ATI EXIT EXAM
a nurse on the postpartum unit is caring for a group of clients with an AP. which of the following tasks should the nurse plan to delegate to the AP?
provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions?
vagal stimulation Vagal Stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation eqipt ready at the pt's bedside bcs vagal stim can cause bradydysrhythmias, ventr dysrhythmias, or asystole
a nurse is caring for a client who has endocarditis. which of the following findings should the nurse recognize as a potential complication?
valvular disease/damage often occurs as a result of inflammation of infection of the endocardium
The nurse is creating a plan of care for a client who has COPD which of the following intervention should the nurse include
Provide a diet that is high in calories and protein
a nurse is assessing a client who has left-sided heart failure. which of the following manifestations should the nurse expect to find?
weak peripheral pulses r/t systemic congestion resulting from right-sided heart fail
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
when descending stairs, I will first shift my weight to my unaffected leg.
a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take?
withhold the blood transfusion The principle of autonomy ensures that a client who is competent has the right to refuse treatment.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the clients plan of care?
wrap blankets around all four side rails affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
-Decreased Urine Output -Butterfly Rash -Joint Inflammation -due to kidney damage, Lupus nephritis, NOT CALCULI
A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make?
"Ask a friend or a family member to help with household chores"
A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow suppression. Which of the following instructions should the nurse plan to include in the teaching?
"Bathe with an antimicrobial soap twice per day"
A nurse is providing discharge teaching to a pt w pulmonary tuberculosis and a new prescription for RIFAMPIN. Which of the following instructions should the nurse include?
"Expect your urine and other secretions to be orange while taking this medication" it is a hepatoxin, inform provider is s/s of hepatitis occur (jaundice, fatigue, discomfort)
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
"People in middle adulthood often find satisfaction in nurturing and guiding young people." Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation
The nurses assisting the provider who is performing a thoracentesis at the bedside for a client. Which of the following actions should the nurse take
1. Wear goggles and mask during procedure 2. Cleanse the procedure area with an anti-septic solution 3. Apply pressure to the site after the procedure The pressure reduces the risk for bleeding at the procedure site
What time should the nurse administer lansoprazole?
30 min before breakfast food diminishes the effectiveness of the medication.
A nurse is planning care for a pt receiving enteral feedings via NG tube. Which action should the nurse take first?
ASPIRATE the stomach contents check the residual
A nurse is caring for a client in an acute respiratory failure who is receiving mechanical ventilation which of the following assessments is the best method for the nurse to use to determine effectiveness of the current treatment regimen
Arterial blood gasses, is the priority need to evaluate ABGs to determine serum oxygen sat and acid-base balance
A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first?
Assess orthostatic blood pressure determine FALL RISK, determines if they are hypovolemic and establishes a baseline for further measurements
a nurse is performing a cardiac assessment on a client. identify the area the nurse should inspect when evaluating the point of maximal impulse.
Auscultate at apex pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse.
A nurse is assessing a client who has lung cancer which of the following clinical manifestations should the nurse expect
Blood tinged sputum secondary to bleeding from the tumor
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
Check the cord routinely for grays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia
Examples of vagal stimulation
Cold water treatment.
A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?
Encourage ambulation once fully awake. Promotes absorption of CO2 used during procedure, minimizing pt discomfort. Nurse should check for nausea before ambulating and administer an anti-emetic med if necessary
A nurse is caring for a client who has Non Hodgkin's Lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding?
Erythema at the IV insertion site The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding.
A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. Which of the following actions should the nurse plan to take?
Flush the tube with 15 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.
A nurse is preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with their arms at their sides and their feet together
A nurse is providing teaching to a client who has chronic asthma and a new prescription for Montelukast. which of the following statements indicates the understanding of the teaching
I will take this medication every night even if I don't have symptoms Montelukast is used for the prophylactic trmt of asthma, and is taken QD in the evening
A nurse is assessing a client who has acute resp distress syndrome (ARDS. Which of the following findings should the nurse report to the provider?
INTERCOSTAL RETRACTIONS indicated increased resp compromise in a client w ARDS
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
Inject air into NPH insulin Inject air into regular insulin Withdraw regular insulin Withdraw NPH insulin
Define EPISTAXIS
NOSE BLEED
furosemide=________
LASIX diuretic for edema
a nurse is reviewing the laboratory results of a client who takes furosemide. which of the following results should the nurse identify as the priority finding?
LOW potassium Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.
A nurse in the emergency room is caring for a client who is experiencing acute respiratory failure which of the following laboratory findings should the nurse expect
Paco2 58mmhg low partial pressure of O2, also SpO2 will be low (<90)
A nurse caring for a pt post op from abdominal surgery. What is an indication that peristalsis is returning?
Passage of flatus
A nurse is caring for a client who is 1 hr postoperative following a thoracentesis which of the following is a priority assessment finding
Persistent cough ABCs! indicates possible tension pneumothorax
A nurse in a providers office is assessing a client who has COPD which of the following findings is the priority for the nurse to report to a provider
Productive cough with green sputum ABCs= more urgent than other findings GREEN indicates INFECTION
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Select a suction catheter that is half the size of the lumen. to prevent hypoxemia and trauma to the mucosa
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating filtration?
Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS?
