ATI CBC Level 4 (A) Correctly Answered!!

A nurse is teaching a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which statement by the client indicates an understanding of the teaching? - ANSWER "I should inspect my skin daily for cuts and rashes" A nurse is caring for a client who has Parkinson's disease. Which of the following actions should the nurse take to promote the client's mobility? - ANSWER Instruct the client to perform range-of-motion exercises -exercising and walking help to delay the progression of the disease A nurse is caring for a client who has had a myocardial infarction and suspects cardiogenic shock. The nurse should monitor for which of the following manifestations? - ANSWER Pulmonary Congestion -Pulmonary congestion is a result of decreased cardiac output due to damage to the cardiac muscle A nurse is assessing a client who has a DNR order and has stopped breathing. The family asks the nurse to resuscitate the client. Which action should the nurse take? - ANSWER Respect the client's preferences. A nurse manager is teaching a group of nurses about OSHA. What information should the nurse include? - ANSWER Sets standards for hazardous exposures in the workplace. A nurse manager identifies that the number of client medication administration errors on the unit has increased. When creating a cause-and-effect chart, which of the following information should the nurse manger include? - ANSWER Possible reasons for the medication errors A nurse manager notices that he has exceeded the amount of money allocated for labor costs for the quarter. Which action should the nurse manager take? - ANSWER involve staff nurses in budge planning. -this promotes awareness of the costs of staffing a unit and encourages cost-effective care. A nurse is providing teaching to a client who has a halo device applied to prevent further cervical spinal cord injury following a diving accident. What info should the nurse include? - ANSWER "Avoid leaning forward when attempting to stand." -the weight of the halo device can alter balance. leaning forward could cause the client to fall. A nurse is working on an interprofessional collaboration plan of care for a client who has a stage 3 pressure ulcer. Which action should the nurse recognize as the. role of the licensed practical nurse (LPN)? - ANSWER Administer pain medication A nurse manager is facilitating conflict resolution between two nurses who disagree about the need to make a referral to a social worker. Which conflict management strategies should the nurse manager use? - ANSWER Offer self to constructively facilitate communication. -The nurse manager will be the impartial third party in this communication A nurse is having a disagreement with a coworker about a client assignment. When following the chain of command, which of the following individuals should the nurse contact to discuss the conflict? - ANSWER The charge nurse -the charge nurse is the nurse's immediate supervisor A triage nurse is prioritizing clients following a mass casualty disaster. Which of the following clients should the nurse treat first? - ANSWER A client who is exhibiting manifestations of shock. -a client exhibiting manifestations of shock requires immediate intervention for survival. A nurse is caring for a client who has a partial-thickness burn and a prescription for a silver sulfadiazine cream. Which intervention should the nurse take? - ANSWER Monitor the client's WBC. -A drop in the WBC count can be an indication of an allergic reaction to the silver sulfadiazine cream A nurse is preparing to administer nitroglycerin topical ointment to a client who had a myocardial infarction. Which action should the nurse plan to take? (move steps in order) - ANSWER 1) Cleanse the client's skin and allow it to dry 2) Apply a thin layer of medication ointment to the dosing paper. 3) Spread the medication over a 6.4 by 8.9 cm area of skin 4) Cover the medication site with plastic wrap 5) Remove the medication in 6 hr. A nurse manager is teaching a group of nurses about professional negligence. Which of the following situations should the nurse manager include as an example? - ANSWER Administering heparin to a client who is undergoing a lumbar puncture. A nurse is teaching a client who has deep-vein thrombosis and is receiving heparin injections. The nurse should instruct the client to report which of the following manifestations as an adverse effect of this medication? - ANSWER An increase in nosebleeds -increase in nosebleeds or bruising can be indications of a hemorrhage, which is an adverse effect of heparin A community health nurse is teaching a newly licensed nurse about the types of psychiatric health care settings available in the community. Which should the nurse identify as a primary care setting? - ANSWER Outpatient counseling clinic -primary care setting clinics provide strategies for clients to prevent or delay mental health issues A nurse manager is informed that the family of a client is preparing to file