ATI Predictor Assessment 1

Question 86

ATI Predictor Assessment 1. The nurse is reviewing the Nurses’ Notes at 2015, Diagnostic Results and Progress Notes at 2000. Which of the following statements made by the caregiver indicates an understanding of the plan of care?

“My baby will need to have a high-calorie formula.”
“I can disconnect the suction to the OG tube while holding my baby.”
“My baby might need to have an ostomy.”
“I passed this gene to my baby and there’s a chance I could pass it onto my next child.”

Question 87

A nurse is providing teaching to an adolescent who has methicillin-resistant Staphylococcus aureus (MRSA) folliculitis on their face. Which of the following statements should the nurse make?

“You should discard disposable razors after 1 week of use.”
“You can continue to participate in contact sports.”
“You should apply an over-the-counter hydrocortisone cream to the affected area daily.”
“Your clothing should be changed daily and washed in hot water.”

Question 88

A nurse is reviewing the laboratory results of a client who has metabolic syndrome. Which of the following findings should the nurse expect?

Decreased blood urea nitrogen
Decreased serum potassium
Increased triglyceride level
Increased calcium level

Question 89

A nurse manager is teaching a newly licensed nurse about documenting information in a client’s medical record. Which of the following entries by the newly licensed nurse indicates an understanding of the teaching?

“The client is uncooperative and refused to take their morning medication.”
“A 2 centimeter by 2 centimeter amount of purulent drainage was noted during a dressing change.”
“A medication error was made on a previous shift. The client’s vital signs are stable.”
“The client was administered 4 units of regular insulin.”

Question 90

A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following recommendations should the nurse make?

Complete any exercise at least 2 hr before bedtime.
Read a book in bed when having difficulty sleeping.
Refrain from ingesting alcohol 3 hr before bedtime.
Keep the bedroom at a cool temperature.

Question 91

A nurse is obtaining informed consent from a client who is scheduled for surgery. Which of the following statements should the nurse make?

“You are unable to refuse treatment once the consent form is signed.”
“The charge nurse will review the risks of the procedure.”
“Your partner will need to witness the consent form.”
“Your provider will discuss other available treatments.”

Question 92

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Inform the client of available community resources.
Assist the client in finding child care options.
Agree upon short-term goals for the client.
Ask the client about their understanding of the diagnosis. ATI Predictor Assessment 1

Question 93

A nurse is assessing a client who reports nausea and vomiting for the past 24 hr. Which of the following findings should indicate to the nurse that the client is experiencing dehydration?

Tachycardia
Urine output of 850 mL per day
Serum sodium level of 130 mEq/L (136 to 145 mEq/L)
Distended neck veins while in a sitting position

Question 94

A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nurse demonstrates veracity?

The nurse offers the client a warm blanket while waiting for the provider.
The nurse reinforces the provider’s explanation of the potential risks of treatment.
The nurse avoids giving information to family members over the phone.
The nurse asks the client their preferred site for an IV insertion.

Question 95

A client who is having suicidal thoughts tells the nurse, “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?

“Why do you think your life is not worth it anymore?”
“You can trust me and tell me what you are thinking.”
“I need to know what you mean by misery.”
“Do you have a plan to end your life?”

Question 96

A nurse is reviewing the chart of a client who has a prescription for eptifibatide. The nurse should identify which of the following medications as a contraindication for this medication?

Warfarin
Metoprolol
Sertraline
Lisinopril

Question 97

A nurse in a mental health facility is caring for a client whose adult child states, “I feel guilty about admitting them to the facility.” Which of the following responses should the nurse make?

“You will feel better once you go home.”
“Why are you feeling this way?”
“I think you made the right decision.”
“I’d like to know more about what’s bothering you.”

Question 98

A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following findings should the nurse expect?

Pressured speech
Blunted affect
Catalepsy
Echopraxia

Question 99

A nurse is caring for a client who is taking desvenlafaxine. Which of the following findings should the nurse document as an adverse effect of this medication?

Insomnia
Weight loss
Diarrhea
Increased salivation

Question 100

A nurse is caring for a client who has a cast due to a compound fracture of the right ankle. Which of the following findings requires immediate intervention?

