Prepare for your exams
Get points
Guidelines and tips

Prepare for your exams

Study with the several resources on Docsity

Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips

Sell on Docsity

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources

Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents

20 Points

For each uploaded document

Answer questions

5 Points

For each given answer (max 1 per day)

All the ways to get free points

Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study

Go to the blog

Nursing Assessment and Interventions: Comprehensive Practice Scenarios, Exams of Nursing

Imperial Valley College Nursing

A collection of clinical scenarios and questions designed to test your knowledge of nursing assessment and interventions. The scenarios cover a range of medical conditions, including Crohn's disease, ulcerative colitis, peritonitis, transfusion reactions, somatic symptom disorder, allergic reactions, alcohol withdrawal, varicose veins, schizophrenia, cystic fibrosis, intestinal obstruction, and medication side effects. Each scenario includes answers and explanations, emphasizing key assessment findings, interventions, and nursing considerations.

Typology: Exams

2024/2025

Available from 03/26/2025

nursejulie 🇺🇸

333 documents

1 / 43

This page cannot be seen from the preview

Don't miss anything!

ATI PN Comprehensive Predictor Exam 13

2024

NGN: What assessment findings are consistent with Crohn's disease, ulcerative colitis, or

peritonitis?

Temperature (100F)

Weight (-9.7 lbs)

Albumin level (2.4)

WBC (14)

Bowel pattern (freq. loose stools)

Abdominal pain location (RLQ)

Heart rate (105) - Temperature: Crohn's, UC & peritonitis.

-Elevation can occur with all three due to inflammation and infection.

Weight: Crohn's & UC.

-Unintended weight loss can occur due to malabsorption in the GI tract.

Bowel pattern: Crohn's.

-If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause

tarry stools.

WBC: Crohn's, UC & peritonitis.

-Elevation can occur due to inflammation and infection.

Heart rate: peritonitis.

-Tachycardia can occur due to inflammation, infection, and dehydration.

Albumin level: Crohn's & UC.

-Because of the malabsorption in the GI tract, the body isn't receiving enough protein.

Abdominal pain location: Crohn's.

-Because it is in the RLQ, it is more consistent with Crohn's. With patients that have

peritonitis, they experience generalized abd. pain that radiates to the shoulder and back.

NGN: What assessment findings can indicate a transfusion reaction in a patient receiving

blood?

Urine output (150mL of clear, yellow)

Skin (pale, cool and dry)

Anxiety

Vital signs (within normal range)

Headache

Back pain - Back pain, headache & anxiety.

Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain, tachycardia,

dyspnea, hypotension.

Partial preview of the text

Download Nursing Assessment and Interventions: Comprehensive Practice Scenarios and more Exams Nursing in PDF only on Docsity!

ATI PN Comprehensive Predictor Exam 13

NGN: What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis? Temperature (100F) Weight (-9.7 lbs) Albumin level (2.4) WBC (14) Bowel pattern (freq. loose stools) Abdominal pain location (RLQ) Heart rate (105) - Temperature: Crohn's, UC & peritonitis.

Elevation can occur with all three due to inflammation and infection. Weight: Crohn's & UC.
Unintended weight loss can occur due to malabsorption in the GI tract. Bowel pattern: Crohn's.
If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause tarry stools. WBC: Crohn's, UC & peritonitis.
Elevation can occur due to inflammation and infection. Heart rate: peritonitis.
Tachycardia can occur due to inflammation, infection, and dehydration. Albumin level: Crohn's & UC.
Because of the malabsorption in the GI tract, the body isn't receiving enough protein. Abdominal pain location: Crohn's.
Because it is in the RLQ, it is more consistent with Crohn's. With patients that have peritonitis, they experience generalized abd. pain that radiates to the shoulder and back. NGN: What assessment findings can indicate a transfusion reaction in a patient receiving blood? Urine output (150mL of clear, yellow) Skin (pale, cool and dry) Anxiety Vital signs (within normal range) Headache Back pain - Back pain, headache & anxiety. Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain, tachycardia, dyspnea, hypotension.

NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling faint. Reports constipation and joint pain for x2 days. In childhood, patient experienced physical abuse, and emotionally detached parents. Reports nervousness and only leaving home when necessary. PMH: freq. hospital visits due to headaches and GI distress. Bowtie: - Condition: somatic symptom disorder

due to physical inactivity & joint pain Interventions: Monitor physical manifestations & assess for presence of 2nd gains from their illness
disorder is characterized by the presence of other real manifestations like dizziness, nausea, back pain, and joint pain. Monitor: Vital signs & pain. NGN: What actions should the nurse take when her pedi patient is exhibiting symptoms of an allergic reaction? Administer 0.9% NS IV Administer epi IM Monitor urine output q2hrs DC supplemental oxygen Monitor vital signs frequently DC IV medication - Administer 0.9% NS IV Administer epi IM Monitor vital signs frequently DC IV medication
Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid shifts can occur quickly during a reaction. Administering epi IM is the first line of therapy for anaphylactic reactions because it constricts blood vessels and dilates bronchioles. Monitoring vital sings frequently will allow the nurse to monitor for signs of shock. NGN: What 5 actions should the nurse plan to take with a patient experiencing hallucinations, following alcohol withdrawal? Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar Administer disulfiram - Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar
Nurse should plan interventions that keep the patient safe and treat the physical manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use, therefore initiate

The nurse should follow-up on reports of fever, as this could indicate a pulmonary infection.
The nurse should discuss participation in sports activities in relation to the child's current physical and pulmonary health. NGN: A patient who is x2 post-op, following a surgical repair of a left hip fracture, is c/o of intermittent abdominal pain. Rates 5/10 on left side of abdomen. Pain began after eating dinner. Last bowel movement was 5 days prior. Reports usual pattern is x1 daily. Assessment: Abdomen distended, dull to percussion, firm and non-tender on palpation. Hypoactive bowel sounds x4. Vital signs are within normal limits. Bowtie: - Condition: Intestinal obstruction
bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain. Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids.
to relieve the pressure from the distention and reduce risk of developing fluid/electrolyte imbalance. Monitor: Bowel sounds & urine output. A nurse is caring for a patient who has a new prescription for clonidine. The nurse should inform the patient that which of the following findings is an adverse effect of this medication? A. Diarrhea B. Dry mouth C. Photophobia D. Bruising - B. Dry mouth
Clonidine is an indirect-acting anti-adrenergic agent used for HTN, severe pain, and ADD. Dry mouth (or xerostomia) is common.
Constipation, dry eyes, and rashes are common adverse effects. A nurse caring for a patient who had a recent stroke. Prior to transferring the patient to the bedside commode, which of the following actions should the nurse take first? A. Ask for help with a two-person assist transfer. B. Assess the patient for functional limitations. C. Request a mechanical lift device. D. Medicate the patient for pain. - B. Assess the patient for functional limitations.
When using the nursing process, the first action the nurse should take is to assess the patient's functional limitations to determine how much the patient can assist with the transfer. A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Which of the following information should the nurse plan to include?

A. Choosing to donate organs can delay the timing of the child's funeral. B. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. C. The family should understand that an autopsy is mandatory prior to organ donation. D. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death. - B. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body.

Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral.
Donation does not affect or delay funeral time/expenses.
A pathologist will perform an autopsy following an unattended death or at the request of the family.
Discussion about donation should take place separately from discussion of child's prognosis. A community health nurse is reviewing the medical records of four newly diagnoses patients. The nurse should identify which of the following patients as having a nationally notifiable infectious condition? A. A patient who is pregnant and has CMV B. An adolescent patient who has foodborne botulism C. A child who has erythema infectiosum D. A young adult who has HSV- 1 - B. An adolescent patient who has foodborne botulism
The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Patients who ingest the toxin can develop dysphagia, drooping eyelids, and vision changes. In 12-36hrs can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment. A nurse is planning care for a patient who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? A. Perform ADLs for the patient to promote rest. B. Allow for freq. rest periods throughout the day. C. Use heat to reduce joint inflammation. D. Develop a daily schedule for acetaminophen up to 6g/day that covers peak periods of pain.
B. Allow for freq. rest periods throughout the day.
The nurse should encourage patients who have RA to balance rest with exercise to maintain muscle strength, joint function, and ROM.
The nurse should allow patients to perform their own ADLs to promote joint mobility and independence.
The nurse should use ice to reduce joint inflammation and heat to alleviate joint discomfort.

