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ATI - MED SURG EXAM 1, 2, AND 3 - CALIFORNIA STATE UNIVERSITY, LONG BEACH TTT 67777
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ATI - MED SURG EXAM 1 - California State University, Long Beach TTT 67777
ATI - MED SURG EXAM 1 TTT 67777 1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse ex... [Show More] pect? a. Bradycardia b. Flushed skin c. Frothy sputum – pg.198 d. Jugular vein distention 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. (Find “hot spots” in the artwork) - CORRECT 3. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply.) a. Monitor the access site for drainage. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position - pg.370: encourage client to lie Supine with head slightly elevated during CCPD and APD treatment. e. Position the client to her other side. 4. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Wash you’r perineal area two times each day with antimicrobial soap. b. Change your pet’s litter box daily. c. Change the water in your drinking glass every 4 hrs. d. Wash your toothbrush in the dishwasher once each month. 5. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take? a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed 6. A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching? a. A possible cause of this problem is long-term lack of dietary protein. b. You probably have a Detachment of your retina. c. You probably have noticed a decline in your central vision. – pg.63 d. The doctor can perform surgery to correct the start paying the folds in your retina. 7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? – Expected Findings: fatigue, Wt loss, abdo.pain, abdo.distention, pruritus. a. Platelets 70,000/mm3 - pg.357 b. Distended abdomen c. Alkaline phosphatase 125 units/L d. Clay colored stools 8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? a. Hyperglycemia – if unavailable, do not attempt to catch up by increasing the infusion rate because client can develop Hyperglycemia. b. Diarrhea c. Constipation d. Hypoglycemia – pg.298 – sudden abruption of infusing rate can cause hypoglycemia. 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? - CORRECT a. Administer the unit of packed RBC’s over 1 hr. b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion. c. Initiate venous access with a 21-gauge needle. d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. 10. A nurse is caring for a female who has toxic shock syndrome. Which of the following findings should the nurse expect? a. Elevated platelet count b. Generalized rash ■ Whole body rash c. Decreased total bilirubin d. Hypertension ■ Hypotension 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. Which of the following instructions should the nurse include? a. Use fluticasone as needed for shortness of breath. b. Limit fluid intake to 1 L per day. c. Obtain a yearly influenza immunization. d. Assist use of pursed-lip breathing. 12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” b. “Clean the incision daily with hydrogen peroxide.” c. “Install a raised toilet seat in your bathroom.” d. “You should use an incentive spirometer every 8 hrs.” 13. Missing 14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately? a. The client reports shortness of breath – sign of surgical complication b. The client has a temperature of 38.1 C (100.5F) c. The client’s incision is red and warm d. The client reports incision pain 15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? a. Place the client in a protective environment b. Obtain a stool specimen with gloves c. Clean surfaces with chlorhexidine-bleach d. Wash hands with alcohol-based hand rub. 16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all the apply.) a. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap b. Select a work surface at the nurse’s waist level c. Apply sterile gloves before opening the pack d. Open the first flap of the sterile package toward the nurse's body e. Place a surgical pack with a sterile drape on the work surface. 17. A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider? a. Nausea b. Flank pain c. Fever d. Rigid abdomen 18. A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the client’s meals? a. Offer frequent, high-carbohydrate meals b. Offer highly seasoned foods c. Offer a snack prior to radiation therapy d. Offer hot beverages with meals 19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? a. Empty water from the ventilator tubing daily. b. Suction the client’s airway every 4 hr. c. Maintain the client in supine position. d. Perform oral care every 2 hr. 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? a. Palmar erythema b. Spider angiomas c. Yellow Sclera d. Mental Confusion 21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication? a. Bowel sounds present in 4 quadrants on auscultation b. Alert and oriented to time place and person c. Lung sounds clear d. Apical pulse 80/min and regular 22. A nurse is caring for a client who has active tuberculosis. Which of the following interventions should the nurse include in the plan of care? a. Perform chest percussion twice daily b. Wear a high-efficiency particulate air mask c. Initiate droplet precautions d. Obtain daily sputum specimen 23. A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medication in the client's medication administration record? a. Potassium chloride b. Levothyroxine c. Acetaminophen d. Metformin 24. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care? a. Avoid use of anticoagulants b. Place pillow under client knees c. Discourage leg exercises while in bed d. Apply compression stocking in lower extremities 25. What interferes with warfarin therapy? a. Potatoes b. Oranges c. Bananas d. Cauliflower 26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective? a. Elevation in BP b. Adventitious breath sounds c. Weight loss of 1.8 kg (4lb) in the past 24 hr d. Respiratory rate of 24/min 27. A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect? a. Weight loss b. Hyponatremia c. Hyperglycemia d. Hypercalcemia 28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40 a. Back pain b. Bradycardia ■ tachy c. Hypertension ■ Hypotension d. Chills 29. A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? a. 75 mL of greenish yellow drainage b. 100 mL of red drainage c. 200 mL of brown drainage – purulent d. 150 mL of serosanguineous drainage 30. A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following findings should the nurse expect? a. Lethargy – pg.382 b. Potassium 4.0 mEq/L c. Hypotension d. Serum creatinine 0.9 mg/dL 31. A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all the apply.) a. You will take medication for this condition for several months b. You will need to eat a high-fiber diet to prevent complications of this condition c. You might notice that you perspire more with this condition d. We will perform laboratory tests to monitor the effect of your medication e. This condition can cause you to gain weight. 