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Questions and Answers
Which of the following statements by the client indicates an understanding of the information about advance directives?
Which of the following statements by the client indicates an understanding of the information about advance directives?
Which of the following interventions should the nurse recommend for a client with Alzheimer's disease who has difficulty sleeping at night?
Which of the following interventions should the nurse recommend for a client with Alzheimer's disease who has difficulty sleeping at night?
Which of the following actions should the nurse take for a client who is 8 hours postpartum and has uterine atony with increased bleeding?
Which of the following actions should the nurse take for a client who is 8 hours postpartum and has uterine atony with increased bleeding?
What should the nurse include in her instructions about effleurage during early stage labor?
What should the nurse include in her instructions about effleurage during early stage labor?
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Which of the following actions should the nurse take to prevent skin breakdown for an older adult client who is incontinent?
Which of the following actions should the nurse take to prevent skin breakdown for an older adult client who is incontinent?
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Which of the following instructions should the nurse take to promote the client's autonomy in terminal cancer care?
Which of the following instructions should the nurse take to promote the client's autonomy in terminal cancer care?
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Which of the following findings indicates an obstetric complication for a client at 40 weeks gestation experiencing a gush of vaginal fluids?
Which of the following findings indicates an obstetric complication for a client at 40 weeks gestation experiencing a gush of vaginal fluids?
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What action should the nurse take immediately after a lumbar puncture for an adolescent client?
What action should the nurse take immediately after a lumbar puncture for an adolescent client?
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Which of the following statements by the client indicates an understanding of teaching about advance directives with end-stage renal heart failure?
Which of the following statements by the client indicates an understanding of teaching about advance directives with end-stage renal heart failure?
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What action should the nurse take for a client with a continuous bladder irrigation who has clots and dark red blood?
What action should the nurse take for a client with a continuous bladder irrigation who has clots and dark red blood?
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What action should the nurse take while obtaining a 12-lead ECG for a client with a history of cardiac dysrhythmias?
What action should the nurse take while obtaining a 12-lead ECG for a client with a history of cardiac dysrhythmias?
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Which information should the nurse include when reinforcing teaching for a client who has genital herpes?
Which information should the nurse include when reinforcing teaching for a client who has genital herpes?
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Which action should the nurse plan when preparing to empty a post-operative client's closed-wound drainage system?
Which action should the nurse plan when preparing to empty a post-operative client's closed-wound drainage system?
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Which instructions should the nurse include for the parents of a toddler who has a new diagnosis of asthma?
Which instructions should the nurse include for the parents of a toddler who has a new diagnosis of asthma?
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Which responsibility should occur during the orientation phase of the nurse-client relationship in a mental health facility?
Which responsibility should occur during the orientation phase of the nurse-client relationship in a mental health facility?
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Where should the fetal heart monitor be placed to auscultate the fetal heart rate for a client who reports having a decrease in fetal movement after an external cephalic version?
Where should the fetal heart monitor be placed to auscultate the fetal heart rate for a client who reports having a decrease in fetal movement after an external cephalic version?
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What action should the charge nurse take when observing a newly licensed nurse perform suctioning for a client with a tracheostomy?
What action should the charge nurse take when observing a newly licensed nurse perform suctioning for a client with a tracheostomy?
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Which interaction should the nurse monitor for a client taking atenolol and using a nitroglycerin transdermal patch?
Which interaction should the nurse monitor for a client taking atenolol and using a nitroglycerin transdermal patch?
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Which action should the nurse take to verify a client's identity before administering medications?
Which action should the nurse take to verify a client's identity before administering medications?
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Which statement made by the client with psoriasis should be reported to the provider?
Which statement made by the client with psoriasis should be reported to the provider?
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Which response in the medical record should the nurse use to determine potential causes of falls in a long-term care facility?
Which response in the medical record should the nurse use to determine potential causes of falls in a long-term care facility?
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Which task should the nurse assign to the AP following the death of a client?
