NURS 493 ATI PN comprehensive Test bank
FYI numbers that are highlighted in yellow are confirmed
VERSION 2 -
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?...
FYI numbers that are highlighted in yellow are confirmed
VERSION2-2016
1. Anurseisplanningcareforapreschool-agechildwhoisintheacutephaseofKawasakidisease.Whichofthe
followinginterventionsshouldthenurseincludeintheplanof care?
a. Give acetaminophen to control the child’s fever
B. Monitor the client’s cardiac status(Peds p120)
c. Administer antibiotics via intermittent IV bolus for 24hrs
d. Provide stimulation with children of the same age in theplayroom
2. Anurseobservesaclientonthepsychiatricunitmutteringandstandingnearawindow.Theclientstates,“The
voicesaretellingmetojump.”Whichofthefollowingisanappropriateresponsebythe nurse?
a. “Do you recognize the voices as belonging to anyone you know?”
B. “I understand the voices are frightening you, but I do not hear any voices.”
c. “That can’t be true. The only voices in this room are yours andmine.”
d. “Youshouldn’tbeafraidwhenyouthinkthevoicesaretellingyoutohurtyourself.” Rationale: try
to reorient the client back toreality.
3. Anurseiscaringforaclientwhoispreparinghisadvancedirectives.Whichofthefollowingstatementsbythe
clientindicatesanunderstandingofadvancedirectives?(Selectallthatapply.)
a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnessesit)
b. “I have the right to refuse treatment.”(Leadershipp38)
c. “Mydoctorwillneedtoapprovemyadvancedirectives.”(justneedstowriteaprescription)
d. “Myhealthcareproxycanmakemedicaldecisionsforme.”(Leadershipp38)
e. “I can’t change my advance directives once submitted.” (yes youcan)
4. Aclientwhoispregnantvoicesherconcernthather3-year-oldsonwillfeelleftoutoncethenewbornarrive. Which of the
following statements by the nurse isappropriate?
a. “Offeryoursonagiftwhenthebabyreceivesone.”(Provideagiftfromtheinfanttogivethesibling)
b. “Teachyoursontochangethebaby’sdiapers.”(Allowoldersiblingstohelpinprovidingcareforthe infant)
c. “Tellyoursontokissthebaby.”(Maternityp126:Letthesiblingbeoneofthefirsttoseetheinfant)Don’tforce interactionsbetch
d. “Moveyoursontoatoddlerbedwhenthebabyarrives.(do this weekspriortobaby’sarrival)
5. Anurseisteachingaclientwhohasnephroticsyndromeaboutdietarymanagement.Whichofthefollowing instructions should
the nurse include in theteaching?
a. Limit total daily sodium intake to 4 to 5 grams
B.Obtain most calories from complex carbohydrates
c. Consume a high-protein diet (Sufficient amount of protein, high potassium, lowsodium)
d. Avoid intake ofsoyproducts.
Rationale:Excessofproteinshouldbeavoidedbecauseaveryhighproteindietmaycausetubulardamagetothe
kidneysasthekidneyswillhavetofiltermoreoftheproteins.Butmoderateproteinintake(about1gm/kgbody weight) is mandatory to
compensate for the protein loss intheurine.
,6. Anurseisinterviewinganadolescentclientwhohasahistoryofphysicalaggressionduetoangermanagement issues.Which
ofthefollowingisanappropriatequestionbythenurse?
a. “Did you think about removing yourself from the situation when you becameangry?”
b. “Whydoyougetangrywhenthingsdon’tgoyourway?”
c. “Howdoyouthinkothersfeelwhenyouexpressanger?”
