ATI Unit 5 Questions

A nurse is completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? SATA A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

A nurse is assessing a client who is receiving a transfusion of PRBCs. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temp C. Sudden oliguria E. Decreased respirations

C. Sudden oliguria

A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? A. Ferrous sulfate B. Epoetin alfa C. Vitamin B12 D. Folic acid

C. Vitamin B12

A client has been admitted to the hospital with DVT of the left leg. The nurse is teaching the client about measures to increase comfort and promote circulation. Which of the following statements by a client indicates an understanding of the teaching? A. "I will wear compression stockings on my legs when I plan to take a walk." B. "I will apply cool compresses to my leg." C. "I will massage my leg when it hurts." D. "I will keep my legs elevated when I'm in bed."

D. "I will keep my legs elevated when I'm in bed."

A nurse is providing teaching to a client who has a new prescription for HCTZ 50 mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching? A. "Take HCTZ prn for edema." B. "Check your weight once each week." C. "Take HCTZ on an empty stomach." D. "Take HCTZ in the morning."

D. "Take HCTZ in the morning."

A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? A. Flexion of the extremities B. Therapeutic hypothermia C. Upright positioning D. Ample hydration

D. Ample hydration

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."

A. "I can snack on fresh fruit."

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following statements indicates teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when preparing meals." D. "I can use whole milk in my oatmeal."

A. "I should remove the skin from poultry before eating it."

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure."

A nurse is caring for a client who is undergoing conservative treatment for DVT. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your blood stream." D. "Treatment with heparin will dissolve the clot and keep the clots from forming."

A. "Your body has a process called fibrinolysis that will eventually dissolve the clot."

A nurse is caring for a client who has an upper GI bleed and act of 24%. Prior to initiating a transfusion of PRBCs, which of the following actions should the nurse take? SATA A. Assess and document the client's vitals B. Restart IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the packed RBCs D. Hang a bag of lactated Ringer's IV solution E. Change IV tubing to a set that has a filter

A. Assess and document the client's vitals C. Verify with another nurse the blood type and Rh of the packed RBCs E. Change IV tubing to a set that has a filter

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Beef liver B. Organges C. Turnips D. Whole milk

A. Beef liver

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Eggs B. Squash C. Kale D. Tofu

A. Eggs

A nurse is examining the ECGs of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

A. Elevated ST segments

While participating in a community health fair, a nurse is providing information to a client who has a blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go to the nearest ED C. Instruct the client to follow-up with a provider within 6 months D. Explain to the client that he is not at risk unless he has manifestations of hypertension

A. Give the client a written record of his BP to bring to his provider

A nurse is assessing a client who has DVT in her left calf. Which of the following manifestations should the nurse expect to find? SATA A. Hardening along the blood vessel B. Absence of a peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

A. Lentils

A nurse is assisting with developing the plan of care for an older adult client who is to receive a unit of PRBCs. Which of the following actions should the nurse recommend? A. Verify the information on the PRBCs with another nurse B. Administer PRBCs through an 18-gauge IV catheter C. Infuse the PRBCs over 2 hr D. Allow the PRBCs to warm at room temp for 1 hr before starting the transfusion

A. Verify the information on the PRBCs with another nurse

A nurse is teaching a client about the proper placement of a nitroglycerin patch. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll apply the patch over areas of my body with little fatty tissue." B. "I can place the patch on any area of my body without hair." C. "I'll put the patch on the same site as the previous patch." D. "I have to apply the patch directly over my heart."