Which task should the nurse assign to the AP following the death of a client?
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For which manifestation should the nurse instruct the client taking allopurinol to monitor and report?
For which manifestation should the nurse instruct the client taking allopurinol to monitor and report?
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Which statement made by a charge nurse about fall precautions indicates an understanding of the teaching?
Which statement made by a charge nurse about fall precautions indicates an understanding of the teaching?
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Which client should the nurse recommend for discharge after one episode of diarrhea?
Which client should the nurse recommend for discharge after one episode of diarrhea?
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What intervention should be included in the plan of care for a newly admitted client with anorexia nervosa?
What intervention should be included in the plan of care for a newly admitted client with anorexia nervosa?
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Which statement by a newly licensed nurse indicates an understanding of the teaching about floating to a different unit?
Which statement by a newly licensed nurse indicates an understanding of the teaching about floating to a different unit?
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Which finding should the nurse report to the provider for a client with dehydration due to diarrhea?
Which finding should the nurse report to the provider for a client with dehydration due to diarrhea?
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Which actions should the nurse take to evaluate the effectiveness of a performance improvement program?
Which actions should the nurse take to evaluate the effectiveness of a performance improvement program?
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Which instruction should the nurse include when teaching staff about preparing for an external chemical disaster?
Which instruction should the nurse include when teaching staff about preparing for an external chemical disaster?
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Which action should the nurse take for a client who has an AV shunt in his right arm?
Which action should the nurse take for a client who has an AV shunt in his right arm?
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What indicates hopelessness in a client with a terminal illness?
What indicates hopelessness in a client with a terminal illness?
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Which behaviors indicate that a preschooler is ready to cooperate? (Select all that apply)
Which behaviors indicate that a preschooler is ready to cooperate? (Select all that apply)
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Which client should the nurse see first?
Which client should the nurse see first?
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What should the nurse say to a client struggling with newborn care?
What should the nurse say to a client struggling with newborn care?
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What action should the nurse take when using a glucometer?
What action should the nurse take when using a glucometer?
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Which OTC meds interact adversely with clopidogrel?
Which OTC meds interact adversely with clopidogrel?
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What should the nurse check for in a client with a long leg cast?
What should the nurse check for in a client with a long leg cast?
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What adverse effect should the nurse include in teaching about cigarette smoking?
What adverse effect should the nurse include in teaching about cigarette smoking?
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In which situation can a nurse medicate a client against his will?
In which situation can a nurse medicate a client against his will?
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What should the nurse monitor in a client taking digoxin?
What should the nurse monitor in a client taking digoxin?
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Who can a charge nurse share a client's medical info with?
Who can a charge nurse share a client's medical info with?
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Which lab finding should a nurse report for a client at 34 weeks of gestation?
Which lab finding should a nurse report for a client at 34 weeks of gestation?
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What finding requires immediate intervention for a client 4 hours post-op?
What finding requires immediate intervention for a client 4 hours post-op?
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What should the nurse report immediately in a client with a history of hypertension?
What should the nurse report immediately in a client with a history of hypertension?
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What action should the nurse take for a client with sudden chest pain and dyspnea?
What action should the nurse take for a client with sudden chest pain and dyspnea?
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Which lab test is most accurate for blood glucose effective management?
Which lab test is most accurate for blood glucose effective management?
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What action should the supervising nurse intervene for a newly licensed nurse?
What action should the supervising nurse intervene for a newly licensed nurse?
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What should the AP obtain for a client on seizure precautions?
What should the AP obtain for a client on seizure precautions?
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What action should the nurse take for a client with dependent personality disorder?
What action should the nurse take for a client with dependent personality disorder?
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What instruction should a nurse give to a client post hip arthroplasty?
What instruction should a nurse give to a client post hip arthroplasty?
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What dietary instruction should be included for a client with hyperemesis gravidarum?
What dietary instruction should be included for a client with hyperemesis gravidarum?