D. “What are you thinking about when you express anger?”(assessing the underlying issue of aggression)
7. Anurseisplanningcareforaclientwhohasasealedradiationimplantandistoremaininthehospitalfor1
week.Whichofthefollowingshouldthenurseincludeintheplanofcare?
a. Wear a dosimeter film badge while in the client’s room.(Med Surgp583)
b. Ensure family members remain at least 3 feet from the client(should be at least6ft)
c. Limit each of the client’s visitors to 1 hr per day.(should be 30minutes)
d. Remove dirty linens from the room after double bagging.Keep in theroom
8. Anurseispreparingtofeedanewlyadmittedclientwhohasdysphagia.Whichofthefollowingactionsshould the nurse plan to
take?talaga
a. Sitatorbelowtheclient’seyelevelduringfeedings(Fundsp215:Observeforaspirationandpocketingof food in the cheeks
or other areas of themouth)
b. Talkwiththeclientduringherfeeding
c. Discouragetheclientfromcoughing duringfeedings(encouragepttocoughtopreventaspiration)
d. Instruct the client to lift her chin when swallowing (tuckchin)
9. Anurseiscaringforapreschoolchildwhoisdehydrated.Whichofthefollowingassessmentfindingsindicates
moderatedehydration?
a. Bradypnea
B. Oliguria(Funds p343)
c. Diaphoresis
d. Excessivetears
10. Anurseisprovidingteachingtoaparentofachildwhohasvaricella.Whichofthefollowingstatementsshould the nurse include in
theteaching?
a. “Your child can return to school after a negative titerresult.”
b. “Yourchildcanreturntoschool24hoursafterbeginningantibiotics.”
c. “Yourchildcanreturntoschooloncethelesionshavecrustedover.”
d. “Your child can return to school once the fever hassubsided.”
11. Anurseisprovidinginformationforaclientwhohasanewprescriptionforsimvastatin.Forwhichofthe
followingshouldthenurseinstructtheclienttomonitorandreporttotheprovider?
a. Muscle weakness -rhabdomyolysis
b. Edema
c. Weightloss
d. FeverRational
e:S i m v a s t a t i n
Althoughmildmusclepainisarelativelycommonsideeffectofstatins,somepeoplewhotakestatinmedicationsto
lowertheircholesterolmayhaveseveremusclepain.Thisintensepainmaybeasymptomofrhabdomyolysis,arare condition that causes
muscle cells to break down. The most common signs and symptoms of rhabdomyolysis include:
" Severe muscle aching throughout the entirebody
, " Muscleweakness
" Dark or cola-coloredurine
The higher the dose of statins, the higher the risk of rhabdomyolysis becomes. The risk also increases if certain
drugs — including cyclosporine (Sandimmune) and gemfibrozil (Lopid) — are taken in combination with statins.
However,theriskofdevelopingrhabdomyolysisfromstatintherapyisverylow,around1.5foreach100,000people
takingstatins.Rhabdomyolysisormilderformsofmuscleinflammationfromstatinscanbediagnosedwithablood
testmeasuringlevelsoftheenzymecreatininekinase.Ifyounoticemoderateorseveremuscleachesafterstartingto take a statin, contact
your doctor. If you have signs and symptoms of rhabdomyolysis, stop taking your statin medication immediately and seek medical
treatment right away. If necessary, your doctor may take steps to help prevent kidney damage and othercomplications.
12. Anurseonamedical-surgicalunitisreceivingreportonfourclients.Whichofthefollowingclientsshouldthe nurse assessfirst?
a. A client who is receiving warfarin and has an INR of3.3
b. AclientwhohadanNGtubeinserted6 hrsagoandhasabdominaldistention
c. Aclientwhois4hrspostoperativefollowingathyroidectomyandreportsfullnessinthebackofthe throat(edema
can lead to respdistress)
d. Aclientwhohasacutekidneyinjury,acreatinineof4 mg/dL,andaBUNof52 mg/dL
13. Anurseisreceivingreportonfourpostpartumclients.Whichofthefollowingclientsshouldthenurseplanto attend tofirst?
a. Aclientwhoreportschangingherperinealpadevery2hrs
b. Aclientwhoreportsabdominalpainduringbreastfeeding
c. A client who has a urine output of 250 mL in 6hrs
D. A client who has hyporeflexia while receiving magnesium sulfate
14. Anurseisprovidingnutritionalteachingregardingappropriatefoodchoicestoaclientwhohasanewdiagnosis
ofuricacidcalculi.Whichofthe followingshouldthenurseincludeintheteaching?
