RN Qbank Missed Questions
NCLEX RN ATI Qbank for final Exam
A client receives isoniazid, rifmapin, and ethambutol. Which statement, if made by the
... [Show More] client to the nurse, MOST concerns the nurse?
1. "I seem to be becoming color blind- I can't see green"
2. "My urine and sweat are reddish-orange"
3. "Sometimes I wonder what I did to deserve all this"
4. "My big toe has started hurting so I can hardly walk"
1. "I seem to be becoming color blind- I can't see green"
A major common adverse effect of ethambutol is optic neuritis, with reduced visual activity; lessened ability to see green is a possible initial sign
The home care nurse visits a client w/a history of type I diabetes. The client has recently suffered permanent loss of vision and is having difficulty adjusting. Which of the following actions, if taken by the nurse, is MOST appropriate?
1. Ask the physician for a psychiatric referral
2. Recommend that the client join a support group
3. Warn client that failure to adapt can increase risk for safety
4. Reassure client that change in visual abilities does not change personal identity
2. Recommend that the client join a support group
Clients often respond more positively to peers w/same health alterations than to health professionals
The nurse cares for clients on the med/surg unit. A NAP reports to the nurse that a comatose client receiving O2 through a tracheostomy has "lots of water in the tubing." Which of the following actions should the nurse take FIRST?
1. Ask the NAP to clarify "lots of water"
2. Instruct the NAP to empty the fluid from the tubing
3. Contact respiratory therapy
4. Empty the fluid from the tubing
4. Empty the fluid from the tubing
Client as risk for aspiration; caring for the tracheostomy is within the scope of nursing practice
The client diagnosed w/type II DM receives treatment for HTN w/atenolol. History reveals that the client has glaucoma and is allergic to sulfa. The nurse is MOST concerned if the HCP orders which medication?
1. Glycerin
2. Pilocarpine
3. Acetazolamide
4. Timolol maleate
3. Acetazolamide
Contraindicated; cross sensitivity can occur d/t allergy to antibacterial sulfonamides and sulfonamide derivatives
The ICU nurse cares for a patient diagnosed w/septic shock. which of the following observations MOST concerns the nurse?
1. The peripheral pulses are strong and bounding and the RR is 26 breaths/minute
2. The WBC differential results indicate that there are predominately band neutrophils rather than segmented neutrophils
3. The skin changes from warm, dry and flushed to cool, clammy and pale
4. There is blood at a venipuncture site and around an IV catheter
4. There is blood at a venipuncture site and around an IV catheter
This is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem; sepsis is the most frequent cause of DIC
The nurse cares for a client requiring fluorescein angiography. The nurse determines that further teaching is required if the client states which of the following?
1. "I'll have to wear dark glasses for a while"
2. "I may notice yellowing staining of my skin, but it will disappear"
3. "I will have to drink more fluids immediately after the test"
4. "The test determines the amount of pressure w/in my eyes"
4. "The test determines the amount of pressure w/in my eyes"
Tonometry measures pressure in the eye; fluorescein angiography measures circulation in the retina
The nurse in the outpatient surgical center instructs a client preparing for surgical removal of a cataract of the left eye w/a lens implant. The nurse determines teaching is effective if the client states which of the following?
1. "My eyelids will be swollen shut for 3 days"
2. "I am happy that I will only need reading glasses"
3. "I can return to normal activities w/out restrictions"
4. "I will have severe pain that will be relieved by narcotics"
2. "I am happy that I will only need reading glasses"
Replacement lens implants are selected to allow correction of refraction for distal vision; client may not require glasses to see distances, but my still require glasses for reading or for close work
The nurse cares for a 4-year-old who sustained a fractured wrist from a fall. The nurse prepares the child for the application of a plaster cast. Which of the following actions by the nurse is MOST appropriate?