a malpractice lawsuit. The nurse should identify which of the following situations as potential malpractice? - ANSWER Failure to identify an infiltrated IV A community health nurse is planning a public health presentation aimed at minimizing health care disparities. Which of the following age groups should the nurse identify as the priority for increasing health literacy? - ANSWER Older Adults -Older adults have the lowest level of health literacy compared to other age groups A charge nurse is planning care for a group of clients. Which task should the nurse delegate to the LPN? - ANSWER Obtain a blood glucose level from a client who has type 1 diabetes mellitus. A nurse is planning care for a child who has cystic fibrosis. Which intervention should the nurse include? - ANSWER Increase the child's daily fat intake to 40% of total calories -due to impaired intestinal absorption of fat A nurse manager is teaching a unit nurse about case management. What information should the nurse manager include in the teaching about the role of the nurse as a case manager? - ANSWER Advocates for services the client needs A nurse is caring for a female client who has an indwelling urinary catheter. Which action should the nurse take to minimize the risk for catheter-related infection? - ANSWER Evaluate the client daily for the necessity of continued catheterization. -increased dwelling time increases the client's risk for infection. Catheter should be DC'd as early as possible A charge nurse is educating unit nurses about the ethical principle of nonmaleficence. Which example should the nurse include in the teaching? - ANSWER A nurse uses a mechanical lift to move a client from a bed to a chair. -prevents harm to the client A nurse is teaching about managing care with the family of a client who has Parkinson's disease and takes dopamine. Which information should the nurse include in the teaching? - ANSWER Allow the client to perform ADLs -promotes and maintains independence for as long as possible A nurse is caring for a client who has cirrhosis. The client has an ammonia level of 120 mcg/dL, slurred speech, and is disoriented to person and place. The nurse should identify that these findings possibly indicate which of the following complications of cirrhosis? - ANSWER Hepatic encephalopathy -elevated ammonia level, slurred speech, and mental status changes are early manifestations of hepatic encephalopathy A nurse is caring for a client who has Addison's disease and is receiving an infusion of 0.9% sodium chloride. The client develops acute adrenal insufficiency. Which action should the nurse take? - ANSWER Check the client's blood glucose level -hypoglycemia is a manifestation of acute adrenal insufficiency. Glucose should be monitored hourly A nurse is caring for a client who has a pressure ulcer. Which action should the nurse take when cleaning the client's wound? - ANSWER Warm the cleansing solution to the client's body temperature -this prevents the solution from lowering the wound temperature and promotes healing A nurse is caring for a client who has hepatic encephalopathy and is receiving lactulose. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication? - ANSWER Decreased ammonia level -this med decreases ammonia levels by producing a laxative effect. Another effect of this med is decreased confusion A nurse is developing a plan of care for a client who has sustained burns to the lower half of his body and is to receive hydrotherapy. Which action should the nurse include in the plan? - ANSWER Use forceps and scissors to remove the loose, dead tissue from the client's wound -This promotes healing A nurse is performing an admission assessment on a client who has meningitis. Which finding should the nurse expect? - ANSWER Positive Kernig's Sign -this is expected due to meningeal irritation. When Kernig's sign is present, the client can't fully extend her leg when lying supine with her thigh flexed toward her abdomen A nurse in a substance use treatment facility is caring for a group of clients. Which action by the nurse demonstrates the ethical concept of fidelity? - ANSWER The nurse keeps a promise to take a walk outside with a client after group therapy -The nurse kept a promise made to a client. A nurse is providing preoperative teaching to a client who does not speak the same language as the nurse. Which action should the nurse take? - ANSWER Contact a trained interpreter to translate the teaching for the client A nurse is assessing an infant who has meningitis. Which manifestation should the nurse expect? - ANSWER Hypothermia -other manifestations can include vomiting, seizures, and nuchal rigidity A nurse who works on a med-surg unit is asked to float to the maternal newborn unit due to short staffing. Which professional organization protects the nurse if she refuses the assignment? - ANSWER American Nurses Association (ANA) A nurse is teaching a client who has a new prescription for carvedilol following a myocardial infarction. What