NR 324 ATI - TEST 4 PRACTICE ASSESSMENT
NR 324 ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is planning care for a client who has a suspected myocardial
... [Show More] infarction. Which of the following should the nurse administer first?
C. Oxygen
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ATI - TEST 4 PRACTICE ASSESSMENT
While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities?
C. Atrial deporlarization
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ATI - TEST 4 PRACTICE ASSESSMENT
A client comes to the emergency department via ambulance to report severe radiating chest pain and SOB. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse assisting with this client client's care first?
C. Initiate oxygen therapy.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is preparing a client for an echocardiogram the following day. Which of the following instruction should the nurse include about this test?
C. It requires lying quietly on one side.
Rationale:
For a Transthoracic Echocardiogram (TTE), the client lies quietly on the left side with slight head elevation. There is no reason for the client to be NPO. The test takes up to 1 hour and there is not discomfort as a transducer with conductive jelly is used on the chest.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is reviewing the laboratory values on a client who has HTN. Blood tests are drawn and reveal the following results. Which of the following results should the nurse identify as critical?
B. Potassium 2.3 mEq/L
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ATI - TEST 4 PRACTICE ASSESSMENT
The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following should the nurse report to the provider?.
D. Uses garlic as a cholesterol lowering agent.
Rationale:
The nurse should be aware that the use of garlic to lower cholesterol may potentiate the action of anticoagulant medication and should report the finding to the provider.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client who enters the emergency department complaining of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction?
C. Perform a 12-lead ECG
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ATI - TEST 4 PRACTICE ASSESSMENT
While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?
A. A cardiac murmur
Rationale:
Cardiac murmurs are relatively lout, turbulent sounds the nurse can hear between usual, expected heart sounds. They create a whooshing or swishing sound.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is reviewing the initial laboratory values for partial thromboplastin time, and prothrombin time, and thrombin time on a client who has an acute episode of disseminated intravascular coagulation (DIC). The nurse should expect the laboratory values to be
B. prolonged.
Rationale:
The nurse should expect the laboratory values to be prolonged because the anticoagulant pathways are impaired and consume the key clotting factors, resulting in clotting dysfunction.
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**ATI - TEST 4 PRACTICE ASSESSMENT**
A nurse is reinforcing discharge teaching for a client who has received an implantable cardioverter/defribillator (ICD). Which of the following information should the nurse include?
B. The client should hold his cell phone on the side opposite the ICD.
Rationale:
The client should keep his cellular phone on the side opposite of the ICD, as close proximity could interfere with the ICD's function. The client should inform airport security of the device. The client does not carry the ICD is in his pocket, this is an IMPLANTABLE device.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is reinforcing teaching for a client who is postoperative following an insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)
A. Count your pulse for 1 min each morning.
C. Do not wear tight clothing over the insertion area.
Rationale:
Avoid coming into contact with metal detectors is incorrect, there is not danger going through a metal detector, but the client should inform airport security because the pacemaker will trigger an alarm.
Do not operate microwave ovens is incorrect. It is save for clients with a pacemaker to operate microwave ovens unless they are old and do not have the appropriate shielding or of they are defective.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
C. The pacemaker spikes before each QRS complex.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response?
D. It prevents strokes in clients who have atrial fibrillation.
Rationale:
Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants such as warfarin help prevent thrombosis formation.
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ATI - TEST 4 PRACTICE ASSESSMENT
A client is telling the nurse in the clinic that he gets a headache after he takes sublingual nitroglycerin (Nitrostat). Which of the following should the nurse remind the client to do?
C. Lie down in a cool environment and rest.
Rationale:
HA is a common side effect of nitroglycerin. The nurse should suggest conservative measures to manage the HA. Generally, HAs that are a side effect of nitroglycerin are transient. They usually last about 5 min an rarely longer than 20 min.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is reinforcing teaching for a client who has a new prescription for warfarin sodium (Coumadin). Which of the following should the nurse include?
B. He should use an electric razor while on this medication.
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***ATI - TEST 4 PRACTICE ASSESSMENT***
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
A. Obtain a venous duplex ultrasound.
Rationale:
Venous duplex utlrasonography is a noninvasive diagnostic test used to detect distal DVT. Performing Homan's sign and dislodge the clot therefore this is inappropropriate. Warm therapy is used with DVTs not cold therapy
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**ATI - TEST 4 PRACTICE ASSESSMENT**
A client complains of SOB and chest pain the first day following multiple long bone fractures. THe nurse would consider which of the following client complications when assessing the client?
B. Fat emboli
Rationale:
The client with a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr.
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***ATI - TEST 4 PRACTICE ASSESSMENT***
A nurse is collecting data from an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation?