The nurse should turn the infant's head to one side to assess the asymmetric tonic neck reflex, which should cause the infant to extend their arm and leg on that side and flex their arm and leg on the other side.
The nurse should tap on the bridge of the infant's nose to assess the glabellar reflex, which should cause the infant to close their eyes tightly. A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36hrs. Which of the following findings should the nurse identify is an indication that the patient has developed oxygen toxicity? A. Wheezes B. Tachycardia C. Restlessness D. Substernal pain - D. Substernal pain
The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased WOB. Another manifestation is crackles.
Tachycardia and restlessness indicate hypoxemia and requires oxygen therapy. A patient is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/in and a BP of 90/44. Which of the following medications should the nurse anticipate administering? A. Naloxone B. Flumazenil C. Acetylcysteine D. Atropine - B. Flumazenil
Flumazenil is a competitive benzo receptor antagonist. It reverses the sedative effects of lorazepam. In addition, the nurse should continue to support the patient's respirations with a bag-valve mask.
Naloxone is the antidote for opiate overdose.
Acetylcysteine is the antidote for acetaminophen overdose.
Atropine is the antidote for cholinesterase inhibitor overdose. A nurse is assessing a patient whose partner recently died. The patient states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A. "It's natural for you to feel this way now, but things will get better with time." B. "You seem to be having a difficult time right now." C. "Why do you feel like your life isn't worth living?" D. "You'd be surprised how many people experience these feelings." - B. "You seem to be having a difficult time right now."

This statement makes an observation, which is a therapeutic response by the nurse. It encourages the patient to express their thoughts and feelings.
Offering false reassurance and minimizing the patient's feelings is not therapeutic.
Asking the patient a "why" questions implies criticism and can make the patient feel defensive. A nurse is teaching a patient who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the patient to monitor and report to the provider? A. Hypotension B. Headaches C. Bruising D. Oliguria - B. Headaches
The nurse should instruct the patient to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events.
Other symptoms to report include HTN, swelling/tenderness of an extremity, fluid retention, or genitourinary candidiasis. A nurse is caring for a patient who has bipolar disorder. The nurse observes that the patient is becoming increasingly restless. The patient is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? A. Provide an opportunity for the patient to express their feelings. B. Move the patient to a quiet place away from others. C. State expectations that set limits on the patient's behavior. D. Administer a PRN dose of haloperidol to calm the patient. - B. Move the patient to a quiet place way from others.
The patient's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other patients by moving this patient to a quiet place away from others. A nurse is caring for a patient who is in labor at 39wks of gestation. During the second stage of labor, the nurse observes early decels on the monitor tracing. Which of the following actions should the nurse take? A. Continue observing the FHR. B. Assist the patient to a knee-chest position. C. Prepare the patient for continuous internal monitoring. D. Prepare for an emergency C-sect - A. Continue observing the FHR

D. Maintain sterile objects within the line of vision. - D. Maintain sterile objects within the line of vision.

Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis.
Sterile technique includes holding hands away from body and above waist level. Items should be kept at least 2.5 cm (1 in) away from the border.
The nurse should use this technique to prevent the solution from running down the label and obscuring the writing, but this action does not maintain sterile technique. A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect? (Normal: 30-40 sec) A. 11 seconds B. 22 seconds C. 30 seconds D. 45 seconds - D. 45 seconds
A manifestation of hemophilia A is a longer clotting time. A nurse manager in a LTC facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? A. Form a committee of staff members to investigate current staffing issues. B. Provide support to staff members who are resistant to staffing changes. C. Schedule a staff meeting to present the different options to staff members. D. Give the staff members advance written notice of staffing changes. - A. Form a committee of staff members to investigate current staffing issues.
The first action the nurse should take when using the nursing process is to assess the current staffing issue. The first stage pf change is the "unfreezing stage", which is gathering information about the problem. A nurse is planning care for a patient who has thrombocytopenia. Which of the following instructions should the nurse include in the plan of care? A. Avoid venipunctures when possible. B. Restrict visitors to family members. C. Limit oral fluid intake in between meals. D. Prohibit fresh flowers in the patient's room. - A. Avoid venipunctures when possible.
Patients who have thrombocytopenia have a decreased PLT count and are at risk for bleeding.