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What indicates understanding of ranitidine instructions?
What indicates understanding of ranitidine instructions?
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What type of isolation precautions should be implemented for a client with pulmonary TB?
What type of isolation precautions should be implemented for a client with pulmonary TB?
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What instruction should the nurse give to a client with COPD?
What instruction should the nurse give to a client with COPD?
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What outcome should be expected from administering pancreatic enzymes for cystic fibrosis?
What outcome should be expected from administering pancreatic enzymes for cystic fibrosis?
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What should the nurse say to a client with paranoid schizophrenia?
What should the nurse say to a client with paranoid schizophrenia?
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What should be ensured in Buck's traction?
What should be ensured in Buck's traction?
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What should be identified as a factor affecting oxygen saturation readings?
What should be identified as a factor affecting oxygen saturation readings?
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What description indicates xanthelasma?
What description indicates xanthelasma?
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What type of precautions are necessary for a client with VRE?
What type of precautions are necessary for a client with VRE?
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What should the nurse do to simplify medical terminology during education?
What should the nurse do to simplify medical terminology during education?
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What statement might indicate a priority concern for an adolescent?
What statement might indicate a priority concern for an adolescent?
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What type of wound dressing should be used for a stage 1 pressure ulcer?
What type of wound dressing should be used for a stage 1 pressure ulcer?
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What action should be taken for a client with pain who has a prescription for ketorolac?
What action should be taken for a client with pain who has a prescription for ketorolac?
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Which actions should a charge nurse take when developing a performance improvement plan for an AP? (Select all that apply)
Which actions should a charge nurse take when developing a performance improvement plan for an AP? (Select all that apply)
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What instruction should a nurse provide for a client undergoing radiation therapy to the neck?
What instruction should a nurse provide for a client undergoing radiation therapy to the neck?
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What fall precaution should the nurse implement for an older adult with impaired mobility?
What fall precaution should the nurse implement for an older adult with impaired mobility?
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What should the nurse include about intermittent catheterization?
What should the nurse include about intermittent catheterization?
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What should the charge nurse do regarding a terminal cancer patient who has declined treatment?
What should the charge nurse do regarding a terminal cancer patient who has declined treatment?
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What information should be provided to a postpartum client about breastfeeding?
What information should be provided to a postpartum client about breastfeeding?
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What action should be taken for a school-aged child upon admission?
What action should be taken for a school-aged child upon admission?
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What intervention should be included in the plan for a client with ascites due to cirrhosis?
What intervention should be included in the plan for a client with ascites due to cirrhosis?
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What food should a nurse recommend to a client taking antibiotics to reduce diarrhea?
What food should a nurse recommend to a client taking antibiotics to reduce diarrhea?
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What action should be taken for a client with increased intracranial pressure?
What action should be taken for a client with increased intracranial pressure?
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What action should be included for a pregnant client in the third trimester with ankle edema?
What action should be included for a pregnant client in the third trimester with ankle edema?
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What intervention should be recommended for a client experiencing delirium?
What intervention should be recommended for a client experiencing delirium?
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Which food should be included in pamphlets about choking hazards for toddlers?
Which food should be included in pamphlets about choking hazards for toddlers?
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What should be instructed regarding sputum examination for a client with TB?
What should be instructed regarding sputum examination for a client with TB?
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What action should be taken for a client at 37 weeks gestation undergoing a nonstress test?
What action should be taken for a client at 37 weeks gestation undergoing a nonstress test?
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What intervention should be included for a client with dysphagia?
What intervention should be included for a client with dysphagia?
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What finding should the nurse monitor and report in a client at 18 weeks gestation with mild hypertension?
What finding should the nurse monitor and report in a client at 18 weeks gestation with mild hypertension?
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What statement should a nurse make to a client’s partner after a recent death?
What statement should a nurse make to a client’s partner after a recent death?
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What response is appropriate to a client who felt neglected during their last hospitalization?
What response is appropriate to a client who felt neglected during their last hospitalization?
