NR 324 ATI - TEST 4 PRACTICE ASSESSMENT
A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following
... [Show More] 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 [Show Less]