32. A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? a. Empty water from the client’s ventilator tubing b. Evaluate the client for a cuff leak c. Suction the client’s airway d. Increase the client’s ventilator flow rate 33. A nurse is reviewing laboratory results for four client who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon? a. INR of 1.6 b. Platelets 95,000/mm3 c. Hct 42% d. WBC 8,000/mm3 34. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective? a. Increased potassium level b. Decreased blood pressure c. Increased heart rate d. Decreased urinary output 35. A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the following positions should the nurse instruct the client to maintain after the procedure? a. Prone b. Supine c. Right lateral d. Left lateral [Show Less]
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ATI - MED SURG EXAM 2 - California State University, Long Beach TTT 67777
ATI - MED SURG EXAM 2 TTT 67777 1. The nurse is preparing the discontinue long term TPN therapy for a client. The nurse should plan to discontinue the... [Show More] TPN gradually to reduce the risk of which of the following adverse effects? a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia- You taper it off to avoid this!!! Rationale PDF p.298: Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly. Rationale PDF nutrition p.58: don’t discontinue abruptly, must taper to prevent rebound hypoglycemia 2. A nurse is preparing a client for an ECG. The client is anxious and says that he is afraid the equipment will give him an electric shock. Which of the following is an appropriate response by the nurse? a. The machine only senses and records electrical currents coming from your heart – pg.170 Electrocardiography uses an electrocardiograph to record the electrical activity of the heart over time. b. The lead wires and cables are insulated for your safety c. The electrode pads will prevent the conduction of electricity to your skin d. The machine voltage delivery is low enough that you won’t feel any discomfort 3. A nurse is caring for client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medications in the client’s medication administration record? a. Potassium chloride b. Levothyroxine c. Acetaminophen d. Metformin 4. A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? a. Elevation in blood pressure b. Adventitious breath sounds c. Weight loss of 1.8 kg (4 lb) in the past 24 hr d. Respiratory rate of 24/min 5. Couldn't paste the picture on here. But it asked where u can hear pericardial friction rub the best at…Erb’s Point (3rd Intercostal, Central) 6. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the nurse indicates an understanding of the teaching? a. I will increase the amount of fresh veggies b. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash c. I will need to take my clothes to the dry cleaners to sterilize them d. I will be sure to wear gloves and wash my hands when I change my cat’s litter box 7. A nurse is performing a venipuncture on an older adult client whose veins are difficult. Which of the following actions should the nurse take? a. Apply cool compresses b. Elevate the client’s extremity using a pillow c. Tap the skin around the insertion site d. Raise the angle of the catheter to 30 degrees above the insertion site 8. A nurse is caring for a client in the ER following a myocardial infarction. which of the following actions should the nurse anticipate if the client develops asystole? a. Administer atropine b. Defibrillate with 200 joules c. Starts a continuous lidocaine infusion d. Begin CPR – first line of medical management is CPR and ACLS. 9. A nurse is caring for a client with severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock? a. Potassium 5.2 mEq/L b. Capillary refill 1.5 seconds c. Urine output 45 mL/hr d. PaCO3 37 mmHg 10. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow coma scale scores should the nurse assign the client? a. 2 b. 5 c. 10 d. 13 11. A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching? a. I will keep an exercise diary b. I will take ibuprofen for mild pain c. I will expect swelling in my feet and ankle d. I will weigh myself every other day 12. A nurse is providing discharge teaching for a client who has new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching a. I’ll insert the obturator after cleaning my stoma b. I’ll cut a slit in a clean gauze pad to use as a stoma dressing c. I’ll cleanse the cannula with half strength hydrogen peroxide d. I’ll remove the soiled tracheostomy ties prior to cleaning my stoma 13. A nurse is caring for a client who has a sealed radiation implant which of the following actions should the nurse take? a. Limit family member visits to 30 min per day – pg. 583 Limit visitors to 30‑min visits, and have visitors maintain 6 feet distance from the source b. Give the dosimeter badge to the oncoming nurse at the end of the shift c. Apply second pair of gloves before touching the clients implant if it dislodges d. Remove soiled linens from the room after each change 14. A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? a. WBC count 15,000/mm b. Hematocrit 35% c. Sodium 130 mg/dl d. BUN 8 mg/dl 15. A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to avoid lifting the right arm for 72 hr b. Check blood pressure in the right arm c. Palpate the site for thrill d. Insert a saline lock into a site 10 cm (4in) distal to the graft 16. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. which of the following should the nurse take first? a. Check the color of the client’s skin – Assessment first b. Prepare the client’s clothing c. Remove all the clients clothing d. Administer an opioid analgesic 17. A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication of a complication at the vascular access site? a. Presence of palpable thrill b. 2 + left radial pulse c. Absence of bruit – pg. 367 d. Dilated appearance of the AV site 18. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a. Decrease traction on the catheter b. Remove the indwelling urinary catheter c. Flush the catheter manually with 0.9% sodium chloride d. Administer ibuprofen 400 mg for pain relief 19. A nurse is caring for a client who has contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications? a. Desmopressin – pg.500 Desmopressin, which is a synthetic ADH, or aqueous vasopressin administered intranasally, orally, or parenterally. Results in increased water absorption from kidneys and decreased urine output. b. Epinephrine c. Furosemide d. Nitroprusside 20. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? a. Valproic acid b. Metformin – pg.530 c. Metoprolol d. Fluticasone Stop Metformin for 48 hr before any type of elective radiographic test with iodinated contrast dye and restart 48 hr after (can cause lactic acidosis due to acute kidney injury). 21. A nurse is preparing a client who is to undergo a thoracentesis. The nurse should place the client in which of the following positions? a. On her affected side with her head lowered b. In high-Fowler’s position with her arms at her side c. Prone position with her arms above her head d. Upright on the edge of the bed leaning over the bedside table 22. A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? a. Position the mouthpiece 2.5 cm (1in) from the mouth b. Hold breaths 3 to 5 seconds before exhaling c. Place hands on the upper abdomen during inhalation d. Exhale slowly through pursed lips 23. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client’s recovery? a. Provide analgesic medication prior to physical activities b. Inform the client to monitor for loose stools while taking opioid analgesia c. Withhold analgesic medication unless the client reports pain d. Administer naloxone if the client’s respiratory rate is greater than 24/min Give analgesic to relieve pain before getting involved in any physical activity 24. A nurse is preparing to assist the provider with thoracentesis for a client who has left pleural effusion. Which of the following interventions is the priority for the nurse? a. Describe the sensation the client will feel during the procedure b. Reinforce the importance of lying still during the procedure c. Administer a sedative medication d. Determine whether the client has an allergy to local anesthetics - Assessment 25. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect? a. Decreased serum lipid levels b. Proteinuria c. Hypoalbuminemia d. Decreased coagulation Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, and elevated serum lipids, anorexia, and pallor. 26. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? a. Limit the client’s fluid intake to 1 L per day b. Keep the client on bed rest for 24 hr c. Change the client’s dressing every 8 hr d. Maintain the client’s affected extremity in extension 27. A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first? a. Urinary output b. Motor responses – pg.75 c. Blood pressure d. Blood glucose 28. 61. A nurse is providing discharge teaching to a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply) a. I will use NSAIDS to treat aches and pains – pg.561 b. I will use cosmetics without moisturizer c. I will disinfect skin lesions with rubbing alcohol d. I will wear long sleeve when outdoor e. I will increase my intake of sodium CLIENT EDUCATION ●● Avoid UV and prolonged sun exposure. Use sunscreen when outside and exposed to sunlight. ●● Use mild protein shampoo and avoid harsh hair treatments. ●● Use steroid creams for skin rash. ●● Report peripheral and periorbital edema promptly. ●● Report evidence of infection related to immunosuppression. ●● Avoid crowds and individuals who are sick, because illness can precipitate an exacerbation. ●● Educate client of childbearing age regarding risks of pregnancy with lupus and treatment medications 29. A nurse is reviewing the laboratory results of a client who has COPD and severe dyspnea. Which of the following ABG values should the nurse expect? a. PaCO2 50 mmHg b. pH 7.4 c. PaO2 95 mmHg d. HCO3 20 mEq/L 30. A nurse is caring for a client who has atrial fibrillation. Which of the following should the nurse expect to administer? a. Dobutamine b. Lidocaine c. Atropine d. Amiodarone – ACLS Class. Pg. 171 31. A nurse is caring for a client who is receiving epidural analgesia. Which of the following findings is the nurse’s priority? a. Bladder distention b. Weakness to lower extremities c. Hypotension – pg. 626 d. Hypoactive bowel sounds 32. A nurse is planning care for a client who has chest drainage system set to low suction following a thoracotomy. Which of the following nursing actions is appropriate to include in the plan of care? a. Check for bubbling in the water seal chamber – pg.104 b. Empty the collection c. Keep the water seal chamber at chest level d. Loop excess tubing below the chest wall Continuous bubbling in the water seal chamber indicates an air leak in the system 33. A nurse is caring for an older adult client who is prescribed packed RBCs. Which of the following actions is appropriate for the nurse to take? a. Obtain vital signs every hour during transfusion b. Administer the transfusion over a 4-hr period c. Infuse lactated Ringer’s solution while transfusing the blood product d. Use a 24-gauge needle for the transfusion 34. A nurse in the intensive care unit is caring for a client who has the following ABG results: pH 7.30; HCO3 19 mEq/L, PaCO2 with the expected reference range. a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis 35. 68. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Change the pet’s litter box daily b. Change the water in your drinking glass every 4 hours c. Wash your toothbrush in the dishwasher once each month d. Wash your perineal area two times each day with antimicrobial soap – pg.90 36. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? a. Administer IV therapy b. Insert a large bore IV catheter c. Monitor urine output d. Obtain a blood specimen for type and crossmatch 37. A nurse is providing a discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching? a. “I will notify my provider if I experience muscle weakness.” – pg. 366: sign of toxicity b. “I will take my digoxin if my pulse is less than 50 beats per minute.” c. “I will increase my dose if my vision becomes blurred.” d. “I will take this medication with fiber to constipation.” 38. A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? a. Diminished breath sounds b. Distended neck veins c. Irregular heart rate d. Itching over the incision [Show Less]