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Which communicable disease should the nurse report to the state health department?
Which communicable disease should the nurse report to the state health department?
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What finding should the nurse expect in a client suspected of bacterial meningitis?
What finding should the nurse expect in a client suspected of bacterial meningitis?
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What lab value is expected for a client with end-stage renal disease?
What lab value is expected for a client with end-stage renal disease?
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What instruction should the nurse follow for a client on warfarin with an INR of 5.5?
What instruction should the nurse follow for a client on warfarin with an INR of 5.5?
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What signs indicate fluid volume excess?
What signs indicate fluid volume excess?
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What should the nurse say regarding the benefits of a Pavlik harness?
What should the nurse say regarding the benefits of a Pavlik harness?
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Where should the nurse document a medication administration error?
Where should the nurse document a medication administration error?
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How should the nurse prepare a sterile field for a dressing change?
How should the nurse prepare a sterile field for a dressing change?
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What term describes the nurse's action of interrupting a bath to obtain food for a client?
What term describes the nurse's action of interrupting a bath to obtain food for a client?
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What isolation precautions should be implemented for a client with herpes simplex?
What isolation precautions should be implemented for a client with herpes simplex?
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What should the nurse take if a space was left blank in documentation?
What should the nurse take if a space was left blank in documentation?
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What disinfectant should be used after a blood spill for a client with AIDS?
What disinfectant should be used after a blood spill for a client with AIDS?
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What safety risk is indicated by electrical wires running under the carpet?
What safety risk is indicated by electrical wires running under the carpet?
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What should be included in the informed consent teaching?
What should be included in the informed consent teaching?
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What should the nurse inform a client taking metronidazole?
What should the nurse inform a client taking metronidazole?
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What should the nurse remind the client undergoing an invasive procedure?
What should the nurse remind the client undergoing an invasive procedure?
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Study Notes
Terminology and Nursing Concepts
- "Decreased level of energy" may indicate hopelessness in clients with terminal illnesses.
- Cooperative behaviors in preschoolers include allowing touch, answering questions, and making eye contact.
Mental Health and Safety
- Clients experiencing command hallucinations (e.g., schizophrenia) should receive priority nursing care.
- Involuntary medicating is permissible for clients attempting self-harm or harming others.
Client Education and Interaction
- Providing guidance to new parents—like swaddling—can alleviate feelings of inadequacy.
- Client education for medications includes interaction awareness, especially between clopidogrel and naproxen.
Patient Assessment and Interventions
- For clients with leg casts, checking passive movement pain is crucial to assess complications.
- Hypoxemia is indicated by an O2 saturation of 89%, requiring immediate intervention.
Sputum and Dietary Considerations
- Clients with cystic fibrosis should be expected to show reduced fat in stools with pancreatic enzyme therapy.
- For clients with hyperemesis gravidarum, eating small meals every 2-3 hours is advised.
Discharge Instructions and Health Teaching
- Clients post-arthroplasty should be instructed to avoid crossing legs for 3 months.
- Effective management of diabetes mellitus is indicated by glycosylated hemoglobin tests.
Safety Protocols
- Ensure sterile practices during dressing changes by keeping objects at least 1 inch away from the sterile field.
- Use of appropriate isolation precautions for clients with VRE includes contact precautions.
Assessment and Observation Techniques
- Distended neck veins indicate potential fluid volume excess in clients on continuous IV.
- Urine that is brown after metronidazole is expected for clients with trichomoniasis.
Emotional Support and Communication
- When supporting clients with terminal illnesses, affirming their decisions is essential.
- Engaging in open-ended conversations with grieving families helps validate their experiences.
Health Indicators and Risks
- Persistent headaches in pregnant clients should be monitored as they can signal complications.
- Xanthelasma appears as yellowish nodules on eyelids and is associated with lipid imbalance.
Autonomy and Patient Engagement
- Empower clients with terminal illnesses by allowing them to choose treatment schedules and times.