Neutropenic precautions are for patients with a decreased level of WBC, putting them at risk for infection. Precautions include restricting visitors to healthy individuals and prohibiting fresh flowers in their room. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? A. Contact the triage officer. B. Implement the patient tracking system. C. Ask the communications officer to release a press statement. D. Notify the incident commander. - D. Notify the incident commander.
The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order. NGN: What should be included in the plan of care for a 8yr old patient with cystic fibrosis? Admission: SOB, wheezes x5 lobes, prod. cough with thick sputum. Vitals: HR 108, R 26, T 98.9F, BP 100/62, O2 92%. Sputum culture (+) B. cepacia A. Initiate droplet precautions. B. Keep the child NPO x12hrs. C. Maintain the child on bed rest x24hrs. D. Administer high-dose antibiotic therapy. - D. Administer high-dose antibiotic therapy.
Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections.
Initiate contact precautions, high-calorie/high-protein diet with unlimited fat, and include ADLs in plan of care. Exercise facilitates mucus excretions and can increase the child's self- esteem. A nurse is caring for school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? A. Chest x-ray B. Serum liver enzyme levels C. ABGs D. Urine culture and sensitivity - B. Serum liver enzyme levels
Valproic acid can cause hepatic toxicity. Assess liver function prior to and periodically during therapy. A nurse receives a request from a patient to review information in his medical record. Which of the following responses should the nurse give? A. "There's a protocol for reviewing your medical record, and I can initiate the process."

Assess the patient for physical needs, safety, and comfort q15-30 min and document the findings.
HCP must renew a prescription for restraints q4hrs for patients 18yrs<, q2hrs for children 9- 17yrs, and q1hr for children <9yrs. A nurse administers an incorrect dose of medication to a patient. The nurse recognize the error immediately and completes an incident report. Which of following facts related to the incident should the nurse document in the patient's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist - B. Time the medication was given
Document the time, the name of the medication, the dose, and the route in which the medication was given on the med administration record. Document the time that the incorrect medication was administered to the patient in the incident report, as this is a fact directly related to the occurrence. A nurse on an inpatient unit is caring for a patient who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? A. Implement fall precautions for the patient. B. Monitor the patient's thyroid function. C. Place the patient on a fluid restriction. D. Discontinue the medication if hallucinations occur. - A. Implement fall precautions for the patient.
Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls.
Monitor the patient's CBC for anemia, thrombocytopenia, leukocytosis, leukopenia, and elevated AST/ALTs.
Can cause constipation, diarrhea, or dry mouth. Nurse should encourage increased intake of fluids. A nurse is providing discharge teaching about disease management for a patient who has a new diagnosis of DM1. Which of the following is the nurse's priority? A. Instruct the patient about the importance of regular medical appointments. B. Encourage the patient to participate in daily exercise. C. Explain proper foot care techniques to the patient. D. Ensure that the patient understands the medication regimen. - D. Ensure the patient understands the medication regimen.
The priority action the nurse should take when using the safety vs. risk reduction approach to patient care is to ensure the patient understands the medication regimen. The greatest risk to the patient is the potential to develop hypoglycemia/hyperglycemia, which can be life- threatening if treated incorrectly.

A patient who is 24hrs post-op following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? A. Ask the patient to rate their pain level. B. Assist the patient in changing positions. C. Administer a PRN analgesic medication. D. Explain the importance of early ambulation. - A. Ask the patient to rate their pain level.

