ATI Proctored Capstone Comprehensive Assessment B

The client can develop a cough due to a buildup of bradykinin in the lungs. 66. A home health nurse is caring for a group of older adult clients.The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A. A client whose family requests hospital based hospice care B. A client who requires transfer to a skilled care facility C. A client who qualifies for telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services: D 67. A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? A. Fever B. Shortened femoral neck C. Edema D. Dark brown urine: C 68. A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? A. Encourage oral fluids B. Apply topical calamine lotion C. Administer acetaminophen as an antipyretic D. Initiate transmission based precautions: D 69. A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder.Which of the following manifestations should the nurse expect? A. Strict adherence to routines 19 / 39 B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents: A 70. A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make? A. "I understand your hesitation, but I'm very proud of you for making the right decision" B. "Organ donation from a first degree relative is your brother's best chance of survival" C. "You're afraid that your other kidney will fail at some point after the organ donation" D. "I know this process won't be easy, but you should focus on saving your brother's life": C 71. A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? A. Check the client's blood type and crossmatch it against the providers orders B. Ask the client to state their blood type prior to beginning blood administration C. Compare information on the blood product to the informed consent form D.Verify the client and blood product information with another licensed nurse.: D 72. A nurse is preparing to transfer a client from the ICU to the medical floor.The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? A. The last time the provider evaluated the client B.The client's most recent ventilator settings C.The time of the client's last dose of pain medication D.The frequency in which the client presses the call buttom: C 20 / 39 73. A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following lab values should the nurse report to the provider? A. Platelets 268,000/mm3 B. Calcium 9.2 mg/dL C. WBC 5,200/mm3 D. Sodium 148 mEq/L: D Sodium is elevated and could indicate issues with renal 74. A nurse is caring for a client who has fluid volume overload.Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Palpate the degree of edema B. Regulate IV pump fluid rate C. Measure the client's daily weight D. Assess the client's vital signs: C 75. A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? A. Creatinine 1.1 mg/dL B. Albumin 2.8 g/dL C.Triglycerides 100 mg/dL D. Alkaline phosphatase 118 units/L: B 76. A home health nurse is evaluating a school-age child who has cystic fibrosis.The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sit still for nebulizer treatments" B. "I think that my child has been running a fever over the last couple of days" C. "My child has only a small amount of mucus after percussion therapy" D. "I am concerned about my child's future participation in team sports": C 77. A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding.Which of the following actions should the nurse take? 21 / 39 A. Insert air in the tube and listen for gurgling sounds in the epigastric area B. Aspirate contents from the tube and verify the pH level C. Review the medical record for previous x-ray verification of placement D. Auscultate the lungs for adventitious breath sounds: B 78. A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect? A. 11 seconds B. 22 seconds C. 30 seconds D. 45 seconds: D 79. A nurse is assessing a client whose partner recently died.The client 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 80. An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? A. The LPN and AP lower the side rails before lifting the client up in bed B. Prior to lifting the client, the LPN and AP raise the bed to waist level C.The LPN and the AP grasp the client under this arms to life him up in bed D.The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift: C 81. A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect? A. Decreased hematocrit B. Hypokalemia C. Hyponatremia D. Increased albumin: C the initial resuscitation period (between 0 and 36 h). characterized by hyponatremia 22 / 39 and hyperkalemia d/t sodium loss in burn tissue and tissue necrosis. Hyponatremia is due to extracellular sodium depletion following changes in cellular permeability. 82. A nurse on a mental health unit is conducting a mental status examination (MSE) on a new admitted client. Which of the following components of the MSE is the priority for the nurse to assess? A. Mood B. Speech C. Ideas of self harm D. Memory loss: C 83. A nurse manager is planning to use a democratic leadership style with the nurses on the unit.Which of the following actions by the nurse manager demonstrates a democratic leadership style? A. Avoids initiating change B. Seeks input from the other nurses C. Makes decisions quickly D. Limits the amount of feedback to the staff: B 84. A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include? A. Limit intake of fluids to 1,000 mL daily B.Take a laxative if no stool has passed after 12 hr C. Empty the appliance when it is one-third to one-half full D. Change the entire pouch system every 1-2 days: C 85. A nurse manager is preparing an educational session about advocacy to a group of nurses.The nurse manager should include which of the following information in the teaching? A. Advocacy is a leadership role that helps others to self- actualize B. Subordinates are advocates for the nurse manager C. Advocacy encourages clients to rely on health care staff for decision making D. Nurse managers should distrust people who advocate against inappropriate professional practices: A