Small, purple-colored skin lesions these are indications of Kaposi's sarcoma (an AIDS-defining illness)
A nurse is caring for a client who has asthma and is receiving albuterol for which of the following adverse effects should the nurse monitor the client.
Tachycardia
What is peristalsis?
The involuntary constriction and relaxation of the muscles of the intestine or another canal, creating wave-like movements that push the contents of the canal forward
A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information about HYPERACUTE REJECTION should the nurse include in the teaching?
The organ will need to be removed if hyperacute rejection occurs. Removing the thransplant is the only treatment for hyperacute rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant.
A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?
The surgical dressing ABCs, check for bleeding. Hemorrhage is a major complication postoperatively, so the nurse should assess for early indications of bleeding, such as visible blood stains on the surgical dressing. Covert manifestations of bleeding include rapid, thready pulse, tachycardia, and decreased urine output.
Define Fremitus
Vibration of chest when someone speaks
A nurse is assessing a client who has a new prescription for clindamycin to treat acute pelvis inflammatory disease. The nurse should report which of the following findings to the provider?
WATERY DIARRHEA, is the priority The greatest risk to this client is pseudomembranous colitis, which is manifested by watery diarrhea. The nurse should report immediately so they can d/c the med -dont be fooled by the other advese effects: vaginitis, furry tongue, n/v- they are NOT THE PRIORITY
a nurse is assessing a client who has pulmonary edema related to heart failure. which of the following findings indicates effective treatment of the client's condition?
absence of adventitious breath sounds ADVENT-I-TIOS breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulm edema is resolving
A nurse is preparing to transfer a client who can bear weight in one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?
assess the client for orthostatic hypotension determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.
a nurse is reviewing the lab results of several male clients who have peripheral arterial disease. the nurse should plan to provide dietary teaching for the client who has which of the following lab values?
cholesterol should be <200 HDL should be >45 mg/dL, LDL should be <130 mg/dL
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
discontinue the existing IV line greatest risk to pt is injury from IV infiltration damaging soft tissue surrounding the catheter
a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate?
droplet
veracity=
ethical principle, the nurse must tell the truth at all times and never deceive others
A nurse receives prescriptions from the provider for performing NASOPHARYNGEAL SUCTIONING on four clients. For which of the following clients should the nurse clarify the provider's prescription?
A client w Epistaxis Avoid providing nasopharyngeal suctioning for a client w nasal bleeding bcs the intervention might cause an increase in bleeding
A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?
A client who has renal failure, a serum potassium of 5.8/mEq/L and is prescribed sodium polystyrene sulfonate HIGH Potassium- indicates that this client is at greatest risk for bradycardia, hypotension, and ECG changes; therefore, this client is the nurse's priority for medication administration. Elevated potassium can cause tall, tented T waves on ECG and can lead to ventricular dysrhythmias. Sodium polystyrene sulfonate is a potassium excreting agent that exchanges potassium for sodium and allows for excretion of potassium through the stool.
A nurse enters a clients room and finds her on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
Client found lying on floor The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.
Droplet precautions
influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis
Dont do w crutches (3):
DONT -place crutches 12in away, should be 15cm -hold a crutch in each hand when sitting -have rests against armpits, causes injury to nerves
A nurse is caring for a pt postop from a cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain?
Expel the air from the JP bulb after emptying to re-establish suction.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.
A nurse is implementing a bowel training program for a client. For the program to be effective the client should be taken to the bathroom at which of the following times?
When the client has the urge to defecate
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility?
Witness the clients signature on the consent form The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure. The provider who is performing the procedure is responsible for describing the procedure to the client.
A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?
You should have a fecal occult blood test every year
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
You should receive a pneumococcal vaccine receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.
A nurse and an AP are providing care for four clients who were admitted to the med-surg unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
a client who has lumbrosacral spinal tumor NOT at risk for dysphagia
a nurse is providing health teaching for a group of clients. which of the following clients is at risk for developing peripheral arterial disease?
client who has diabetes mellitus risk for microvascular damage & progressive art disease
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
compare prescriptions with medications the client received while are the facility create a current, accurate list of every medication the client is or should be taking. comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction (MI)?
creatine kinase-MB isoenzyme specific to myocardium, elevations= myocardial muscle injury
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?
dyspnea on exertion due to ventricular compromise and reduced cardiac output
a nurse in an emergency department is caring for a client who has a BP of 254/139. the nurse recognizes that the client is in a hypertensive crisis. which of the following actions should the nurse take first?
elevate the head of the client's bed Greatest risk to pt is organ injury from severe HTN. Nurses first action should be to elevate HOB to decrease BP and promote oxygenation
a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take?
gently shake the container of medication prior to administration ensure that the medication is mixed
a nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. the nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?
inquire about the presence or absence of claudication claudication= impairment of walking (pain increases w walking) and is relived by stress Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
a nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. the nurse should plan to monitor for which of the following as an adverse effect of this medication?
lightheadedness furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness/diviness
A nurse of a medical-surgical unite is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?
observing a postoperative client who is confused A nurse who uses delegation is responsible for delegating tasks to the right person. A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff.
A nurse is teaching a client who is starting to take an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify his provider if he experiences which of the following adverse effects of his medication?
persistent cough need to d/c med