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ATI - MED SURG EXAM 3 - California State University, Long Beach TTT 67777
ATI - MED SURG EXAM 3 TTT 67777 1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following finding... [Show More] s should the nurse report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.0 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 3. 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 b. Stool for occult blood c. Urine for white blood cells d. Serum calcium 4. 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 ondansetron. 5. 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 6. 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 7. 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 8. 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 9. 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 10. 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 11. 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 b. Hypoglycemia c. Hypoalbuminemia d. Decreased Hematocrit 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? a. Offer the client high carbohydrate meal options b. Provide the client with four full meals a day c. Encourage the client to drink at least 360 ml of fluids with meals d. Have the client lie down for 30 minutes after meals 13. 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 a. Born with a high weight b. Chronic infections of the middle ear c. Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin d. Perforation of the ear drum e. Frequent exposure to low volume noise 14. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? a. Administer the plasma immediately after thawing b. Transfuse the plasma over 4 hours c. Hold the transfusion if the client is actively bleeding d. Administer the transfusion through a 24-gauge saline lock 15. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive trousseau. Which of the following electrolyte imbalance should the nurse suspect? a. Hyponatremia b. Hyperchloremia c. Hypermagnesemia d. Hypocalcemia 16. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? a. Change the transparent dressing over the insertion site every 48 hours b. Clean the insertion site with mild soap and water c. Measure your right arm circumference once weekly d. Use a 10milliliter syringe when flushing the catheter 17. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? a. RBC count of 4.7 million/mm b. BUN 22-mg/ dl c. WBC count of 16,000/ mm d. Blood glucose of 120 mg/dl 18. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? a. I will spread my protein allowances over the entire day b. I should increase my intake of canned salmon to three times per week c. I will season my food with lemon pepper rather than salt d. I should limit my intake of hard cheese to 3 ounces each day 19. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Administer 20 ml of 0.9 sodium chloride after each dose of medication b. Flush the catheter using a 5 ml syringe c. Verify the placement with an x-ray prior to the initial dose d. Change the transparent membranes dressing daily 20. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Do not shake your inhaler before use. b. Exhale fully before bringing the inhaler to your lips c. Depress the canister after you inhale d. Use peroxide to clean the mouthpiece if your inhaler 21. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? a. A client who has angina reports substernal chest pain b. A client who has pancreatitis reports pain in the left shoulder c. A client who is postoperative reports incisional pain d. A client who has peritonitis reports generalized abdominal pain 22. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 -10 at the operative site. b. The client’s capillary refill in the left toe is 6 c. The client has an oral temperature of 38.3 (100.9 F) d. The client has 100 ml of blood in the closed suction drained. 23. A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to intervene? a. Right upper quadrant pain b. Capillary blood glucose level of 164 mg/dl c. WBC counts 13,000/mm3 d. Crackle in bilateral lower lobes 24. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? a. Reverse Trendelenburg b. Side Lying c. High Fowlers d. Feet elevated 25. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make? a. “This finding may indicate possible medication toxicity” b. “Your provider will prescribe a different medication regimen” c. “This is an expected adverse effect of this medication.” d. “You will need to increase your fluid intake to resolve this problem” 26. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse take? a. Administer the unit through secondary IV tubing b. Verify the blood product with assistive personnel c. Begin an IV infusion of 0.9% sodium chloride d. Insert another 22-gauge IV catheter 27. A nurse is planning care for a client who is 12 hr. postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? a. Check the client’s blood pressures every 8 hr. b. Administer opioids PO c. Assess urine output hourly d. Monitor for hypokalemia as a manifestation of acute rejection 28. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a. Captopril b. Ibuprofen c. Digoxin d. Phenytoin 29. A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the following findings should the nurse expect? a. Blanching of the hands b. Hyperactive reflexes c. Calf pain with foot dorsiflexion d. Vitiligo on affected extremities 30. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients? a. A client who has a peripherally inserted central catheter in the left arm b. A client who has left-sided Bell’s palsy c. A client who has a right upper extremity arteriovenous fistula d. A client who has right-sided weakness due to Parkinson’s disease 31. A nurse is providing teaching to a client who has DVT. Which of the following findings should the nurse identify as a risk factor for the development of DVTs? a. Hypertension b. Cirrhosis c. NSAIDS use d. Oral Contraceptive Use 32. A nurse is caring for client who has Cushing’s disease. Which of the following actions should the nurse take first? (Click Exhibit button for additional information) a. Check the client’s medication administration record for antihypertensive medication. b. Verify the client’s understanding of sodium restriction. c. Auscultate the client’s lung sound d. Determine the need for further glucose monitoring. 33. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect? a. Proteinuria b. Flank pain c. Hyperalbuminemia d. Hypotension 34. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? a. Oliguria b. S3/S4 galloping heart sounds c. Poor skin turgor d. Pitting edema 35. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? a. Notify the provider when tidaling ceases. b. Assisting the client out of bed three times daily. c. Vigorously strip the chest tube twice daily. d. Administer morphine 2 mg IV bolus every 3 hr PRN for pain. 36. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for home management of heart failure? a. Obtain daily weight. b. Use of salt substitute. c. Monitor Intake and Output d. Limit daily activity. 37. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? a. I need to maintain pressure over the pacemaker site with an elastic bandage. b. I need to check my pulse rate every day for a full minute. c. The pacemaker will deliver shock if I develop a dysrhythmia d. When a microwave oven is in use, I need to stay out of the room. 38. A nurse in a clinic is providing preventive teaching to an older adult client during well visit. The nurse should instruct the client that which of the following immunization are recommended for healthy adults after age 60? Select all the Apply. a. Herpes Zoster b. Influenza c. HPV d. Meningococcal e. Pneumococcal Polysaccharide 39. A nurse is assessing a client who is 4hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report immediately? a. Bruising around the incision site b. Pallor in the affected extremity c. Urine output 150mL over 4hr d. Temperature of 37.9 (100.2) 40. A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? a. Crackles auscultated bilaterally b. Capillary refill of 2 seconds c. Diminished peripheral pulses d. Engorged neck veins 41. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? a. Increase intake of fiber rich foods b. May operate a motor vehicle when no longer taking analgesics c. Take tub baths instead of showers d. May place a small pillow under the head when sleeping 42. A nurse is assessing for elderly signs of compartment syndrome for a client who has a short leg fiberglass cast. Which of the following findings should the nurse expect? a. Bounding distal pulses b. Capillary refill less than 2 seconds c. Erythema of the toes d. Intense pain with movement 43. A nurse is caring for a client who is postoperative following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial blood gases 60 min later. Which of the following lab findings indicates a positive response to the oxygen therapy? a. PaCO2 34 mmHg b. Bicarbonate 20 mEq/L c. PaO2 90 mmHg d. ph 7.32 44. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear (VIII)? a. Loss of the peripheral vision b. Disequilibrium with movement c. Deviation of the tongue from midline d. Inability to smell 45. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a. Glasgow coma scale score changes from 14 to 9 b. Bilateral pupil diameter changes from 4 to 2 mm c. Pulse pressure changes from 30 to 20 mm Hg d. WBC count changes from 9000 to 16,000 mm3 46. A nurse is caring for a client who is taking furosemide. The client has a potassium level of 3.1 mEq/L. Which of the following should the nurse assess first? a. Urine output b. Level of orientation c. Cardiovascular status d. Muscle weakness 47. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? a. Instruct the client to take deep breaths and hold them during the procedure b. Administer a stool softener following the procedure c. Ask the client to empty his bladder prior to the procedure d. Assist the client into the left lateral position during the procedure 48. A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of following electrolytes imbalances? a. Hyperatremia b. Hypermagnesemia c. Hypokalemia d. Hypocalcemia 49. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC’s. Which of the following findings is an indication of a hemolytic transfusion reaction? a. Hypotension b. Bradypnea c. Bradycardia d. Hypothermia 50. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? a. Prepare the client for temporary pacing. b. Initiate IV fluid therapy for the client c. Measure the client’s blood pressure d. Administer atropine to the client 51. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted central catheter. Which of the following actions should the nurse take? a. Apply slight pressure when resistance is met b. Measure the catheter after removal c. Remove the catheter with one continuous motion d. Place a dry sterile dressing to the site after removal 52. A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take? a. Provide humidified oxygen b. Implement fluid restriction c. Administer antibiotic medication d. Administer acetaminophen orally 53. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the following manifestations should the nurse include in the teaching? a. Hypoxemia b. Hyperventilation c. Hypocarbia d. Hypervolemia 54. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? a. Obtain the client’s vital signs b. Clear items from the client’s surrounding area c. Loosen the client’s restrictive clothing d. Lower the client to the floor 55. A nurse is teaching a client who is receiving total parenteral nutrition at home through a central venous access device about transparent dressing changes. Which of the following instructions should the nurse include in the teaching? a. Change the dressing every 48 hr. b. Replace the extension tubing with each dressing change c. Use clean technique when changing the dressing d. Wear a mask during dressing change 56. A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect? a. Decreased respiratory rate b. Hypotension c. Bradycardia d. Urinary diuresis 57. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? a. Spider angiomas b. Palmar erythema c. Mental confusion d. Yellow Sclera 58. A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching? a. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning” b. “I use my heating pad on a low setting to keep my feet warm.” c. “I soak my feet in hot water before trimming my toenails” d. I rest in my recliner with my feet elevated for about an hour every afternoon” 59. A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis. Which of the following instructions should the nurse include in the teaching? a. Swallow the medication with 120mL (4 oz) of water b. Take the medication with a vitamin E supplement c. Sit upright for 30 min after taking the medication d. Take the medication with lunch 60. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Initiate beta blocker therapy b. Insert a urinary catheter c. Prepare the client for intravenous pyelogram d. Administer IV fluids to the client 61. A nurse is completing an assessment of an older adult client and notes redness areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care? a. Apply an occlusive dressing b. Manage the redness areas three times daily c. Support bony prominences with pillows d. Turn and reposition the client every 4 hr. 62. A nurse is caring for a client who has completed 10 daily cycles of Total parenteral Nutrition (TPN). Which of the following findings indicates that the client is receiving adequate TPN supplementation. a. Improved Mobility b. Weight gain of 9.1 kilograms to 20 pounds c. Potassium level of 2.5 meq/l d. BUN level of 15 mg/dL 63. A nurse is providing teaching to a client who is post-operative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? a. I will consume can soup whenever sores appear in my mouth b. I will drink orange juice to increase my vitamin C intake c. I will rinse my toothbrush with hydrogen peroxide and water after each use d. I will inspect my mouth once each week for sores. 64. A nurse is performing ear irrigation for a client. Which of the following actions should the nurse take? a. Tilt the client's head 45 degrees b. Insert the tip of the syringe to .5 centimeters 1 inch into the ear canal c. Point the tip of the syringe toward the top of the ear canal d. Use cool fluid for irrigation 65. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? a. Check the client's urine output b. Reposition the client in bed c. Increase the client's fluid intake d. Administer PRN pain medication 66. A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a. I will draw up regular insulin into the syringe first b. I will insert the needle at a 15-degree angle c. I will store prefilled syringes in the refrigerator with the needle pointing downward d. I will shake the NPH vial vigorously before drawing up the insulin 67. A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN). Which of the following nursing actions are appropriate? (Select all the apply) a. Obtain the client's weight daily b. Increase the rate of infusion if Administration is delayed c. Monitor serum blood glucose during infusion d. In to use 0.9% sodium chloride if the solution is not available e. Verify the solution with another RN prior to infusion 68. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? a. Check potassium levels b. Administer 0.9% sodium chloride c. Begin bicarbonate continuous IV infusion d. Initiate continuous IV insulin infusiond 69. A nurse is reviewing the laboratory results of a female client who asked about acupuncture treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory results contraindication to receiving acupuncture? a. Absolute neutrophil count 5000/mm3 b. C-reactive protein 0.7 mg/dl c. Platelets 160,000/mm3 d. Hemoglobin 12g /dl 70. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a Pain Scale of 0 to 10. Which of the following should the nurse take? a. Gently massage the area around the client’s incision b. Place pillows under the client's knee c. Apply an ice pack to the client’s knee d. Perform range of motion exercises to the client’s knee 71. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? a. Hypertension b. Positive Chvostek’s sign c. Muscle weakness d. Oliguria 72. A nurse at a long-term care facility is assessing an older adult client. Which of the following findings should the nurse identify as an indication that the client has recall memory impairment? a. Inability to state what he has for dinner last night b. Inability to Name the members of his family c. Inability to count backwards from 10 d. Inability to state his current age 73. A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer? a. Chlorpromazine b. Dobutamine c. Mannitol d. Propanol 74. A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to First? a. A client who has thrombocytopenia and reports and nosebleed b. A client who has chronic obstruction pulmonary disease and oxygen saturation of 89% c. A client who has multiple sclerosis and Ataxia and vertigo d. A client who has left-sided paralysis and slurred speech from a prior stroke 75. A home care nurse is planning to use non-pharmacological pain relief measures for an older client who has severe chronic back pain. Which of the following guidelines should the nurse use? a. Use imagery with clients who have difficulty with focus and concentration b. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus c. Discontinue opioids before trying non-pharmacological methods of pain relief d. Distraction changes the client's perception of pain but does not affect the cause 76. A nurse is caring for a client who has pneumothorax and a chest tube with closed water seal drainage system. Which of the following actions should the nurse take? a. Strip or clear the chest tube every 8 hours b. Refill the water chamber if the fluid is low c. Empty the system at least every 8 hr d. Change the chest to site dressing every 24 hour. 77. A nurse is in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block? a. Prolonged PR intervals b. More p waves than QRS complexes c. Non-discernible p waves d. No correlation between p and QRS waves 78. A nurse is preparing to administer a unit of packed RBC's to a client who is anemic. Identify the sequence of steps the nurse should follow. a. Obtain venous access using a 19-gauge