B. "I can place the patch on any area of my body without hair."

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

B. Ankle swelling

A nurse on telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS complex pattern

B. Atrial rate of 300/min with QRS complex of 80/min

A nurse is preparing to administer PRBCs to a client who is anemic. Which of the following actions should the nurse take? SATA A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the PRBCs over a 6-hour period D. Ask another nurse to check the PRBCs label against the medical record E. Prime the transfusion tubing with 0.9% NaCl

B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the PRBCs label against the medical record E. Prime the transfusion tubing with 0.9% NaCl

A nurse is caring for a client who is receiving continuous cardiac monitoring. Which of the following medications should the nurse anticipate administering to treat atrial fibrillation? A. Atropine B. Diltiazem C. Epinephrine D. Phenytoin

B. Diltiazem

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo B. Epistaxis C. Exophthalmos D. Spondylolisthesis

B. Epistaxis

A nurse is administering a unit of PRBCs to a client who is post op. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A. Maintain IV access with 0.9% NaCl B. Stop the infusion C. Send the blood container and tubing to the blood bank D. Obtain a urine sample

B. Stop the infusion

A nurse is providing teaching to a client about a new prescription for captopril to treat hypertension. Which of the following client statements indicates an understanding of the teaching? A. "I might have a sore throat that will go away after a few days." B. "I will take this medication with food to avoid getting an upset stomach." C. "I might feel dizzy at times while taking this medication." D. "I will take ibuprofen if I get a fever while taking this medication."

C. "I might feel dizzy at times while taking this medication."

A nurse is teaching a client who has a new prescription for warfarin. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll use a safety razor to shave each day." B. "I'll be sure to eat lots of spinach." C. "I'll avoid contact sports like football." D. "I'll take ibuprofen if I get a headache."

C. "I'll avoid contact sports like football."

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

C. Check the affected extremity for warmth and redness

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

C. Grilled chicken salad with fresh tomatoes

A nurse is providing a teaching to a client who has anemia and a new prescription of epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? A. Hospitalization is requires when administering each treatment B. The max effect of the medication will occur in 6 months C. Hypertension is a common adverse effect of this medication D. Blood transfusions are needed with each treatment

C. Hypertension is a common adverse effect of this medication

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? A. Administer ferrous sulfate supplementation B. Increase dietary intake of folic acid C. Initiate weekly injections of vitamin B12 D. Initiate a blood transfusion

C. Initiate weekly injections of vitamin B12

A nurse is preparing to transfuse a unit of PRBCs for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% NaCl with the blood B. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs

C. Witness the informed consent document

A nurse is providing a teaching for a client who has a new prescription for nitroglycerin administered through a transdermal patch. Which of the following client statements indicates an understanding of the teaching? A. "I need to wear the patch continuously for it to be effective." B. "I will stop using the patch immediately if it gives me a headache." C. "I should change the patch whenever I have chest pain." D. "I need to rotate the location of my patch every few days."

D. "I need to rotate the location of my patch every few days."

A nurse is assessing a client who has been taking simvastatin to treat hyperlipidemia. Which of the following statements by the client indicates an adverse effect of the medication that should be reported to the provider immediately? A. "I have has occasional constipation." B. "I have had some gas." C. "My head has been hurting for some days." D. "My legs feel weak and achy."

D. "My legs feel weak and achy."

A nurse is planning care for a client during sickle-cell crisis. Which of the following interventions should the nurse include in the clients plan of care? A. Maintain the clients knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake

A nurse is caring for a client who has PVD and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration to the extremities? A. Insufficient skin care B. Dehydration C. Immobitility D. Impaired circulation

D. Impaired circulation

A nurse is reviewing lab values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

D. Iron toxicity

A nurse is planning care for a client who is having percutaneous trans luminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. Instruct the client about long-term cardiac conditioning program B. Administer scheduled does of acetaminophen C. Check for peak lab markers of myocardial damage D. Monitor for bleeding

D. Monitor for bleeding

A nurse observes tachycardia, dyspnea, cough, and distended neck veins in a client who is receiving a transfusion of PRBCs. Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A. Warm the unit of blood to room temp before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

A nurse is reviewing informed consent with a client who is scheduled for a cardiac catheterization. Which of the following is the responsibility of the nurse? A. Explaining the procedure to the client B. Offering alternative treatments C. Informing the client of the consequences of refusing the procedure D. Verifying the client's understanding to the procedure being performed

D. Verifying the client's understanding to the procedure being performed

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements should the nurse identify as an indication that the client is adhering to the treatment plan? A. "I would have never believed I could get use to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156 over 98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

A. "I would have never believed I could get use to enjoying my food without salt."