A. Increased blood pressure in the arms with decreased blood pressure in the legs
Rationale:
There is a narrowing next to the ductus areteriosus which results in an increased pressure proximal to the defect with a decreased distal to the obstruction. Therefore, an increase blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.
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ATI - TEST 4 PRACTICE ASSESSMENT
When checking a client's capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following?
A. Arterial insufficiency
Rationale:
To test the capillary refill, the nurses presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. Taking longer than 3 seconds indicates impaired arterial blood flow to the extremity.
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ATI - TEST 4 PRACTICE ASSESSMENT
Whenever a nurse is caring for clients who are receiving heparin, which of the following medications should the nruse have on hand in the event of an overdose?
C. Protamine
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client who takes nitroglycerin (Nitrostat) tablet at the onset of anginal pain. AFter taking the pill, the client states that his chest pain is relieved, but then he develops a sudden pounding headache. The nurse understands that the headache is
D. A common adverse reaction.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is collecting data from a client who has HTN and has a prescription for propranolol (Inderal). A history of which of the following conditions should be reported to the provider?
D. Heart failure
Rationale:
Propanolol is used with caution in clients who have heart failure to to the depressive effect on the myocardial contractility; therefore, the nurse should report this finding to the provider.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client who is admitted with a DVT of the left leg. Which of the following interventions should the nurse include in the client's plan of care?
B. Strict bedrest
Rationale:
Bedrest is considered supportive therapy for DVT and should be included in the plan of care.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is administering monitoring medications and realizes the nifedipine (Procardia) was administered to the wrong client. Which of the following is the priority nursing action?
A. Check the client's vital signs.
Rationale:
Nifedipine is an antihypertensive medication. The nurse should immediately check the client's vital signs for any significant alterations an then notify the provider.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client who is admitted to the hospital with CHF who has been taking digoxin (Lanoxin) 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse perform first?
C. Check the client's vital signs.
Rationale:
Nausea is a symptom of digoxin toxicity. The nurse should take the client's vital signs to determine if the client is experiencing bradycardia. The nurse should withhold the drug and call the provider if the client has bradycardia.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is reinforcing teaching regarding diet to a client after a myocardial infarction. The nurse evaluates the reinforcement as effective if the client selects which of the following options?
B. Baked turkey, mashed potatoes, squash and salad.
Rationale:
Low sodium, low fat diet is usual cardiac diet.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is contributing to the care plan for a client who has developed DVT. Which of the following interventions should the nurse include?
C. Elevate the affected extremity when the client is resting.
Rationale:
Supportive treatment for DVT includes elevation of the extremity when the client is in bed or in a chair.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is helping with the admission of a client from the emergency department. The client is prescribed clopidogrel bisulfate (Plavix). Which of the following precautions should the nurse anticipate?
A. Bleeding
Rationale:
Plavix is an antithrombotic and antiplatelet aggregate used to lessen the chance of a heart attack or stroke. Bleeding precautions are implemented to limit client exposure to injury-causing events that may lead to internal or external bleeding.
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***ATI - TEST 4 PRACTICE ASSESSMENT***
A nurse is caring for an infant who has a congenital heart defect. Which of the following is associated with increased pulmonary blood flow?
B. Patent ductus arteriosus
Rationale:
With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriousus and back to the pulmonary artery and lungs.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?
B. Irregular pulsations
Rationale:
PVCs are early ventricular depolarization that cause a pause immediately afterwards. The pause in the usual heart rhythm results in an irregular apical pulse. PVCs have a wide variety of causes, and the client typically perceives them as "palpitations."
PVCs = feelings of heart skipping a beat!
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***ATI - TEST 4 PRACTICE ASSESSMENT***
In preparation for the discharge of a client with peripheral arterial disease PAD, the nurse should reinforce which of the following instructions?
B. Adjust the thermostat so that the environment is warm.
Rationale:
Clients who have PAD should not wear any constrictive clothing.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is talking with a client who is about to start using transdermal nitroglycerin (Nitro-Dur) to treat angina pectoris. Which of the following is an appropriate instruction for this medication therapy?
B. Apply the transdermal patch in the morning.
Rationale:
The client should apply the patch every morning after showering and leave it in place for a minimum of 12 hours.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client on a medical surgical unit with a DVT who has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate response by the nurse?
D. "Heparin will be continued until the warfarin reaches a therapeutic level."
Rationale:
Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, they work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which usually occurs within 1 to 5 days. When PT and INR are within therapeutic range, the heparin can be discontinued.
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ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is caring for a client who just had a cardiac catheterization. The post procedure nursing care plan for this client should include which of the following nursing interventions?
A. Have the client rest in bed for 2 to 6 hr.
Rationale:
Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.
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