Localized stabbing pain upon movement
Pruritus under the cast
Edema present when the leg is in a dependent position
Paresthesia of the distal extremity

Question 101

A nurse is caring for a client who has difficulty holding utensils while eating. The nurse should obtain a referral for which of the following members of the interprofessional team?

Physical therapist
Social worker
Dietitian
Occupational therapist

Question 102

. ATI Predictor Assessment 1A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use?

Ventrogluteal
Dorsogluteal
Vastus lateralis
Rectus femoris

Question 103

A nurse is providing care to a child who was placed in 90-90 skeletal traction 12 hr ago. Which of the following actions should the nurse take?

Encourage the child to use the trapeze bar for position changes.
Maintain the child’s leg in an extended position while in traction.
Perform neurovascular assessment on the affected extremity every 4 hr.
Release the child’s traction weights when changing bed linens.

Question 104

A nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium sprinkle capsules. Which of the following actions should the nurse take?

Crush the medication and mix it with orange juice.
Place the medication under the client’s tongue.
Instruct the client to chew the medication before swallowing.
Administer the medication with applesauce.

Question 105

A nurse is talking to a client who has schizophrenia and reports experiencing auditory hallucinations. Which of the following responses should the nurse make?

“I don’t hear the voices. Concentrate on my voice instead.”
“They cannot hurt you. Don’t be afraid of what they say.”
“Let’s go to a quiet room where the voices won’t follow.”
“The voices are not real, and you need to get to group.”

Question 106

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L (1.3 to 2.1 mEq/L). Which of the following findings should the nurse expect?

Hypotension
Tachycardia
Muscle cramps
Hyperreflexia

Question 107

A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

Report the incident to Adult Protective Services.
Interview the client with his adult child present.
Tell the client he must answer every assessment question.
Advise the client to consult a social worker.

Question 108

A nurse is providing teaching to a client who gave birth 8 hr ago and is exclusively breastfeeding. Which of the following information should the nurse include?

“Consume additional calories each day to support milk production.”
“Avoid eating seafood to minimize risk to the newborn.”
“Wait 1 hour to breastfeed after consuming alcohol.”
“Caffeine slowly enters breast milk after maternal consumption.”

Question 109

A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

Monitor for abdominal ascites.
Implement a low-carbohydrate diet.
Review serum amylase levels.
Place warm compresses on areas of pruritus.

Question 110

A nurse is planning to provide teaching to a client who has a new prescription for disulfiram. Which of the following statements should the nurse include in the teaching?

“Mouthwash should be used after each meal.”
“Cologne should be used in place of antiperspirant.”
“An identification card should be carried while taking this medication.”
“Alcohol consumption should be limited to two drinks per day.”

Question 111

A nurse on a pediatric unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Determine if the pain medication has been effective.
Provide care for a new tracheostomy.
Administer a glycerin suppository.
Apply a bandage on a superficial wound.

Question 112

A community health nurse is collaborating with local organizations to plan educational programs for at-risk populations. Which of the following programs should the nurse implement to reach populations in the community that are at increased risk for testicular cancer? ATI Predictor Assessment 1

Social media campaign for survivors of prostate cancer
Education for clients who experience benign prostatic hypertrophy
Tri-fold pamphlets to be distributed at a health fair for older adults
Information booth at a community resource fair for young adults.

Question 113

A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?

Clothe the newborn in light cotton.
Check the newborn’s temperature every 8 hr.
Administer 120 mL (4 oz) of water between feedings.
Place the newborn 45 cm (18 in) from the light source.

Question 114

A nurse at a correctional facility is counseling a client who had a positive tuberculin skin test. Which of the following client statements should the nurse identify as understanding of the information?

“The tuberculin skin test might be falsely positive if my immune system is low.”
“I will need to take several medications if I have tuberculosis.”
“I will need to have a repeat tuberculin skin test in 48 to 72 hours.”
“The standard treatment for tuberculosis involves hospitalization until my sputum cultures are negative.”

Question 115

A nurse is inspecting a client’s IV pump prior to use. Which of the following findings should the nurse tag and report as a safety hazard?

The electrical cord is taped to the floor.
The electrical plug has two prongs.
The IV pump is plugged into an unused outlet.
The IV pump has a free-flow protective device.