- Encourage assertiveness in clients with dependent personality disorders during discharge teaching.
Clinical Knowledge and Skills
- Utilize transparent films as dressings for stage 1 pressure ulcers.
- Recognize that countertransference may occur when personal feelings influence care decisions.
Documentation and Reporting Protocols
- Document medication errors (e.g., overshooting dosage) in incident reports for transparency.
- Report communicable diseases like Neisseria gonorrhoeae to health authorities as required.
Nursing Interventions for Specific Conditions
- Clients with early labor should be taught effleurage techniques to manage discomfort.
- Regularly remind clients with delirium of day and time orientation to reduce confusion.
Additional Practical Guidelines
- Practice safe handling by ensuring that electrical wires are not a tripping hazard for older patients.
- Advise dietary adjustments for clients on antibiotics to mitigate diarrhea, such as incorporating yogurt.
Critical Assessments in Labor
- Assessing and noting any complications in vaginal fluid discharge at 40 weeks is vital for maternal and fetal health.### Lumbar Puncture Care
- Inform the adolescent that headaches may occur post-procedure.
Advance Directives
- Discussing advance directives with family is essential after signing; shows client understanding of the process.
Bladder Irrigation Post-TURP
- Administer 20-30 ml of 0.9% sodium chloride for bladder irrigation if clots and dark blood are observed.
ECG Procedure
- Instruct the client to stay as still as possible during a 12-lead ECG to ensure accurate results.
Genital Herpes Management
- Increase fluid intake to alleviate dysuria in clients with genital herpes.
Postoperative Drainage Care
- Compress the container prior to replacing the drainage bag to maintain suction.
Asthma Management for Toddlers
- Administer Montelukast daily each evening to children diagnosed with asthma.
Nurse-Client Relationship
- Defining responsibilities occurs during the orientation phase in a mental health facility.
Fetal Heart Rate Monitoring
- Place the fetal heart monitor on the lower left side to assess fetal heart rate in right occiput anterior position.
Tracheostomy Suctioning
- Limit suction duration to 30 seconds to prevent hypoxia; monitor newly licensed nurses for adherence.
Monitoring Medication Interactions
- Observe for hypotension in clients taking atenolol and nitroglycerin together.
Client Identity Verification
- Verify the client’s identity using a photograph before medication administration to ensure safety.
Psoriasis and Body Image
- Report statements indicating poor body image, such as avoiding scales, to the provider.
Fall Risk Assessment
- Review medication records for clients in long-term care facilities to identify potential fall causes.
Post Mortem Care Assignment
- Assign the task of completing post mortem care to an unlicensed assistive personnel (AP).
Allopurinol and Stevens-Johnsons Syndrome
- Monitor and instruct clients on the signs of skin rash accompanied by fever, indicating a severe reaction.
Fall Precautions in Long-Term Care
- Encourage sitting while dressing as a fall prevention strategy.
Client Discharge Recommendations
- Recommend discharge for stable clients, such as those with a sodium level of 140 mEq/L post-diarrhea.
Nutritional Support for Anorexia
- Include the administration of liquid supplements in the care plan for clients with anorexia nervosa.
Floating and Documentation
- Document the support received from a nurse when floating to different units to ensure accountability.
Reportable Findings for Dehydration
- Report a BUN level of 18 mg/dL in dehydration cases, as it signals potential complications.
Performance Improvement Evaluation
- Identify and implement data collection methods to assess program effectiveness in nursing care.
Chemical Disaster Preparedness
- Move clients to above-ground rooms with windows during external chemical disasters for safety.
AV Shunt Care
- Avoid performing range of motion exercises on the right arm in clients with an AV shunt to prevent complications.
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Description
Prepare for the ATI Exit Exam 2023 with these helpful flashcards. Each flashcard covers essential nursing concepts and patient indicators that you might encounter in clinical practice. Test your understanding and improve your knowledge in patient care and assessment.