needle 3 b. Obtain the unit of packed rbc's from Blood Bank 1 c. Verify blood compatibility with another nurse 2 d. Initiate transfusion of the unit of packed rbc's 4 e. Remain with the client for the first 15 to 30 minutes of the infusion 5 79. A nurse is teaching a client who is to begin chemotherapy about peripherally inserted central catheter. Which of the following statements should the nurse include in the teaching? a. We will replace the PICC every month b. We can draw blood samples from the PICC for diagnostic test c. We will change the dressing daily d. We can measure your blood pressure in either arm 80. A nurse is assessing a client who has Pyelonephritis and reports flank pain. Which of the following actions should the nurse take? a. Assist the client to a sitting position b. Percuss the side of tenderness first c. Auscultate for a bruit over the coastal vertebral area d. Thump the area of tenderness directly with a closed fist 81. A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider? a. Peripheral pulses 2 + bilaterally b. Weight gain 1.1 kilogram to 2.4 pound in 24-hour c. Urine specific gravity 1.045 d. Creatinine 0.8 milliliter 82. A nurse is caring for an older adult client who is 72 hr. postoperative following a total hip arthroplasty. The client requires a PRN medication prior to ambulation. Which of the following medications should the nurse anticipate administering? a. Indomethacin b. Meperidine c. Naproxen d. Oxycodone 83. A nurse is caring for a client who has Haemophilus Influenzae type B. which of the following types of isolation should the nurse implement? a. Droplet b. Contact c. Airborne d. Protective 84. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include, as an indication the client is no longer infectious? a. Mantoux skin test reveals and induration of less than 1mm b. Client no longer coughing up blood tinged sputum c. Positive Quantiferon TB d. Negative sputum culture for acid fast bacillus 85. A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's Airway which of the following interventions should the nurse take first? a. Cleanse the client wound b. Administer Analgesic medication c. Increase the room temperature d. Start an IV with a large bore needle 86. A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Obtain ABG values b. Perform an ECG c. Turn the client to his left side d. Clamp the catheter 87. A nurse is providing discharge teaching to a client who has impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Wash your perineal area 2 times each day with antimicrobial soap b. Change the water in your drinking glass every 4 hours c. Wash your toothbrush in the dishwasher once each month d. Change your pet litter box daily 88. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing the client? a. Serum Ammonia b. Glucose level c. Phosphate level d. Serum troponin 89. A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? a. The client reports being extremely thirsty with a sore throat b. The amount of drainage is gradually decreasing c. The clients abdomen becomes distended and firm d. The drainage is bright green in color with brown fecal material 90. A nurse is caring for a client who takes Lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication? a. I have a heightened sense of taste b. I have a nagging, dry cough c. I have to urinate frequently d. I seem to be bruising more easily 91. A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the nurse take to verify tube placement? a. Deflate the cuff to check the tube placement b. Place the client’s head and neck in a flexed position c. Observe for symmetry of chest expansion d. Document the tube length where it passes the chin 92. A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? a. Take a laxative to prevent constipations b. Take an antacid 30 min before taking the medication c. Monitor heart rate once daily d. Drink 2 to 3 L of fluid daily 93. A nurse is caring for a client who presents to the emergency department after experiencing a heat stroke. Which of the following actions should the nurse take? a. Apply a cooling blanket. b. Assess axillary temperature every 15 min. c. Administer an antipyretic d. Administer lactated Ringers. 94. A nurse is presenting an in-service program about Parkinson’s disease (PD). Which of the following statements should the nurse include in the teaching? a. PD cause clients to have an increased sympathetic nervous system response b. PD results in the development of neurofibrillary tangles within the client’s brain c. PD results from a decreased amount of dopamine in the client’s brain d. PD manifestations worse due to the clients decreased production of acetylcholine. 95. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? a. Thrombocytopenia b. Thalassemia c. Rheumatoid arthritis d. COPD 96. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are testing on the floor. Which of the following actions should the nurse take? a. Pull the client up in bed b. Tie knots in the ropes near the pulleys to shorten them c. Increase the elevation of the affected extremity d. Remove one of the weights 97. A nurse is reviewing a medical record of a client who has acute gout. The nurse expects an increase in which of the following laboratory results? a. Intrinsic factor b. Chloride level c. Uric acid d. Creatinine kinase 98. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? a. “I will check my pulse before I take this medication.” b. “I’ll check my blood pressure so it doesn’t get too high.” c. “I’m going to include more cantaloupe in my diet.” d. “I will try to limit foods that contain salt.” [Show Less]
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ATI FUNDAMENTALS - QUESTIONS AND ANSWERS WITH RATIONALE TTT 67777
ATI FUNDAMENTALS - QUESTIONS AND ANSWERS WITH RATIONALE
TTT 67777
1. MISSING
2. A nurse is caring for a client who is scheduled to have his alanin... [Show More] e aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
a. “This test will indicate if you are at risk for developing blood clots
b. “This test will determine if your heart is performing properly”
c. “This test will provide information about the function of your liver”
d. “This test is used to check how your kidneys are working”
Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and BUN measure your kidney function.
