ATI – Comprehensive Practice 2019 A
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?
(ANS
- elevate the affected leg
ambulation should be encouraged
a nurse is teaching a group of guardians about child safety measures. which of the
following statements by a guardian indicates an understanding of the teaching?
(ANS- I should have my child avoid sun exposure between 10 am and 2 pm
a home health nurse is providing teaching about infection prevention to a client
who has cancer and is receiving chemotherapy. Which of the following statements
by the client indicates an understanding of the teaching?
(ANS- I will walk for short distances throughout the day
a nurse is providing dietary teaching to the parents of a 6 month old infant. which
of the following instructions should the nurse include?
(ANS- Introduce new foods one at a time over 5 to 7 days
a charge nurse is planning care for a client who has mechanical restraints in place.
which of the following interventions should the nurse include in the plan?
(ANS- Provide a staff member to stay with the client continuously
can be physically or using an audiovisual device
need to document every 15-30 minutes, a new prescription should be in every 4 hrs
for adults, every 3 hrs for 9-17 years and every hour for those younger
a community health nurse is assisting with the development of a disaster
management plan. the nurse should include which of the following nursing
responsibilities in the disaster response stage of the plan?
(ANS- performing a rapid needs assessment
a nurse manager is assisting with the orientation of a newly licensed nurse. which
of the following actions by the nurse requires the nurse manager to intervene?
(ANS- tells the hospital chaplain a clients diagnosis
a nurse is caring for a client who is in labor at 39 weeks of gestation. during the
second stage of labor, the nurse observes early deceleration on the monitor tracing.
which of the following actions should the nurse take?
(ANS- continue observing the fetal heart rate
these are an expected finding
a nurse manager is planning to make changes to the current scheduling system on
the unit. to facilitate the staff’s acceptance of this change, which of the following
actions should the nurse manager take first?
(ANSprovide information about scheduling issues to the staff
unfreezing stage – increase understanding of why change is needed
a nurse is planning teaching about allowable foods for a client who has a history of
uric acid based urinary calculi formation. which of the following foods should the
nurse include in the teaching?
(ANSoranges
can eat citrus fruits
no chicken, no organ meats like liver, no red wine (avoiding purine)
a charge nurse is teaching a newly licensed nurse how to identify true labor. which
of the following should the nurse include in the teaching?
(ANS- the cervix transitions to an anterior position
contractions will be felt in the lower abdomen and back, intensity increases with
ambulation, cervix shortens and thins
a nurse on a medical surgical unit is caring for a client prior to a surgical
procedure. which of the following findings should indicate to the nurse that the
client has the ability to sign the informed consent?
(ANS- the client is able to accurately describe the upcoming procedure
a charge nurse assigns a newly licensed nurse to care for a client who has a chest
tube. The nurse expresses concern about having limited experience with
monitoring chest tube drainage. which of the following actions should the charge
nurse take first to provide teaching about chest tubes?
(ANS- ask the nurse about their knowledge of the procedure