Question 116

A community health nurse is talking with a client who has chronic kidney disease and is unsure if they want to begin hemodialysis. Which of the following statements should the nurse make?

“Many clients undergoing hemodialysis can resume their usual activities.”
“Why are you unsure about starting hemodialysis?”
“Can you clarify what makes you unsure about starting hemodialysis?”
“I recommend you talk to your family about initiating hemodialysis.”

Question 117

A nurse is assessing a client who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?

Change in vocal tone after drinking liquids
Nocturia with episodes of incontinence
Oral temperature of 38^C (100.4^F)
Weight loss of 1.8 kg (4 lb) in 1 month

Question 118

A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility. Which of the following clients should the nurse recommend for discharge?

A client who is experiencing an exacerbation of COPD and has been BiPap at night.
A client who is 1 day postoperative following a laparoscopic cholecystectomy and has a temperature of 37.7^C (99.9^F).
A client who reports intermittent chest pain and has received nitroglycerin four times in the past 8 hr.
A client who is receiving a continuous insulin infusion of 5 units/hr following an episode of DKA 2 hr ago.

Question 125: Child Maltreatment

A charge nurse in the emergency department is reviewing the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child maltreatment?

A 21-month-old toddler who has digoxin poisoning after opening and ingesting a relative’s pills
A 12-month-old infant who is not wearing a coat in their car seat in the winter
A 15-month-old toddler who had a submersion injury after falling face-first into a toilet
A 3-month-old infant who has a complex skull fracture from rolling off the changing table

Question 126: Nursing Delegation

A nurse is delegating tasks to an assistive personnel (AP). For which of the following clients should the nurse have the AP measure vital signs?

A client who has a new onset of weakness
A client who is requesting pain medication 2 days after surgery
A client who has a new onset of chest pain
A client who is transferring to the intensive care unit

Question 127: Surface Decontamination

A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?

Hydrogen peroxide
Isopropyl alcohol
Chlorine bleach
Chlorhexidine

Question 128: Toddler Development

A nurse is caring for a toddler who is 24 months of age during a well-child clinic visit. Which of the following is an expected finding?

Ocular strabismus
Slightly bowed legs
Thoracic breathing pattern
Anterior fontanelle less than 1 cm

Question 130: Lab Values and Skin Integrity

A nurse is evaluating morning laboratory values on a group of clients. Which of the following findings indicates a risk for impaired skin integrity?

Decreased fibrinogen level
Decreased albumin level
Increased bilirubin level
Increased calcium level

Question 131: Defense Mechanisms

A nurse is caring for a client whose partner recently died from an opioid overdose. The client tells the nurse, “Now, I volunteer for the local chapter of Narcotics Anonymous.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Repression
Displacement
Sublimation
Rationalization

Question 132: Dietary Teaching for Cholesterol

A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

Beef liver
Egg whites
Steamed clams
Broiled lobster

Question 133: Wound Irrigation

A nurse is observing a new nurse irrigate a client’s wound. Which of the following actions should the nurse identify as an indication that the new nurse understands wound irrigation? ATI Predictor Assessment 1

Cleanses the wound with povidone-iodine on cotton balls
Administers analgesia PO 20 min prior to irrigation
Warms the irrigation solution in the microwave prior to application
Irrigates the wound from the cleanest to the most contaminated area

Question 134: IV Infusion Monitoring

A nurse is monitoring an intravenous infusion for a client who is dehydrated. The nurse should discontinue the IV for which of the following findings?

Serous drainage at the catheter insertion site
Small air bubble noted in the tubing
Blood return noted in the tubing
Blanched skin at the catheter insertion site

Question 135: Dysphagia Care

A nurse is providing dietary teaching for a client who has dysphagia. Which of the following instructions should the nurse include?

Cough between bites to clear the mouth.
Talk while eating.
Take sips of liquids while chewing food.
Tilt the head back when swallowing.

Question 136: Adolescent Nutrition

A nurse is teaching an adolescent about increasing calcium intake. Which of the following foods should the nurse recommend?

Eggs
Chicken
Spinach
Raisins

Question: 137 of 180

A nurse is transcribing a new prescription in a client’s medical record for enoxaparin 30 milligrams, subcutaneously every 12 hours. Which of the following documentation should the nurse use?

