Exam 2 ATI Quizbank

A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (SATA) A. Hemodialysis B. Biopsy C. Immunosuppression D. Balloon angioplasty E. Surgical repair

A, B, C. Hemodialysis, biopsy, immunosuppression Clients who develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and creatinine levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to undergo a biopsy to determine the correct diagnosis. Immunosuppressive medication therapy is essential after kidney transplantation to protect the new kidney.

A nurse is reviewing the laboratory results of a client who has end-stage renal disease (ESRD) and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.

A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorous D. Eat a diet high in protein

A. Limit fluid intake A client who has CKD should limit fluid intake to prevent hypervolemia.

A nurse is checking the laboratory values of a client who has chronic kidney disease (CKD). The nurse should expect elevations in which of the following values? A. Potassium and magnesium B. Calcium and bicarbonate C. Hemoglobin and hematocrit D. Arterial pH and PaCO2

A. Potassium and magnesium Clients who have CKD have hyperkalemia, hyperphosphatemia, and hypermagnesemia as well as elevations in serum creatinine and BUN **Hemoglobin, hematocrit, calcium, and bicarbonate decrease in CKD. Arterial pH decreases or remains at expected levels, and PaCO2 decreases.

A nurse is teaching a client with chronic kidney disease (CKD) about predialysis dietary recommendations. The nurse should recommend restricting the intake of which of the following nutrients? A. Protein B. Carbohydrates C. Calcium D. Monounsaturated fats

A. Protein Dietary restrictions for clients who have CKD vary based on the degree of kidney function; however, most clients need protein limitations. Predialysis protein restriction can help preserve some kidney function.

A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes B. Premature ventricular complexes at 12/min C. Telemetry monitoring showing pacing spikes with no QRS complexes D. Hiccups

A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the set rate of the pacemaker.

A nurse is caring for a client who has a traumatic brain injury (TBI) and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms B. The client internally flexes his wrists C. The client curls into a fetal position D. The client internally rotates his legs

A. The client rigidly extends his arms A client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline.

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure. Which of the following findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L B. The client's pupils are dilated C. The client's heart rate is 56/min D. The client is restless

A. The client's serum osmolarity is 310 mOsm/L Mannitol isan osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A decrease in cerebral edema should result in a decrease in intracranial pressure. **Dilated pupils, bradycardia, and restlessness are manifestations of increased intracranial pressure

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower the head of the client's bed D. Advance the catheter approximately 2.5 cm (1 in) further

A. Turn the client from side to side The nurse should assist the client in turning from side to side to facilitate the removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter. **The nurse should elevate the head of the client's bed to promote outflow, and should not push the peritoneal catheter further into the peritoneal cavity because this action introduces bacteria into the peritoneal cavity and increases the client's risk of peritonitis.

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output

A. Widened pulse pressure A widening of the pulse pressure is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in LOC, and nausea and vomiting.

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury (AKI). The client reports diarrhea, a dull headache, palpitations, and muscle tinging and weakness. Which of the following actions should the nurse take first? A. Administer an analgesic to the client B. Check the client's electrolyte values C. Measure the client's weight D. Restrict the client's protein intake

B. Check the client's electrolyte values The nurse should check the client's most recent potassium value because these findings are manifestations of hyperkalemia, which can lead to cardiac dysrhythmias.

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

B. Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nare C. Motor loss on one side of the body D. Bleeding from the top of the scalp

B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm

B. Much greater amplitude than the usual QRS complexes **The QRS complexes usually demonstrate the opposite polarity of the client's usual QRS complexes for those with PVCs, and a compensatory pause follows the PVC before the usual rhythm resumes, unless more PVCs follow in immediate succession.

A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? A. WBC 6,000/mm^3 B. Potassium 3.0 mEq/L C. Clear, pale yellow drainage D. Report of abdominal fullness

B. Potassium 3.0 mEq/L A potassium level of 3.0 is below the expected range and can cause dysrhythmias. Dialysis removes fluid, waste products, and electrolytes from the blood and can cause hypokalemia. **Clear, pale yellow drainage is an expected finding after peritoneal dialysis has been established, and abdominal fullness is expected during the dwell period, when the dialysate stays in the peritoneal cavity.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Provide breaths with a manual resuscitation bag B. Start chest compressions C. Administer oxygen D. Establish an airway

B. Start chest compressions. The nurse should perform cardiopulmonary resuscitation, which starts with chest compressions followed by opening the airway and breathing for clients; evidence indicates a great survival rate when chest compressions are started before a breath is initiated.

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? A. Allergy to egg products B. Vomiting and diarrhea for the last 6 hr C. Serum potassium of 3.6 mEq/L D. Serum creatinine of 1.2 mg/dL

B. Vomiting and diarrhea for the last 6 hr Vomiting and diarrhea for 6 hours deplete the client's fluid volume, which results in dehydration that can cause renal failure following a procedure that uses contrast dye. Therefore, the nurse should notify the provider.

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I don't have to take my antihypertensive medications now that I have a pacemaker" B. I should keep a pressure dressing over the generator until the incision is healed" C. "I should check my heart rate at the same time each day" D. "I cannot stand in front of our new microwave oven when it is on"

C. "I should check my heart rate at the same time each day" The nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider.

A nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? A. A client who has slurred speech and exhibits anger B. A client who reports nausea and vomiting C. A client who is difficult to arouse and is unable to respond to questions D. A client who is uncooperative and has uncoordinated movements

C. A client who is difficult to arouse and is unable to respond to questions The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and nursing knowledge to identify which risk poses the greatest threat. A client who is difficult to arouse and is unable to respond to questions could have a decreased LOC due to alcohol intoxication or traumatic brain injury. The greatest risk to this client is neurological sequelae of head trauma or death.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths

C. Confirm unresponsiveness Before the nurse can formulate a plan of action, they must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

A nurse is caring for a client who experienced a traumatic brain injury (TBI). Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign

C. Dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately. ** A halo sign indicates leakage of CSF that can occur with a skull fracture. It does not indicate increased intracranial pressure

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 Sodium reduction helps control blood pressure

A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. Decreased blood glucose B. Decreased bronchospasms C. Increased urine output D. Increased temperature

C. Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.

A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils

C. Level of consciousness The priority assessment is level of consciousness. A change in the client's LOC can be the first indication of a change in neurologic status.

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? A. Trendelenburg B. Prone C. Semi-Fowler's D. Sims'

C. Semi-Fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine B. Stop CPR and move away from the client C. Push the charge button to prepare to shock D. Apply the defibrillator pads to the client's chest

D. Apply the defibrillator pads to the client's chest After obtaining the AED, the nurse should first apply 2 large adhesive defibrillator pads on the client's anterior chest wall to enable the machine to analyze rhythm and deliver the shock appropriately if indicated.

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this presense as indicating which of the following? A. Confusion B. Orientation C. Attention D. Arousal

D. Arousal Withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation.

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease (CKD). The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia D. Hyperkalemia

D. Hyperkalemia A client who has chronic kidney disease can have hyperkalemia. Other manifestations of hyperkalemia can include palpitations, dysrhythmias, nausea, and muscle weakness.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? A. Diarrhea B. Increased serum albumin C. Hypoglycemia D. Peritonitis

D. Peritonitis Peritonitis is an adverse effect of peritoneal dialysis. Prevention requires using sterile technique and frequently assessing the catheter exit site. The nurse should obtain cultures of the dialysate outflow (effluent) if peritonitis is suspected.

An emergency room nurse is assessing a client who has a new traumatic brain injury (TBI). The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions

The first action the nurse should take when using the ABC approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.