1. Tell the child the cast will feel cold when it is first applies
2. Allow the child to play w/a doll wearing a cast on the arm
3. Tell the child the application of the cast will not hurt
4. Ask the child if she would like to meet another child w/a cast
2. Allow the child to play w/a doll wearing a cast on the arm
Preschoolers need to see and play w/the equipment; this is the age of the greatest number of fears
The nurse evaluates the nutritional intake of the adolescent girl attending camp. The adolescent eats all of the food provided at the camp cafeteria. Each of the day's three meals contains foods from all areas of the "My food plate", and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating for about two years. Which description, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
1. Her diet is low in calories and high in iron
2. Her diet is low in calories and low in iron
3. Her diet is high in calories and low in iron
4. Her diet is high in calories and high in iron
3. Her diet is high in calories and low in iron
900 x 3 = 2,700 calories/day and females 12-18 years old need 2,000 kcal/day (males 12-13 years old need 2200 kcal/day; males at 14 years old need 2400 kcal/day; males 15 years old need 2600 kcal/day; males 16-18 years old need 2800 kcal/day); 3 mg x 3 = 9 mg/day of iron and females 12-13 years old need 8 mg/day and females 14-18 years old need 15 mg/day of iron (males 12-13 years old need 8 mg/day and males 14-18 years old need 11 mg/day of iron); w/pregnancy 30 mg/day is required
A patient is brought to the ED by a family member, who reports that the patient had a sudden onset of decreased LOC, blurred vision, HA, and slurred speech. Before sending the patient for a stat head CT scan, which of the following actions should the nurse take FIRST?
1. Elevate the HOB 90 degrees
2. Obtain a finger-stick blood glucose level
3. Pad the side of the patient's bed
4. Obtain a urine specimen from the patient
2. Obtain a finger-stick blood glucose level
Symptoms are suggestive of a possible TIA or CVA; assessment of other possible underlying causes that can be quickly and easily corrected should be ruled out; patient w/hypoglycemia may present w/similar symptoms
The nurse cares for a client in balanced suspension traction. The client reports pain in the affected extremity, and the nurse administers the prescribed pain medication. One hour later the client tells the nurse that the pain is unrelieved. Which action should the nurse take FIRST?
1. Contact the physician
2. Turn on client's radio
3. Ask the client to rate his pain using a numeric rating scale
4. Perform a neurovascular assessment
4. Perform a neurovascular assessment
Pain unrelieved by medication is a sign of acute compartment symdrome
A patient has a vagotomy w/antrectomy to treat a duodenal ulcer. Post-op the patient develops dumping syndrome. Which of the following statements, if made by the patient, indicates to the nurse that further teaching is necessary?
1. I should eat bread w/each meal
2. I should eat smaller meals more frequently
3. I should lie down after eating
4. I should avoid drinking fluids w/my meals
1. I should eat bread w/each meal
Should decrease intake of carbohydrates since they are first food to be digested; undigested food is dumped into the jejunum, r/i distention, cramping, pain, diarrhea 15-30 minutes after eating; causes diaphoresis, diarrhea and hypotension
The nurse instructs a client diagnosed w/COPD about how to perform pursed lip breathing. Which of the following statements by the client to the nurse indicates further teaching is necessary?
1. "I will tighten my stomach muscles as I finish breathing out"
2. "I will take twice as long to breathe out as I did to breathe in"
3. "I will breathe in deeply through my nose, hold it, and then breathe out"
4. "I will pretend I am whistling when I breathe out"
3. "I will breathe in deeply through my nose, hold it, and then breathe out"
Incorrect action; breathe should never be held during pursed lip breathing
The nurse cares for a client receiving aluminum hydroxide gel. The nurse determines that teaching is effective if the client makes which statement?
1. I will only take this medication before bedtime
2. I will decrease side effects by taking this medication before meals
3. I will take the medication 1 hour after meals
4. I will take the medication when I feel epigastric pain
3. I will take the medication 1 hour after meals
Antacids neutralize gastric acids, increase gastric pH, and inactivate pepsin; contains sodium, check if patient is on sodium restrictive diet
The nurse cares for a patient after a laminectomy and spinal fusion. The patient receives both continuous IV infusion and PCA medicated demand dosing of morphine. As the nurse takes VS, the patient, who appears to be sleeping comfortably, suddenly looks startled and says, " Whoops, I keep forgetting to push this" and pushed the PCA pump button. Which of the following responses by the nurse is BEST?