Enoxaparin 30 mg SQ q AM and q HS
Enoxaparin 30 mg subcut every 12 hr
Enoxaparin 30 mcg SC q12 hour
Enoxaparin 30 mg sub q every AM and HS

Question: 138 of 180

A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

A Coombs test determines cystic fibrosis.
Serum alpha-fetoprotein levels can assist in identifying neural tube defects.
A chorionic villi sampling will be performed during week 34 of the pregnancy.
Amniotic fluid screening identifies fetal bladder anomalies.

Question: 139 of 180

A nurse is caring for a client who has acute respiratory distress syndrome and is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia?

Suction the client’s endotracheal tube every hr.
Keep the head of the client’s bed flat.
Turn the client every 4 hr.
Perform oral care with chlorhexidine.

Question: 140 of 180

A nurse is providing a change-of-shift report about a client who is 36 hr postoperative to another nurse. Which of the following information should the nurse include in the report?

Client provided with breakfast tray at 0800.
Client was nauseated immediately after surgery.
Checked for peripheral IV blood return prior to antibiotic.
Client’s pain relieved by position change.

Question: 141 of 180

A nurse is performing a skin assessment on a client who has risk factors for the development of skin cancer. The nurse should understand that melanoma has which of the following qualities?

Asymmetric, with variegated coloring
A central crater with rolled borders
Wart-like texture
Firm and rubbery

Question: 142 of 180

A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. Which of the following complications of this procedure should the nurse suspect?

Bleeding
Peritonitis
Poor dialysate flow
Fibrin clot formation

Question: 143 of 180

A nurse is planning care for a child who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following actions should the nurse anticipate?

Administer daily omeprazole.
Offer PRN loperamide.
Provide a diet high in fiber.
Restrict fluid intake.

Question: 144 of 180

A nurse is caring for a client who is near the end of life. The client’s partner asks the nurse to ease the client’s breathing difficulty. Which of the following actions should the nurse take?

Administer a bronchodilator to the client.
Place the client in Trendelenburg position.
Use a fan to increase air circulation in the room.
Decrease the frequency of intake of oral fluids. ATI Predictor Assessment 1

Question: 145 of 180

A nurse is providing teaching to the guardian of a preschooler who was newly diagnosed with a latex allergy. The nurse should include that a cross-reaction can occur with which of the following foods?

Bananas
Grapes
Pears
Watermelon

Question: 146 of 180

A nurse is providing teaching to a client who has a prescription for methylprednisolone. Which of the following findings should the nurse include as an adverse effect of this medication?

Hypertension
Weight loss
Tremors
Drowsiness

Question 147

A nurse in a community mental health facility is assessing a group of clients who have eating disorders. Which of the following clients should the nurse refer to the provider?

A client who has an oral temperature of 35.4° C (95.7° F)
A client who has a resting heart rate of 60/min
A client who has had 320 mL urine output in the last 8 hr
A client who has a blood pressure of 100/68 mm Hg

Question 148

A nurse is providing discharge instructions to the caregivers of a child who is postoperative following a tonsillectomy. Which of the following statements should the nurse include in the teaching?

“Call your provider if your child has an increase in swallowing.”
“Use a warm-mist vaporizer in your child’s room at night.”
“Encourage your child to blow their nose frequently to clear secretions.”
“Offer your child a smoothie through a straw.”

Question 149

A nurse is teaching a group of farm workers who work with pesticides about minimizing exposure. Which of the following information should the nurse include in the teaching?

“Change clothes after working in the field.”
“Apply petroleum jelly to the nostrils prior to working in the field.”
“Wipe fruits and vegetables from the field with a dry cloth before consuming.”
“Store protective equipment in vehicle while not working.”

Question 150

A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following foods is appropriate for the nurse to offer as an evening snack?

Avocados and toast
Apple slices
Bologna sandwich on wheat bread
Cheddar cheese and crackers

Question 151

A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first?

Determine the client’s living situation.
Problem solve with the client.
Offer community resources to the client.
Assist the client with decision-making.

Question 152

A nurse suspects another nurse is experiencing chemical impairment during their shift. Which of the following is an appropriate action for the nurse to take?

