1.A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the
following findings should the nurse report to the surg... [Show More] eon?
1. Heart rate 90/min
2. Absent bowel sounds → normal findings after major bowel surgery; takes several days to return
to normal.
3. Hgb 8.2 g/dl
4. Gastric pH of 3.0
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.
2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should
the nurse plan to administer?
a. Desmopressin
b. Regular insulin
c. Furosemide
d. Lithium carbonate
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and keeps
pt. on urinating
3. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse
take first (Click on the “Exhibit” button for additional information about the client. There are three tabs
that contain separate categories of data.)
a. Obtain a sputum sample for culture
b. Prepare the client for a chest x-ray
c. Initiate airborne precautions
d. Administer ondansertron.
Rationale: No idea what the Exhibit is all about; wont be able to answer it.
4. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough
pain. Which of the following prescriptions should the nurse anticipate?
a. Transmucosal fentanyl
b. Intramuscular meperidine
c. Oral acetaminophen
d. Intravenous dexamethasone
Rationale:ATI pg. 27
5. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of
the following should the nurse analyze to determine whether the client is experiencing a myocardial
infarction?
a. PR interval
b. QRS duration
c. T wave
d. ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
6. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which
of the following instructions should the nurse include?
a. Pat the skin on the radiation site to dry it
b. Apply OTC moisturizer to the radiation site
c. Cover the radiation site loosely with a gauze wrap before dressing
d. Use a soft washcloth to clean the area around the radiation
site Rationale: pg. 584. Dry the area thoroughly using patting motions.
7. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client
has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should
anticipate administering which of the following prescribed medications?
a. Diphenhydramine
b. Acetaminophen
c. Pantoprazole
d. Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent
cardiovascular/respiratory distress.
8. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
a. Lungs clear
b. Apical pulse 82/min
c. Hyperactive bowel sounds
d. Blood pressure 90/50 mm Hg
Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation, paralytic ileus. So
effectiveness would indicate opposite of this
9. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse
should recognize these findings as indication of which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Compensated respiratory alkalosis
d. Uncompensated respiratory acidosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis
10. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of
the following labs should the nurse expect during the first 24 hours
A. Decreased BUN ELEVATED DT fluid loss
B. Hypoglycemia (High due to stress)
C. Hypoalbuminemia (Low due to fluid loss)
D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)
(Page 481 ch 75 med surge ati pdf 10.0)
11. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the
following actions should the nurse take ?
a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderate
carbs page 317, chapter 49 Peptic ulcer disease med surge ati pdf 10.0)
b. Provide the client with four full meals a day (Small frequent meals)
c. Encourage the client to to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1
hr prior and following a meal)
d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement
of food within the intestines)
12. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following
factors should the nurse include in the teaching? SATA. (p.70 chapter 13)
Born with a high weight
Chronic infections of the middle ear
Use a loop diuretic
Perforation of the ear drum
13. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for
3 years. Which of the following test should the nurse monitor?
a. Fasting blood glucose [Show Less]