Using the nursing process, the first action the nurse should take is to assess the patient's level of pain. If indicated, the nurse should administer an analgesic, then wait 30-45 min to allow the analgesic to take effect before encouraging the patient to ambulate. Management of the patient's pain is a priority for encouraging post-op activity. A nurse is caring for a patient who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the patient's IV site q8hrs. B. Check the WBC count q48hrs. C. Monitor the patient's mouth q8hrs. D. Change the IV tubing q48hrs. - C. Monitor the patient's mouth q8hrs.
Monitor mouth at least q8hrs for manifestations of an infection (like sores or lesions).
Check IV site q4hrs for REEDA.
Monitor WBC count q24hrs.
Change IV tubing q24hrs. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? A. Popcorn B. Diced steamed carrots C. Whole celery sticks D. Marshmallows - B. Diced steamed carrots
Choose foods that are soft and do not present as a choking hazard. A nurse is caring for a newborn whose parents asks why the baby is receiving vitamin K. The nurse should explain to the parents that the newborn is receiving vitamin K to prevent what? A. Bleeding B. Potassium deficiency C. Infection D. Hyperbilirubinemia - A. Bleeding
Vitamin K helps clotting factors.

C. Decreased cholesterol D. Decreased esophageal reflux - B. Decreased hallucinations

Chlorpromazine is an anti-psychotic medication administered to decreased manifestations of schizophrenia. A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following should the nurse expect? A. Fever unresponsive to antipyretics B. Pain in weight-bearing joints C. Decreased heart rate D. Peeling of the soles of feet - A. Fever unresponsive to antipyretics
Acute phase: high fever unresponsive to treatment and tachycardia.
Subacute phase: pain in weight-bearing joints and peeling of the soles of their feet. A nurse is preparing to teach about dietary management to a patient who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the patient to decrease in their diet? A. Calories B. Protein C. Potassium D. Fiber - D. Fiber
Consume a low-fiber diet to reduce diarrhea and inflammation.
Increase protein, potassium and caloric intake to at least 3,000 kcal/day. A nurse is assessing a patient for compartment syndrome. Which of the following should the nurse expect? A. Fever B. Shortened femoral neck C. Edema D. Dark brown urine - C. Edema
Compartment syndrome S/S: increased pain, pallor, paresthesia from the increased edema. A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following should the nurse expect? A. Strict adherence to routines B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents - A. Strict adherence to routines

Children with autism will exhibit strict adherence to routines/rituals, a fixation to specific objects, and a resistance to change. A nurse on a pedi unit has received change-of-shift report for four children. Which of the following patients should the nurse assess first? A. 6mo-old infant who has croup and an O2 sat of 92% RA. B. 15yr-old who is 2hrs post-op following an open education and internal fixation of the left ankle and is requesting pain medication C. 3yr-old toddler who has gastroenteritis, moderate dehydration and had x2 loose BM in the past 24hrs. D. 10yr-old who is awaiting surgery for an appy and experienced sudden relief from pain - D. 10yr-old who is awaiting surgery for an appy and experienced sudden relief from pain
Use the urgent vs. non-urgent approach. Findings indicate peritonitis from a ruptured appendix. Notify HCP immediately. A nurse is working with a patient who has PTSD. Patient asks the nurse to recommend a nonpharmalogical therapy to use to provide relief of the manifestations. Which complementary therapies should the nurse recommend to help alleviate the distress? A. Spinal manipulation B. Acupuncture C. Therapeutic touch D. Guided imagery - D. Guided imagery
Helping patients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist patients who have PTSD by relieving anxiety and pain.
Spinal manipulation is not a therapy the patient can do themselves. Involves adjusting and aligning the spine, which helps with back pain, asthma and allergies.
Acupuncture requires special training. Improves immune, neurologic, cardiac and endocrine function. Helps relieve pain and assist with substance withdrawal.
Touch therapy is not a therapy a patient can do themselves. Helps alleviate pain, depression, healing of body tissues, and physiological needs (reducing blood pressure, fever and nausea). A charge nurse assigns a newly licensed nurse to care for a patient who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following should the charge nurse take first to provide teaching? A. Refer the nurse to the procedure manual B. Use a diagram to explain the procedure C. Demonstrate the procedure D. Ask the nurse about their knowledge of the procedure - D. Ask the nurse about their knowledge of the procedure

