ATI nurs 180 role transition of professional nurse and clinical exam
Total Questions : 50
Showing 25 questions, Sign in for moreA nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement?
Explanation
Rationale
A. Contact precautions are appropriate for MRSA to prevent the transmission of bacteria through direct or indirect contact with the infected area. This includes wearing gloves and gowns when caring for the client and ensuring proper hand hygiene.
B. Droplet precautions are used for pathogens that are spread through respiratory droplets, which is not applicable to MRSA.
C. Protective equipment is typically used for immunocompromised patients to prevent infections, but it is not the standard for MRSA.
D. Airborne precautions are necessary for diseases that spread through airborne particles, which does not include MRSA.
A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take?
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.
A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider?
Explanation
Rationale:
A. Hypotension is not a common adverse effect of estradiol; instead, it may cause hypertension.
B. Bruising can indicate thrombocytopenia or other clotting issues, which are serious adverse effects of estradiol and should be reported immediately.
C. Headaches are a common side effect of estradiol but are usually not severe; they typically do not require reporting unless they are persistent or severe.
D. Oliguria is not a known adverse effect of estradiol and may indicate other underlying issues that are unrelated to this medication.
A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?
Explanation
Rationale:
A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.
B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.
C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.
D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.
A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?
Explanation
Rationale:
A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.
B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.
C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.
D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.
A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?
Explanation
Rationale:
A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.
B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.
C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.
D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.
A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?
Explanation
Rationale:
A. Urine output of 120 mL in 4 hours is within acceptable limits, especially following anesthesia. Normal output can vary, but 30 mL/hr is often used as a guideline.
B. A systolic blood pressure that is only 12 mm Hg lower than preoperative levels may be concerning, but it does not necessarily require immediate reporting unless other symptoms are present.
C. Audible stridor is a sign of airway obstruction or severe respiratory distress and requires immediate medical attention. It should always be reported to the provider.
D. An occasional premature ventricular contraction (PVC) can be common postoperatively and may not necessitate reporting unless accompanied by significant symptoms or changes in hemodynamic status.
A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication?
Explanation
Rationale:
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
Explanation
Rationale:
A. Sitting with their head in their hands and appearing to cry indicates emotional distress rather than aggression or potential violence.
B. Pacing is often a sign of agitation or anxiety and can be indicative of a potential escalation to violence, especially in individuals with a history of aggressive behavior.
C. While expressing discontent with staff may show frustration, it does not directly indicate imminent violence.
D. Taking numerous, deep breaths may suggest the client is attempting to calm themselves and is not a reliable indicator of potential aggression.
A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?
Explanation
Rationale:
A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.
B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.
C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.
D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.
A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take?
Explanation
Rationale:
A. Withholding the next dose of warfarin may not be necessary at this point, as the INR is elevated but not critically high. Monitoring is essential, but vitamin K administration is indicated if the INR exceeds therapeutic levels significantly.
B. Withholding the heparin infusion is not appropriate since the aPTT is critically elevated, indicating that the client is at risk for bleeding. Heparin should be adjusted, but not entirely withheld without further evaluation.
C. Preparing to administer vitamin K is appropriate because the INR is elevated (1.8), indicating an increased risk for bleeding. Vitamin K is used to reverse the effects of warfarin.
D. Preparing to administer alteplase (a thrombolytic) is unnecessary and inappropriate in this situation, as the client is already receiving anticoagulation therapy with heparin and warfarin.
A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?
Explanation
Rationale:
A. Diarrhea is not a typical manifestation of ovarian cancer and may be more related to gastrointestinal issues.
B. Urinary retention can occur but is not a common initial symptom associated with ovarian cancer.
C. Abdominal bloating is a common symptom associated with ovarian cancer and should be included in the educational session. It may occur due to fluid accumulation or tumor growth.
D. Purulent discharge is not a typical manifestation of ovarian cancer and may suggest an infection rather than a cancer diagnosis.
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?
Explanation
Rationale:
A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.
B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.
C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.
