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
... [Show More] surgeon?
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 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
Rationale:ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abd pain).
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 ondansertron.
Rationale: No idea what the Exhibit is all about; wont be able to answer it.
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
Rationale:ATI pg. 27
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
Rationale: ST elevation indicates MI. ST depression indicates ischemia
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
Rationale: pg. 584. Dry the area thoroughly using patting motions.
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
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent
cardiovascular/respiratory distress.
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
Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation, paralytic ileus. So
effectiveness would indicate opposite of this
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
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis
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 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)
12. 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)
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. (p.70 chapter 13)
Born with a high weight
Chronic infections of the middle ear
Use a loop diuretic
Perforation of the ear drum
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? (Chapter 92 page 606 med surge ati pdf 10.0)
Administer the plasma immediately after thawing (Blood must be warm, you also have a 30 minute window to
give it so bacteria doesn’t grow. So it doesn’t necessarily have to be right away.)
Transfuse the plasma over 4 hour (Can be in 2 to 4 hours)
Hold the transfusion if the client is actively bleeding (YOU HAVE TO GIVE IT. That’s the whole point!
The patient is losing blood so you have to replace it. We give fresh frozen plasma because he or she may
have clotting deficiencies)
Administer the transfusion through a 24 gauge saline lock (Has to be a 18 or 20 gauge)
15. A nurse is assessing a clients who reports numbness and tingling of his toes and exhibits a positive
TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect? (ch 44 page 277 MS
ATI PDF 10.0)
Hypoatremia
Hyperchloremia
Hypermagnesemia
Hypocalcemia (low calcium = low ca causes increased firing = spasms. Learned this is LVN school.)
16. A home health nurse is teaching a clients how to care for a peripherally central catheter in his right arm. Which
of the following statements should the nurse include in the teaching?
(Chapter 27 cardiovascular diagnostics and therapeutic procedures p. 165 MS ATI PDF 10.0)
Change the transparent dressing over the insertion site every 48 hours - transparent dressing can be up to 7 days
Clean the insertion site with mild soap and water - when showering, must insertion site must be covered !!!!!
No water can be in it .
Measure your right arm circumference once weekly- does not say in the chapter
Use a 10 milliliter syringe when flushing the catheter - flush with 10 ml NS b4 and after med
administration
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?
(P.166 MS ATI PDF 10.0)
RBC count of 4.7 million/mm 3
BUN 22 mg/ dl - not dramatically high enough to pay attention to.
WBC count of 16,000/ mm 3 - phlebitis is a complication , infection is a complication that can happen 7
days after insertion , also temp increase if 1 degree can happen.
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?
(p.382 chapter 59)
I will spread my protein allowances over the entire day - the doctor issue the patient an allowed amount
of protein so its ok.
I should increase my intake of canned salmon to three times per week (NO SODIUM)
I will season my food with lemon pepper rather than salt (We do not want to give the dietary sodium,
potassium, phosphorus , and magnesium. I don’t know what lemon pepper has, but we want to RESTRICT
sodium, potassium, phosphorus and magnesium.)
I should limit my intake of hard cheese to 3 ounces each day (NO SODIUM at all)
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? (PAGE 166 ch 27 MS ATI
PDF 10.0)
Administer 20 ml of 0.9 sodium chloride after each dose of medication (you only flush with 10 ml of NS, not
20. 20 is for flushing blood)
Flush the catheter using a 5 ml syringe - you use a 10mL syringe to flush
Verify the placement with an x ray prior to the initial dose
Change the transparent membranes dressing daily (dressing can last for up to 7 days)
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?
Do not shake your inhaler before use (suppose to shake it)
Exhale fully before bringing the inhaler to your lips
Depress the canister after you inhale (depress the canister before inhaling, and 5 seconds later you inhale)
Use peroxide to clean the mouthpiece if your inhaler (warm water)
Textbook pg 573.
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? (page 30)
A client who has angina reports substernal chest pain
A client who has pancreatitis reports pain in the left shoulder - referred pain is pain that is felt in
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