1. "Good. The more you can keep the morphine at an even level, the better"
2. "Tell me where you are feeling pain and show me on this pain chart the level of pain you are feeling"
3. "You seem very comfortable using the pump"
4. "The combination of the surgery and the medication can temporarily affect the memory"
2. "Tell me where you are feeling pain and show me on this pain chart the level of pain you are feeling"
Assessment of pain status and apparent discrepancy between the patient's having appeared comfortable and relaxed and suddenly "remembering" pain; patient's response to nurse's question may l/t needed patient teaching
The nurse observes a client have a tonic clonic seizure lasting about 90 seconds, followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to have another seizure. It is MOST important for the nurse to take which action?
1. Administer diazepam as ordered
2. Monitor serum glucose levels closely
3. Assess the client's blood pressure and pulse
4. Remove excessive clothing
1. Administer diazepam as ordered
Implementation; give IV to stop seizure activity; support ABCs, protect client from injury, provide oxygen, establish and IV access
The nurse admits the client from the post-op recovery area after abdominal exploratory surgery. After the nurse determines the client's VS, which action should the nurse perform NEXT?
1. Position the client on her left side, supported w/pillows
2. Check the chart, and determine the status of the fluid balance from surgery
3. Check the client's abdominal dressing for any evidence of bleeding
4. Monitor the incision and pulmonary status for the presence of infection
3. Check the client's abdominal dressing for any evidence of bleeding
Assessment; dressing should be checked on admission to the room and frequently for the next several hours
The nurse on the surgical unit cares for a client after an ileostomy. It is MOST important for the nurse to take which of the following actions?
1. Empty the ileostomy bag from the bottom
2. Apply lotion to the skin around the stoma
3. Cover the ileostomy w/gauze
4. Measure the output from the ileostomy
4. Measure the output from the ileostomy
Output from the ileostomy is liquid and usually copious in amount; include in client's intake and output
The nurse reviews records and determines which of the following clients is at highest risk for developing pneumonia?
1. A 15-year-old client diagnosed w/cystic fibrosis
2. A 36-year-old client who has smoked for 16 years
3. A 57-year-old client diagnosed w/hypertension
4. A 78-year-old client diagnosed w/colon cancer
4. A 78-year-old client diagnosed w/colon cancer
Risk factors for pneumonia include advanced age, underlying lung disease, bedridden, and post-op as well as immunosuppressed
The nurse cares for a newborn diagnosed w/a myelomeningocele. The nurse identifies that which of the following actions is MOST important?
1. Monitor for elevated temperature, irritability, and lethargy
2. Perform ROM exercises to feet, ankles, and knee joints
3. Apply lotion to healthy skin and gently massage skin
4. Measure occipitofrontal circumference daily
1. Monitor for elevated temperature, irritability, and lethargy
Infant is at risk to develop infection (meningitis) b/c of myelomeningocele sac; change dressing every 2-4 hours using aseptic technique
The nurse assesses a client in the outpatient clinic for treatment of MS. The nurse should assess for which clinical manifestations?
SATA
1. Urinary retention
2. Decreased LOC
3. Hypoactive DTRs
4. Intestinal obstruction
5. Numbness or tingling sensation
6. Decreased short-term memory
1. Urinary retention
5. Numbness or tingling sensation
6. Decreased short-term memory
- Causes progressive demyelination of spinal cord, will see gradual weakness l/t paralysis, alteration in innervation of bladder and urinary tract
- Client will also experience decreased sensitivity to pain, facial pain, and decreased temperature perception
- Cognitive changes are seen late in the disease and include decreased concentration, decreased ability to perform circulations, impaired judgement
A patient newly diagnosed w/Meniere's disease is counseled by the office nurse as to important dietary modifications. Which of the following comments, if made by the patient to the nurse, BEST indicates that teaching is successful?