information should the nurse include? - ANSWER "You should check your pulse before taking this medication" -The client should withhold his med and notify his provider if his heart rate is less than 60/min A nurse is assessing a newborn. Which of the following findings should the nurse identify as a manifestation of sepsis? - ANSWER Grunting -grunting, nasal flaring, retractions, apnea, tachycardia, hypotension, lethargy, pallor, petechiae, hypoglycemia, hypotonia, and/or decreased oxygen saturations are other symptoms of sepsis A nurse is reviewing the lab values of a client who is in hypovolemic shock. Which of the following findings should the nurse expect? - ANSWER pH level 7.25 -metabolic acidosis; the client's pH level is decreased due to insufficient tissue perfusion A nurse is teaching an educational session about reducing health care-associated infections. Which instruction should the nurse include? - ANSWER Bathe the clients daily with chlorhexidine wipes A nurse is caring for a client who is post-op following a craniotomy to remove a brain tumor. The nurse should notify the provider about which of the following findings? - ANSWER Fixed an nonreactive pupils to light -This is an indication of a neurological deficit due to a herniation of the brain A nurse is teaching a client who had an organ transplant about cyclosporine therapy. Which instruction should the nurse include in the teaching? - ANSWER "Avoid drinking grapefruit juice when taking this medication." -Grapefruit juice can decrease the metabolism of cyclosporine, which can cause an increase in serum levels and increase the risk for toxicity A nurse is providing discharge teaching for a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include? - ANSWER "Lie down when you take this medication" -nitroglycerin is a vasodilator that can cause hypotension. Other adverse effects include headache, flushing, and tachycardia A chief nurse officer (CNO) is comparing the quality of health care at her facility to the best-performing facilities nationwide to determine if quality improvement is required. Which of the following processes should the CNO plan to use as a comparison tool? - ANSWER Benchmarking -Benchmarking measures products, services, and practice against top-performing organizations. Facilities use this as a tool for developing desired standards of organizational performance A nurse is caring for a client who has sepsis and has developed DIC. Which action should the nurse take? - ANSWER Administer anticoagulants to the client -to limit clotting A nurse is caring for clients on a med-surg unit. Which of the following actions by the nurse demonstrates the professional characteristics of human dignity? - ANSWER The nurse treats each of his assigned clients with equal respect A nurse is caring for a client who is in the active phase of labor and has an amniotic fluid embolus. Which action should the nurse take? - ANSWER Give O2 via nonrebreather mask at 10L / min -additionally, the nurse should prepare for intubation and mechanical ventilation A nurse is caring for a client who is 6hr post-op following a TKA. Which action should the nurse take to prevent a pulmonary embolism? - ANSWER Apply compression stockings to both o the client's legs A nurse is teaching a group of nurses about the role of a case manager. What information should the nurse include in the teaching? - ANSWER Identifies cost-effective equipment A nurse is reviewing the lab values of a client who has Addison's disease. Which finding should the nurse expect? - ANSWER Potassium 6.2 mEq/L -A high potassium level is due to lack of cortisol concentration levels, which leads to a f&e imbalance. A nurse is preparing to conduct research regarding catheter-related infections for a performance improvement initiative. Which of the following activities should the nurse identify as components of the research process? (SATA) - ANSWER Formulate the research problem (to determine the type of research design) Conduct a pilot study (this can assist the nurse to identify the strengths and limitations of a planned, larger-scale study) Communicate the conclusions of the study (once the outcomes are disseminated, the new evidence-based practice can be incorporated into the daily practice of the facility) A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which action should the nurse plan to take? - ANSWER Transfuse the platelets through a small filter -this removes the white blood cells Following a mass casualty disaster, a nurse is assigning a triage tag to a responsive client who has a major burn injury covering 15% of his body surface area. Which triage category should the nurse assign to the client? - ANSWER Red -This is a significant injury that requires immediate treatment A nurse is caring for a client who has sepsis. Which manifestation should indicate to the nurse that this client might be progressing to septic shock? - ANSWER Hypothermia -This is due to the body's inability to compensate for the infection