Report to the nurse manager.
Set up a time to meet with the nurse.
Assume care of the nurse’s assigned clients.
Ask another staff nurse to confirm the suspicion.

Question 153

A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first?

A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3° C (101° F)
A 60-year-old client who has COPD, is receiving O₂ 2 L/min via a nasal cannula, and has an oxygen saturation of 89%
A 26-year-old female client who has pelvic inflammatory disease and is unable to void

Question 154

A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation?

Atropine .4 mg IV stat
Lorazepam 1.0 mg IV PRN every 6 hr
Sucralfate 1 g PO 1 hr ac
Enoxaparin 30 mg SC every 12 hr

Question 155

A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?

A client who has agonal respirations
A client who has an open skull fracture and is unresponsive
A client who has a traumatic arm amputation
A client who has a fracture of the femur

Question 156

A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIs). Which of the following information should the nurse plan to include in the teaching about UTI prevention?

Decrease intake of citrus foods and beverages.
Wear nylon underwear.
Empty the bladder before and after intercourse.
Increase the time between voiding.

Question 157

A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make?

Art therapist
Speech-language pathologist
Social worker
Recreational therapist ATI Predictor Assessment 1

Question 158

A nurse is caring for a client who has an acute spinal cord injury. Which of the following findings should the nurse recognize as autonomic dysreflexia? ATI Predictor Assessment 1

Decrease in blood pressure
Increase in heart rate
Client report of eye twitching
Client report of sudden headache

Question 159

A nurse is performing postmortem care on a client. Which of the following actions should the nurse take?

Tape the eyelids closed.
Remove dentures and place in a labeled container.
Cover body with a clean sheet.
Lower the head of the bed to a supine position.

Question 160

A nurse in an urgent care clinic is caring for a client who sprained their ankle. Which of the following provider prescriptions should the nurse expect?

Apply heat to the affected extremity for the first 24 hr.
Wrap the affected extremity with a compression dressing.
Administer acetaminophen for moderate pain and inflammation.
Advise the client to begin walking 4 hr following the injury.

Question 161

A nurse is assessing a client who is 6 hr following a vaginal birth and experienced a placental abruption. Which of the following findings should the nurse report to the provider?

Moderate lochia rubra on the perineal pad
1+ nonpitting ankle edema
Urine output 400 mL within two voids
Petechiae on the skin under the blood pressure cuff

Question 162

A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

The gastric residual volume is 250 mL following 2 hr of infusion.
The client is lying in a supine position.
The infusion pump for administering continuous feeding is turned off.
The enteral feeding bag and tubing are not dated.

Question 163

A nurse manager in a community health clinic is reviewing the medical records of clients who have diagnoses of communicable diseases. Which of the following infectious diseases should the nurse report to the Centers for Disease Control and Prevention?¹

Impetigo²
Pneumocystis pneumonia
Human papilloma virus
Hepatitis A

Question 164

A nurse receives change-of-shift report. Which of the following clients should the nurse attend to first?

A client who has a productive cough and an oral temperature of $36^{\circ}\text{C}$ ($96.8^{\circ}\text{F}$).
A client who reports tingling in the fingers following a thyroidectomy.
A client who is in a long leg cast and has $+2$ pedal pulses bilaterally.
A client who has dark, foul-smelling urine and a urine output of $320 \text{ mL}$ in the last $8 \text{ hr}$.

Question 165

A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?

“This technique prevents injury to the sciatic nerve.”
“This technique decreases the risk of subcutaneous infiltration.”³
“This technique allows a larger amount of medication to be injected.”⁴
“This technique increases the absorption rate of the drug.”⁵

Question 166

A client asks the nurse if it is safe to take a ⁷glucosamine supplement. The nurse should assess for which of the following potential contraindications?

Shellfish allergy
History of smoking
Cardiac dysrhythmia
Family history of malignant hyperthermia

Question 167

A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

Set up the sterile field 7.6 cm (3 text in) below waist level.
Hold the bottle of sterile solution with the palm over the label while pouring.
Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border.
Place the lid of a bottle of sterile solution within the sterile field.

Question 168

A nurse is caring for a toddler who has varicella zoster. Which of the following actions should the nurse take?