1. "I have seen a lot of dietetic foods in the store. I will focus on buying them"
2. "I will avoid Chinese restaurants and fast-food places when I go out to eat"
3. "I will buy one of those commercial salt substitutes to use when I have a craving for salt"
4. "I understand that I can have corned beef and smoked fish, but not pickles or creamed sauces"
2. "I will avoid Chinese restaurants and fast-food places when I go out to eat"
Patients w/Meniere's disease require a low-sodium diet to decrease fluid retention (endolymphatic fluid, which is clear, intracellular fluid located in the labyrinth of the inner ear); many Chinese restaurants use MSG and soy sauce, both of which are high in sodium; fast-food places and products also have a tendency to be high in sodium
The school nurse is observing a high-school basketball game. Two cheerleaders are tumbling and hit each other in mid-air. One of the cheerleader's begins to cry and says, "I think my arm is broken." Which of the following actions should the school nurse take FIRST?
1. Call 911
2. Immobilize the arm
3. Observe the arm for deformity
4. Cut away the teen's sweater on the affected arm
4. Cut away the teen's sweater on the affected arm
Inspection is the first step of physical assessment; remove the clothing to inspect for bleeding, swelling, or deformity
The nurse determines that a client brought in to the urgent care center may be in shock. It is MOST important for the nurse to place the client in which position?
1. Trendelenburg position
2. Elevate the HOB 45 degrees
3. On the left side
4. Elevate the lower extremities
4. Elevate the lower extremities
Improves circulation to the brain and vital organs without increasing workload or impairing respiratory effort
A client is scheduled for surgery in 10 days for removal of a piloidal cyst. The nurse notes the client is diagnosed w/adrenal insufficiency and has been taking prednisone 5 mg PO BID. The nurse expects the physician to take which of the following actions?
1. Continue the medication as prescribed before surgery
2. Discontinue the medication before surgery
3. Reduce the dosage of medication before surgery
4. Increase the dosage of medication before surgery
4. Increase the dosage of medication before surgery
Surgery increases the demand for corticosteriods; nurse should monitor VS and blood sugar, and check for infection and bleeding
Because of persistent absenteeism and decreased peformance, a 35-year-old African American who works at a national cell telephone company is referred to the occupational nurse's office. The client tells the nurse of feeling tired all of the time and has HAs unrelieved by 2 tablets of acetaminophen. It is MOST important for the nurse to take which action?
1. Obtain the client's BP
2. Schedule an appointment w/the nephrologist
3. Ask the client when the last appointment with the HCP was
4. Instruct the client to schedule an appointment w/the HCP
1. Obtain the client's BP
Race, age, gender and s/s are reflective of HTN; fatigue may indicate early development of kidney disease
The nurse supervises care for a client who just had a short leg cast applied. The nurse determines that care is appropriate if which is observe?
SATA
1. The cast is covered w/a light sheet
2. The staff handles the cast using the palms of their hands
3. The affected limb is elevated to the level of the heart
4. The nurse compares the toes of the casted leg w/the opposite leg
5. The staff places a fan in the client's room
6. The staff turns the client every 4 hours
2. The staff handles the cast using the palms of their hands
3. The affected limb is elevated to the level of the heart
4. The nurse compares the toes of the casted leg w/the opposite leg
5. The staff places a fan in the client's room
- Prevents development of pressure area
- Decreased edema
- Assess for neurovascular functioning; also assess circulation, motion, and sensation in the casted extremity
- Increases circulation of air in room to facilitate drying of the cast
The nurse on the med/surg unit reviews lab results. The nurse notes that a client's serum albumin level is 2.5 g/dL, fasting blood sugar is 110 mg/dL, potassium is 4.2 mEq/L, and sodium is 140 mEq/L. It is MOST important for the nurse to assess for which finding?
1. Edema
2. Nausea
3. Muscle weakness
4. Blurred vision
1. Edema
Normal serum albumin is 3.5 to 5.5 g/dL; albumin deficit decreases oncotic pressure and fluids shift from vascular area to tissue
The office nurse prepares a patient diagnosed w/epilepsy for a PET scan. Which of the following directions to the patient is MOST important for the nurse to include?