a. Roastbeef
b. Chickenbreast
c. Low-fat yogurt(avoid purine foods: organ meats & shellfish &poultry)
d. Tunafish
15. Anurseintheemergencydepartmentiscaringforaclientwhohasafull-thicknessburnofthethoraxand
uppertorso.Aftersecuringtheclient’sairway,whichofthefollowingisthenurse’spriorityintervention?
a. Preventinginfection
b. Offering emotionalsupport
c. Providing painmanagement
D. Initiating IV fluid resuscitation repeat
16. Anurseiscaringforaclientwhowillundergoaprocedure.Theclientstatesshedoesnotwanttheproviderto
discusstheresultswithherpartner.Whichofthefollowingisanappropriateresponseforthenursetomake?
a. “The provider will be tactful when talking to yourpartner.”
B. “You have the right to decide who receivesinformation.”
c. “Is there a reason you don’t want your partner to know about yourprocedure?”
d. “Your partner can be a great source of support for you at thistime.”
, 17. Anurseisprovidingteachingaboutdietaryrecommendationstotheparentsofaschool-agechildwhohasacute
kidneyinjury.Whichofthefollowingrecommendationsshouldthenurseincludeintheteaching?
a. Provide low-calciumfoods
b. Provide high-phosphorusfoods
C. Provide low-potassiumfoods
d. Provide high-sodium foods
Rationale:P.380MSPHOSPHATE,POTASSIUM,SODIUMANDMAGNESIUMNEEDTOBE RESTRICTED
18. Anurseisplanningcareforaschool-agechildwhois4 hr postoperativefollowingperforatedappendicitis.
Which of the following actions should the nurse include in the plan of care?
a. Apply a warm compress to the operative site every 4hr
b. Offer small amounts of clear liquids 6 hrs followingsurgery
c. Give cromolyn nebulized solution every 8hr
D. Administer analgesics on a scheduled basis for the first 24hrs
19. Anurseisassessingaclientwhois8hrpostpartumandhasbeenunabletovoid.Whichofthefollowingactions should the nurse
takefirst?
a. Pour warm water over the client’sperineum
b. Offer the client asitz-bath
c. Insert a sterilecatheter
d. Administer ananalgesic
20. Anurseisprovidingnutritionalteachingforanolderadultclientwhohasseizuredisorderandanew
prescriptionforphenytoin.Whichofthefollowingstatementsbythenurseisappropriate?
a. “Limit foods that contain folic acid while taking thismedication.”
b. “You shouldexpectachangeinthecolorofyourstoolwhiletakingthis medication.”
c. “IncreaseyourintakeofvitaminDwhiletakingthismedication.”-phenytoincomplication(bone pain
andweakness)
d. “Plan to take this medication withantacids.”
21. Anurseisassessingaclientwhosustainedfracturestobothlegsinamotor-vehiclecrash.Whichofthe
followingfindingsindicatestheclientisexperiencinga fatembolism?
a.!"#"$%&'")*#%"$%"+#'*,'-,)."*/01'$#&$"#"+#23456
b. Decreased pedalpulses
c. Pain unrelieved by opioidanalgesics
d. Crepitus at the kneejoint
22. Anurseisteachingaclientwhoisat41weeksofgestationaboutanonstresstest.Whichofthefollowing information should
the nurse include in theteaching?
a. “You will have a Doppler transducer applied to your abdomen during thetest.”
b. “You should massage one of your nipples to stimulate contractions of youruterus.”
c. “You will need blood work before and after thetest.”
d. “You should avoid eating or drinking for 4 hrs before thetest.”
23. Ahomehealthnurseisassessingaclientwhohasamyotrophiclateralsclerosis(ALS)andhashadrecentweight
loss.Whichofthefollowingisthepriorityadmissiondataforthenursetoobtain?TALAGA
a. Changes inappetite
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