ATI #10
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 monitoring strip?
Pacemaker spikes before each QRS complex An atrial pacemaker spikes after the P wave
What EKG finding will you see in a patient with hyperkalemia?
Peaked T wave
A nurse in a clinic is caring for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take? A) instruct the client about preventing reinfection by using a diaphragm B) Tell the client to expect some joint pain C) obtain information about the clients recent sexual experiences D) collect a urine specimen from the client
Answer: C
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching? A. Pyelonephritis increases a pregnant woman's risk for preterm labor B. Pyelonephritis is most often caused by staphylococcus saprophyticus C. Pyelonephritis is an infection of the lower urinary tract D. Pyelonephritis often causes no symptoms in affected clients
Answer: A B: most common cause D: manifestations include flank pain, fever, chills, anorexia, nausea, and vomiting
A nurse is assessing a client with diabetes insipidus. Which of the following findings should the nurse expect? A) dehydration B) polyphagia C) hyperglycemia D) bradycardia
Answer: A DI causes massive dehydration d/t excessive secretion of dilute urine, they would be tachycardic not bradycardic
A staff nurse is teaching a client with Addison's Disease about the disease process.The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? a) it is caused by the lack of production of insulin by the pancreas b) it is caused by the lack of production of aldosterone by the adrenal gland c) it is caused by the overproduction of growth hormone by the pituitary gland D) it is cause by the overproduction parathormone by the parathyroid gland
Answer: B "It is caused by the lack of production of aldosterone by the adrenal gland"-Addison's disease is caused by the lack of production of adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland. A) type I diabetes C) acromegaly D) hyperparathyroidism
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A) hyperactive bowel sounds B) Nausea & vomiting C) bradycardia D) increased UO
Answer: B Other manifestations: abdominal tenderness/pain, anorexia, nausea, vomiting, restlessness, and confusion
A nurse is assessing a client with hyperthyroidism. The nurse should expect the client to report which of the following manifestations? A) sensitivity to cold B) constipation C) frequent mood swings D) weight gain of 10lbs in 3 weeks
Answer: C Client would have heat intolerance Increased peristalsis, diarrhea Excessive excess of thyroid hormone is released (thyroid hormone regulates metabolic rate) Clients have emotional lability (flips between hyperexcitability to irritability) Expect the client to report weight loss not weight gain
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? A) kussmaul respirations B) apneustic respirations C) Cheyne- Stokes respirations D) Stridor
Answer: C Kussmaul: rapid, deep, regular resps, seen in metabolic acidosis apneustic: prolonged inspiratory phase alternating with expiratory pauses Stridor is continuous high pitch sound heard in inspiration
A nurse is caring for a client who is 1-day postoperative following a laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make? A) you should ask your family to bring you some food from home B) clients frequently complain about the taste of hospital food C) I would be happy to get you some food you prefer to eat D) because of your surgery you have an altered ability to taste and smell
answer: D because they breath from a tracheal stoma, sense of taste and smell bypass the olfactory & gustatory nerve cells