Wear a mask while in the room with the toddler.
Wipe the stethoscope with an alcohol-based gel after use.
Place the toddler in a room with positive-pressure airflow.
Schedule the toddler for private time in the playroom.

Question 169

A nurse is teaching a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following instructions should the nurse include in the teaching? ATI Predictor Assessment 1.

Use a washcloth to bathe the treatment area.
Remove the dye markings after each radiation treatment.
Avoid sun exposure from 1100 to 1600.
Wear clothing over the area of radiation treatment.

Question 170

A nurse is planning to teach a group of newly licensed nurses about hypermagnesemia. Which of the following manifestations should the nurse include in the teaching?

Personality change
Elevated hematocrit
Bradypnea
Peaked T waves

Question 171

A nurse is planning to provide preoperative teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Ask a family member to translate the information for the client.
Use a telephone medical interpreter service.
Request an assistive personnel who speaks the client’s language to translate.
Direct all information to the person who is translating for the client.

Question 172

A home health nurse is performing an in-home fall assessment for a client. Which of the following findings should the nurse identify as a potential hazard for the client?

Electrical cords secured to the baseboards
A computer chair with wheels that lock
A standard toilet seat in the bathroom
Carpeted floors in the kitchen

Question 173

A nurse is assessing a client prior to administering morphine. Which of the following findings should the nurse identify as a contraindication to the administration of this medication?

Absent bowel sounds
Respiratory rate of 14/min
Blood pressure of 100/60 mm Hg
Urine output of 100 mL/hr

Question 174

An assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess first?

A 6-year-old child who has glomerulonephritis and a blood pressure of 130/78 mm Hg
A 2-year-old child who has Kawasaki disease and a temperature of 39° C (102.2° F)
A 4-year-old child who has a closed-head injury and a heart rate of 60/min
An 8-year-old child who has type I diabetes mellitus and a respiratory rate of 26/min

Question 175

A nurse is providing teaching about managing anxiety to a client who has anxiety disorder. Which of the following recommendations should the nurse make for when the client experiences mild anxiety?

“Try doing progressive muscle relaxation.”
“Surround yourself with a crowd of people.”
“Focus on taking shallow, rapid breaths.”
“Suppress your feelings to the best of your ability.”

Question 176

A nurse is caring for a client who is having a seizure. Which of the following actions should the nurse take to prevent client injury?

Place the client in a prone position.
Insert a padded tongue blade into the client’s mouth.
Loosen the client’s restrictive clothing.
Restrict the movement of the client’s extremities.

Question 177

A nurse in an emergency department is caring for an 18-year-old adolescent.

Based on the provided exhibits:

Exhibit 1 (Vital Signs): Temp 39° C (102.2° F), HR 110/min, RR 22/min, BP 130/90 mm Hg, $O_{2}$ sat 96%.
Exhibit 3 (Assessment): Headache, neck pain, photophobia, vomiting, purpura on lower extremities, Kernig and Brudzinski signs positive.
Exhibit 4 (History): Seizure at home, history of migraine and HSV-1.

Condition: Bacterial Meningitis

Actions to Take:

Initiate respiratory isolation.
Administer an antibiotic.

Parameters to Monitor:

Neurological assessment.
Electrolytes.

Question 178

A nurse is caring for a client who is at 34 weeks of gestation and has just had an amniocentesis. Which of the following actions should the nurse plan to take?

Schedule the client for an aPTT test.
Collect a blood sample from the client for a direct Coombs test.
Administer Rho(D) immune globulin if the client is Rh positive.
Monitor the client for uterine contractions.

Question 179

A nurse in a pediatric office is caring for an infant. (Select all that apply)

Based on the provided exhibits:

Exhibit 1 (Nurses’ Notes): Beefy red rash, satellite pustule lesions.
Exhibit 3 (Prescriptions): Diaper candidiasis; topical nystatin cream.

Recommendations:

Use alcohol-free diaper wipes.
Use superabsorbent disposable diapers.
Apply talcum powder to diaper area.
Wash diaper area vigorously to remove zinc oxide diaper cream.
Change diapers immediately after they are soiled.
Apply topical antiviral cream with each diaper change.

Question 180

A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following actions should the nurse take?