Planning is the most important step in managing time effectively. Other activities include setting goals, establishing priorities, and scheduling activities. A nurse is caring for a patient who has a terminal illness and request no lifesaving measures. What should the nurse say? A. "You will need to draft a healthcare surrogate so a designee can make this decision for you." B. "I will make sure that no one performs any lifesaving measures if your heart stops." C. "Your HCP determines if you should have lifesaving measures if your heart stops." D. "I will provide you with information about medical treatment to include in your living will." - D. "I will provide you with information about medical treatment to include in your living will."
The nurse's responsibility is to provide the patient with information about specific instructions for addressing medical treatment in a living will. A charge nurse observes a staff nurse document a dressing change in the patient's chart that was not performed. What should the charge nurse do first? A. Ensure the staff nurse changes the dressing B. Notify the nurse manager C. Complete an incident report D. Gather more information about the staff nurse's actions - D. Gather more information about the staff nurse's actions
First step is to assess the reasons for the staff nurse's negligent actions. After discussing actions, then the charge nurse should decide the next course of action. A nurse is caring for a patient following a vacuum-assisted birth. What complications should the nurse monitor for related to vacuum-assisted births? A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta - C. Cervical laceration
Complications include perineal, vaginal and cervical lacerations. NGN: Performing an abdominal assessment - 1. Inspection

Auscultation
Percussion
Palpation A nurse is teaching a group of guardians about child safety measures. Which statements indicate understanding? A. "I will make sure my 4yr-old child wears a helmet when using a skateboard." B. "I should have my child avoid sun exposure between 10am and 2pm."

C. "I can give my 2yr-old child a whole hotdog on a bun." D. "When my infant is in the carrier, I will place it on a raised, flat surface whenever possible." - B. "I should have my child avoid sun exposure between 10am and 2pm."

Sunburn prevention: apply sunscreen, wear protective clothing, and avoid the sun between 10am and 2pm. A nurse is caring for a patient who has cancer and is deciding between two treatment plans. Patient asks nurse for assistance in making a decision. What should the nurse say? A. "I understand this is a difficult decision." B. "Tell me more about your understanding of the options." C. "You will make the right choice." D. "I will ask your provider to talk with you further." - B. "Tell me more about your understanding of the options."
Offers a general lead that facilitates communication between the nurse and patient, and will help the nurse explore the patient's feelings about the treatment options. A hospice nurse is consulting with a patient and family about receiving home services. Which statements indicate understanding of hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. "A hospice nurse will come the house each time our mother needs pain medication." C. "Now that my mother is receiving hospice services, we will not be able to get respite care." D. "Hospice care focuses on arranging treatment that will prolong our mother's life." - A. "We can expect the hospice nurse to provide support for us after our mother's death."
Hospice includes: bereavement services and respite care.
Nurse will teach family how to administer pain medications but is also available on call 24hrs/day.
Hospice focuses on providing palliative, psychosocial, and spiritual care without the intent of prolonging life. A home health nurse is providing teaching about infection prevention to a patient that has cancer and is receiving chemo. Which statements indicate understanding? A. "I will leave my drinking water out of my refrigerator for at least 1hr so it will be room temp." B. "I will clean my toothbrush in my dishwasher once a month. C. "I will take my temp once a week and let my HCP know if it's high." D. "I will walk for short distances throughout the day." - D. "I will walk for short distances throughout the day."
The patient should ambulate short distances as tolerated throughout the day. Helps reduce pulmonary stasis and prevent the development of respiratory infections.

Nursing Assessment and Interventions: Comprehensive Practice Scenarios, Exams of Nursing

Related documents

Partial preview of the text

Download Nursing Assessment and Interventions: Comprehensive Practice Scenarios and more Exams Nursing in PDF only on Docsity!

ATI PN Comprehensive Predictor Exam 13