D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
Explanation
Rationale:
A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.
B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.
C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.
D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?
Explanation
Rationale:
A. Offering flavored gelatin can provide some hydration, but it does not provide sufficient electrolytes necessary for rehydration in gastroenteritis.
B. Initiating oral rehydration therapy for the toddler is essential in treating dehydration caused by infectious gastroenteritis. Oral rehydration solutions contain the right balance of electrolytes and fluids to replenish losses.
C. While chicken broth may provide some fluid and salt, it is not as effective as a specific oral rehydration solution tailored for children with gastroenteritis.
D. The BRAT diet (bananas, rice, applesauce, and toast) is no longer recommended as the primary diet for children with gastroenteritis, as it does not provide adequate nutrition or electrolytes.
A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?
Explanation
Rationale:
A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.
B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.
C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.
D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.
A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Explanation
Rationale:
A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage.
B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction.
C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications.
E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.
A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?
Explanation
Rationale:
A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.
B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.
C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.
D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.
A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give?
Explanation
Rationale:
A. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.
B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.
C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.
D. Although the provider can provide more detailed information about treatment, it does not address the client's right to review their own medical record.
A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?
Explanation
Rationale:
A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.
B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.
C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.
D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.
A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?
Explanation
Rationale:
A. A quick inhalation is not the correct technique; the child should take a slow, deep breath in while pressing down on the inhaler to ensure effective medication delivery.
B. Taking the medication 15 minutes before playing sports allows time for the medication to take effect, making this the best choice.
C. The mouthpiece should be cleaned more frequently, typically after each use, to prevent buildup of medication and bacteria.
D. Waiting 10 seconds between inhalations is generally advised; however, the more important instruction here is the timing of medication before sports.
A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?
Explanation
Rationale:
A. Similar to the previous question, a quick inhalation is not recommended; the child should take a slow, deep breath for effective medication delivery.
B. Taking the medication 5 minutes before playing sports is ideal as it allows the medication to work quickly, ensuring better performance and control of asthma symptoms during activity.
C. Cleaning the mouthpiece with warm water every 2 weeks is insufficient; it should be cleaned more frequently, typically after each use, to maintain hygiene.
D. Waiting 10 seconds between inhalations is appropriate, but the focus on the timing before sports is critical for proper management of asthma symptoms.
A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Explanation
Rationale:
A. Administering methylergonovine maleate is appropriate if the uterus is boggy, as it helps to promote uterine contractions and prevent postpartum hemorrhage.
B. Massaging a firm fundus is incorrect; instead, the nurse should massage a boggy (soft) fundus to encourage it to contract.
C. Documenting fundal height is essential to monitor the uterine involution and ensure the uterus is returning to its pre-pregnancy size.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal bleeding or clots, which may indicate complications.
E. Determining whether the fundus is midline is necessary to assess for displacement, which can affect uterine tone and bleeding.
A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?
Explanation
Rationale:
A. Comparing the nurse's skills to coworkers may not provide an accurate evaluation as it can vary based on individual roles and responsibilities.
B. While client satisfaction reports can reflect overall performance, they may not specifically address time management skills.
C. Maintaining regular notes about the nurse's time management skills allows for ongoing assessment and provides concrete examples during the appraisal, making it the most effective method.
D. Asking another staff nurse for evaluation can introduce bias and may not provide a comprehensive view of the nurse's time management skills.
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Explanation
Rationale:
A. Making a referral for social services is appropriate as they can assist the client with discharge planning, home care services, and resources for palliative care to support the client's wishes.
B. While it is important to explain the risks of leaving against medical advice, the priority is to support the client’s desire to go home, rather than focusing on the potential consequences at this moment.
C. Contacting the facility chaplain could be beneficial for emotional support, but it does not address the immediate need for facilitating the client’s wish to go home.
D. Encouraging the client to continue with inpatient care contradicts their expressed desire to be with family, which is a crucial aspect of their emotional well-being in this situation.
Sign Up or Login to view all the 50 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