3. A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?
a. Notify the client’s provider.
b. Report the incident to the pharmacy.
c. Complete an incident report.
d. Measure the client’s respiratory rate.
Rationale: Morphine can cause respiratory depression if given too much. Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn’t put the client’s health in risk.
4. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? (Round the answer to the nearest whole number.)
Click on the syringe that has 8 mL of med.
20 mg x (5mL/12.5mg) = 8 mL
5. A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
• So it says each dose for the final answer, but we are given 80 mg/kg/day.
• 80 x 20 = 1600 / 4 (dose is given every 6 hours a day) = 400 mg
6. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
a. Label the pump with a defective equipment sticker.
b. Unplug the pump.
c. Obtain a replacement pump.
d. Notified the biomedical department to fix the pump.
Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire.
7. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing? Ch
a. Serum albumin 3 g/dL
b. Total lymphocyte count 2400 mm3
c. HCT 42%
d. HGB 16g/dL
Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk for poor wound healing. The other lab values are within normal limits.
8. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page 244
a. Apply the cuff above the clients antecubital fossa.
b. Use a cuff with a width that is about 60% of the client's arm circumference.- width of the cuff should be 40 % of arm circumference
c. How the clients sit with his arm resting above the level of his heart.- MUST BE AT HEART LEVEL
d. Release the pressure on the client's arm 5 to 6 mm per second.- pressure release should not be more than 2 to 3 mm hg per second
Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.
Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.
9. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? Chapter 53 Airway management page 563
a. Hold the suction catheter with the clean non-dominant hand.
b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum.
c. Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE SUCTION CATHETER . you throw it away after being used.
d. Use surgical asepsis when performing the procedure.
Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10-15 seconds to avoid hypoxemia
10. A nurse is documenting client care. Which of the following abbreviations should the nurse use?ati book was not thorough so i had to go on different sites for charts - not confident with this, please double check.
a. “SS” for sliding scale
b. “BRP” for bathroom privileges
c. “OJ” for orange juice- do not
d. “SQ” for subcutaneous- do not
11. MISSING
12. A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should the nurse take?
a. Ensure that the width of the BP cuff is 50% of the client’s upper arm circumference. It says 40%
b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION
c. Recheck the clients BP and her other arm for comparison.
d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes
13. A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562
a. Supine and low-Fowler's position
b. Right lateral in Trendelenburg position
c. Side lying with the right side of the chest elevated
d. Prone with pillows under the extremities
14. A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?
a. Dietitian consult
b. Speech therapy referral
c. Oral suction at the bedside
d. Clear liquids
Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular. Liquids must be THICK.. Clear liquids can cause aspiration
15. A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set.(ati funds video enema)
1. Administer the enema solution.(2)
2. Remove the enema tube from the clients rectum.(4)
3. Wrap the end of the enema tube with a disposable tissue.(5)
4. Insert the enema tube into the client's rectum.(1)
5. Clamp the enema tube.(3)
16. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube?
a. Place the end of the NG tube in water to observe for bubbling.
b. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. AIR NOT WATER OR BY ASPIRATING GASTRIC FOR PH.
c. Assess the client's gag reflex.
d. Measure the pH of the gastric aspirate.
17. A nurse is teaching a group of newly licensed nurses about the Braden Scale. Which of the following responses by the newly licensed nurse indicates an understanding of the teaching?
a. “The client’s age is part of the measurement.” - rationale is same as b.
b. “The scale measures six elements.” - The six elements are 1. Sensory Perception, 2. Moisture, 4. activity, 5. mobility ,6. nutrition , 7. friction and shear.
c. “The higher the score, the higher the pressure ulcer risk.”- the higher the score the better chance the patient has of NOT getting an ulcer . score of 12 or less is high risk. Anything above 18 is healthy.
d. “Each element has a range from 1 to 5 points.”- each elements is scored from 1-4 actually .
18. A nurse is caring from a client who has a tracheostomy. Which of the following actions should the nurse take?
a. Clean the skin around the stoma with normal saline.
b. Secure the tracheostomy ties with one finger to fit snugly underneath. → 2 snug fingers widths under neck strap
c. Soak the outer cannula in warm tap water. STERILE NS
d. Use a cotton tip applicator to clean the inside in the inner cannula.
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