ATI – Priority Setting & Team Work Advanced Test – Flashcards
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A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first?
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Initiate a bladder training schedule
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A nurse is caring for a client who is 48 hr post operative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?
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Absent dorsalis pedis pulse
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A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern?
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Promoting oxygenation
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A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?
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A client who has a fever of 38.4°C (101.2°F) with tenderness in the right lower quadrant
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A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of a 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first?
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Check pedal pulse
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Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?
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Perform fingersticks for glucose levels on clients who have diabetes mellitus
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A nurses caring for a group of pediatric clients. Which of the following clients requires immediate intervention?
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A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting
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A nurses caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast?
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Evaluate neurovascular status
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A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first?
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Evaluate level of consciousness
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A nurse in a providers office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurses priority concern?
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A client who is 34 weeks of just station and reporting abdominal tenderness
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A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching?
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Used properly fitted bicycle helmet
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A nurses caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?
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Engage the client in physical activity
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A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first?
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A client following knee replacement surgery complaining of pain and warmth in the calf
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A nurses caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor?
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Maternal respirations
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A nurses caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is a priority concern of the nurse?
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Preventing injury
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A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurses priority concern?
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Incomplete amputation of the foot
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A nurse is caring for a client who was admitted to the unit three hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern?
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Oxygen saturation of 90% on oxygen at 2 L per nasal cannula
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A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post operative clients. Which of the following requires immediate intervention?
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A preschooler who is post operative following a tonsillectomy and is experiencing frequent swallowing
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A nurse is caring for toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse?
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Obtain an oxygen saturation level
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A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor?
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Decreased respiratory effort
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A nurse is assessing four clients. Which of the following should he nurse assess first? a. Client with COPD with respirations 23/min b. Client with gastric cancer, reporting nausea & vomiting c. Client with rheumatoid arthritis with joint swelling d. Client with chest tube & has asymmetrical chest movement
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d. Client with chest tube & has asymmetrical chest movement This may indicate a tension pneumothorax
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nurse enters a client's room and sees the client on the floor. What should the nurse do first? a. complete incident report b. notify client's provider c. move client back into bed d. obtain client's vital signs
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d. obtain client's vital signs
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a nurse is preparing to apply a condom catheter to a male client. which of the following actions should the nurse take after performing hand hygiene and applying clean gloves? a. provide perineal care to the patient b. prepare drainage bag & tubing c. check condition of penile shaft d. place a bath blanket over the client's upper torso
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c. check condition of penile shaft
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nurse in the PACU is caring for a client who is postoperative following an abdominal hysterectomy. which of the following actions should the nurse take first? a. encourage client to cough & deep breathe b. change client's perineal pad c. place client in side-lying position d. monitor the client's urinary output
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c. place client in side-lying position *Greatest risk to client is injury from an obstructed airway. Side lying position allows tongue to move to side instead of obstructing airway.
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nurse assessing a client who has cancer and received morphine for pain. which of the following findings is the nurse's priority? a. orthostatic hypotension b. respiration rate 10/min c. absence of bowel movements for 5 days d. bladder distention
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b. respiration rate of 10/min
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A nurse is planning care for four clients. Which of the tasks can the nurse delegate to the LPN? a. assess a client's postoperative abdominal incision b. provide discharge teaching for a client who had a laparoscopic cholecystectomy c. perform a wet-to-dry dressing change for a client with a pressure ulcer d. initiate blood transfusion for a client who has low hemoglobin
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c. perform wet-to-dry dressing change
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a nurse is receiving change-of-shift report for a group of clients. which of the following clients should he nurse attend to first? a. a client who is schedule for discharge and required wound care teaching b. client who is postoperative and requests pain medication before ambulation c. a client who is to receive an antibiotic in 1 hr and has a prescription for a peak and trough level d. a client who has received nitroglycerin sublingual for chest pain and requires a 12-lead EKG
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d. a client who has received nitroglycerin sublingual for chest pain and requires a 12-lead EKG
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a nurse in a rehabilitation facility is performing the role as a case manager for a group of clients. which of the following actions should the nurse take: a. Offer clients alternative therapies that differ from traditional western medicine b. manage the day to day operation of a specific health care unit c. ensure clients receive optimal care in a cost-effective manner d. providing continuing education of nursing staff
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c. ensure clients receive optimal care in a cost-effective manner
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a nurse is planning care for a client who has residual effects from an ischemic stroke. which of the following inter professional consults should the nurse request first? a. speech-language pathologist b. occupational therapist c. physical therapist d. social worker
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a. speech-language pathologist
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a nurse is managing care for a client with recent unexplained weight loss and a low serum albumin level. which of the following members of the interprofessinal care team should the nurse consult? a. occupational therapist b. case manager c. registered dietitian d. social worker
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c. registered dietitian