1. "Be prepared to feel a warm sensation when the dye is injected"
2. "You'll want to empty your bladder before the test"
3. "Be sure to remove all your jewelry before you go in"
4. "You will be asked to think in different ways during the test"
2. "You'll want to empty your bladder before the test"
Ensures that patient will be comfortable and able to lie still throughout the procedure, which may last as long as 2 hours; after radioisotope administration, patient will wait 30-45 minutes on a stretcher or table so the substance can circulate to the brain; then the scan is done
The nurse cares for a client receiving albuterol 2 puffs and beclomethasone 2 puffs through inhalers. The nurse should include which statement when counseling the client?
1. "Use the albuterol inhaler and then use the beclomethasone inhaler"
2. "Use the beclomethasone inhaler and then the albuterol inhaler"
3. "You should take 1 puff of each inhaler, wait a minute, and then repeat the process"
4. "Either the inhaler can be used first as long as you wait 2 minutes between puffs"
1. "Use the albuterol inhaler and then use the beclomethasone inhaler"
Albuterol is a bronchodilator that opens the passageways so that the steroid medication (beclomethasone) can get into the bronchioles
The home care nurse counsels a client diagnosed w/glaucoma. The nurse determines that teaching is successful if the client makes which of the following statements?
1. "Because of glaucoma, the correction in my eyeglasses needs to be changed"
2. "I will schedule appointments w/my physician early in the morning"
3. "I'm glad that surgery can reverse the damage caused by glaucoma"
4. "I will be happy when I don't have to use the eyedrops anymore"
2. "I will schedule appointments w/my physician early in the morning"
IOP tends to be higher in the early morning hours; an early morning assessment is likely to be more accurate
The nurse knows that which of the following clients is at highest risk for developing Dupuytren contracture?
1. A 75-year-old woman from Russia diagnosed w/osteoarthritis
2. A 54-year-old man from Norway diagnosed w/DM
3. A 34-year-old woman from Haiti diagnosed w/a fractured femur
4. An 11-year-old boy from Poland diagnosed w/Duchenne MD
2. A 54-year-old man from Norway diagnosed w/DM
Dupuytren contracture is a slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers; r/f inherited autosomal dominant trait; occurs most often in men over 50 years of age, of Scandinavian or Celtic descent, and is associated w/DM, gout, arthritis, and alcoholism
The nurse responds to a call light and finds the client's IV tubing disconnected from the client's central line. The client is restless and complains of difficulty breathing. After the nurse locks the open catheter, which series of interventions should the nurse perform FIRST?
1. Place the client in a flat supine position, initiate O2 therapy, and notify HCP
2. Place the client in a high Fowler's position, initiate O2 therapy, and notify HCP
3. Place the client on the left side in Trendelenburg position, initiate O2 therapy, and notify the HCP
4. Place the client on the left side w/the lower extremities elevated, initiate O2 therapy, and notify the HCP
3. Place the client on the left side in Trendelenburg position, initiate O2 therapy, and notify the HCP
This position decreases the likelihood that the air will enter the pulmonary circulation; is a priority
A client receiving phenelzine sulfate is diagnosed w/Cushing symdrome and found to be hypokalemic. Which food is BEST for the nurse to recommend the client add to the diet?
1. Banana and raisin fruit salad
2. Spinach and tuna fish salad
3. Whole-wheat bread and cream cheese
4. Guacamole and brown rice
2. Spinach and tuna fish salad
Both are high in potassium and neither is contraindicated w/MAOI; most vegetables are acceptable w/MAOI
Bananas are contraindicated b/c of tyramine which is contraindicated w/MAOI
A client diagnosed w/alcoholism is scheduled to take disulfiram. Which statement, if made by the client to the clinic nurse, MOST concerns the nurse?
1. "I will take it at night so it helps me sleep"
2. "I like to work on crafts, especially unfinished furniture"
3. "I understand that disulfiram loses its effectiveness over time"
4. "I hope this works, I'm tired of being drunk"
2. "I like to work on crafts, especially unfinished furniture" [Show Less]