Ati Rn Exit Predictor 2024 Exam

A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? (a. implement a regular toileting schedule b. encourage the client to wear athletic socks when ambulating c. place all 4 bed rails in the upright position d. require a family member to remain at the bedside) {Ans: a. implement a regular toileting schedule}A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? {Ans: 2.High-pitched cry}The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to {Ans: 2. perform the Valsalva maneuver "holding breath and bearing down" before doing the catheterization.}A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? (a. Left lower quadrant b. Left upper quadrant c. Right upper quadrant d. Right lower quadrant) {Ans: D. Right lower quadrant}Bladder retraining