defense mechanisms.
Terminal Diagnosis Discharge Planning
- Coordinating with social services supports patients’ desires to transition home for end-of-life care.
Bonding Behavior Post-Delivery
- Sharing positive attributes of the newborn with visitors illustrates bonding behaviors and the mother's nurturing connection.
Compartment Syndrome Indicators
- Edema is a significant finding in assessing potential compartment syndrome and indicates the need for immediate intervention.
Dietary Management in Crohn’s Disease
- Reducing fiber intake can help manage gastrointestinal symptoms related to Crohn's disease and prevent further complications.
Democratic Leadership in Nursing
- Engaging nursing staff in decision-making processes exemplifies democratic leadership, fostering a collaborative environment.
COPD Assessment Findings
- An arterial blood gas analysis showing a pH of 7.31 indicates acidosis and requires further evaluation and management of respiratory status.
Peripheral Arterial Disease Care
- Applying lotion to feet is an essential practice for patients with peripheral arterial disease to prevent skin breakdown and improve comfort.
Tuberculosis Transmission Prevention
- When interacting with tuberculosis patients, ensuring they wear surgical masks during transport minimizes the risk of disease transmission.
Responding to Grief and Loss
- Acknowledging the client’s grief without minimizing their feelings provides compassionate support during challenging bereavement periods.
Emergency Department Triage
- Prioritizing unstable vital signs in patients is crucial for ensuring timely and appropriate medical intervention.
Patient Transfer from ICU
- Reporting recent pain medication administration is critical when transferring care from intensive to general medical settings to ensure consistent pain management.
Postoperative Complications Awareness
- Immediate assessment of patients with abdominal distention and absent bowel sounds is vital to identify postoperative complications early.
Newborn Assessment Follow-Up
- Reporting nasal flaring in a newborn is important as it could indicate respiratory distress or other underlying issues requiring prompt attention.
Discharge Teaching for Type 1 Diabetes Management
- Reinforcing self-care and management strategies for type 1 diabetes is essential for empowering patients to maintain their health post-diagnosis.### Medication Administration for Pediatric Patients
- Amoxicillin/clavulanate should be given every 4 hours, ensuring timely medication delivery.
- Always shake the medication bottle well before dispensing to ensure a uniform mixture.
- Store the suspension in the refrigerator to maintain its effectiveness.
- Immediate reporting of any diarrhea to a healthcare provider is crucial to prevent complications.
- Unused medication should be discarded after 21 days to ensure safety and efficacy.
Nursing Management in Long-Term Care
- Forming a staff committee can effectively address weekend staffing issues through collective input.
- Providing support for staff resistant to changes can improve morale and compliance.
- Scheduling a meeting to discuss staffing options fosters transparency and collaboration.
- Giving advance notice of scheduling changes can aid in staff planning and reduce anxiety.
Child Health Monitoring
- For a toddler with a blood lead level of 3, recommend rescreening in one year—no immediate action such as chelation therapy is needed at this level.
Mental Health Assessment
- In bipolar disorder assessment, flight of ideas refers to rapid shifts in thoughts that may occur during manic episodes.
Effective Time Management for New Nurses
- Making a list of activities is the priority step in time management, helping nurses organize tasks efficiently.
Kidney Donation Concerns
- A nurse should validate the donor's fear of potential kidney failure, addressing emotional concerns sensitively.
Injection Technique for Obese Patients
- Utilize the ventrogluteal site for IM injections in obese patients to access muscle tissue safely and effectively.
Safety Precautions for Clients on Risperidone
- Implement fall precautions for clients on risperidone, as they may experience dizziness or sedation.
Blood Transfusion Protocol
- Verification of patient and blood product information with another licensed nurse is essential for patient safety during transfusions.
Addressing Policy Violations Among Staff
- Discuss unit policies directly with nurses violating break time rules, promoting adherence to professional standards.
Discharge Recommendations in Critical Care
- Discharge a client receiving oral antibiotics for cellulitis, as they are stable and managing their condition effectively.
Effectiveness of Ginger Tea in Pregnancy
- A reduction in nausea episodes indicates the effectiveness of ginger tea for pregnant clients.
Calculating Medication Dosage
- For a patient weighing 198 lb, administer an intravenous bolus of 18 grams of mannitol.
Monitoring Post-Operative Patients
- After conscious sedation, checking the patient's oxygen saturation is critical upon noticing restlessness and lightheadedness.
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Test your knowledge with this comprehensive set of ATI Comp B RN flashcards for 2023. Covering important nursing concepts including isolation precautions and medication management, these cards are essential for any nursing student preparing for exams. Check your understanding of critical nursing interventions and pharmacological effects.
