Exam 3 ATI

A nurse is caring for a client that is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale 0-10. Which of the following actions should the nurse take first? A) Administer a bolus of medication B) Check the display on the PCA pump C) Obtain an order for another pain medication for breakthrough pain D) Encourage the client to administer a demand dose.

C)

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest? A) Tennis B) Canoeing C) Swimming D) Rowing

C)

A nurse is providing discharge instructions to a client who has congestive heart failure. Which of the following statements by the client indicates to the nurse that the teaching was effective? A) "I will do all of my activities in the morning and rest every afternoon." B) "I should attempt to exercise every day of the week." C) "I plan to slow down if I am tired the day after exercising." D) "I will take my diuretic before sleep and drink fluids during the day."

C) "I plan to slow down if I am tired the day after exercising."

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification? A) Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B) Laboratory testing of serum potassium upon admission C) 0.9% normal saline IV at 50 mL/hr continuous D) Bumetanide (Bumex) 1 mg IV bolus every 12 hr

C) 0.9% normal saline IV at 50 mL/hr continuous

A nurse is preparing to administer potassium chloride (KCL). The provider prescribes potassium chloride (KCL) 20 mEq suspension PO daily. The bottle is labeled KCL elixir, 10 mEq/mL. Which of the following should the nurse administer? A) 1 mL B) 1.5 mL C) 2 mL D) 2.5 mL

C) 2 mL

A nurse is reviewing a client's laboratory values and finds a serum potassium of 6.2 mEq/L. Which of the following treatment options should the nurse expect to implement? A) Start an IV potassium infusion B) Encourage eating several bananas. C) Administer sodium polystyrene sulfonate (Kayexalate) D) Plan to start 100mL of 0.9% sodium chloride with 10 units of regular insulin.

C) Administer sodium polystyrene sulfonate (Kayexalate)

A client with valvular heart disease is at risk for developing left-sided heart failure. The nurse knows to monitor which of the following parameters to determine if the client has developed this disorder? A) Appetite B) Body weight C) Breath sounds D) Blood pressure

C) Breath sounds

A nurse is preparing to administer potassium chloride (KCL). The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take? A) Give the ordered KCL as prescribed B) Omit the KCL dose and document it was not given. C) Call the prescribing physician and inform her of the client's serum potassium level results. D) Call the lab to verify the client's results.

C) Call the prescribing physician and inform her of the client's serum potassium level results.

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. Which of the following scheduled medications should the nurse plan to administer? A) Lisinopril (Zestril) B) Digoxin (Lanoxin) C) Furosemide (Lasix) D) Potassium iodide (SSKI)

C) Furosemide (Lasix)

A provider prescribes 40 mEq of potassium chloride to infuse in 500 mL of dextrose 5% in water at the rate of 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr to the client? (Round to the nearest whole number.)

125 mL/hr

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level? A) FLACC B) Oucher C) FACES D) Visual Analog Scale

A

A nurse is reinforcing discharge teaching with a client recently diagnosed with heart failure. Which of the following statements should the nurse include in the teaching? A) "Exercise at least three times per week." B) "Take diuretics in the early morning and before bedtime." C) "Notify the provider of a weight gain of 1 lb in 24 hr." D) "Count pulse for 30 seconds and multiply by 2 before taking digoxin."

A) "Exercise at least three times per week."

A nurse is teaching a client who takes furosemide (Lasix) and has a serum potassium level of 3.2 mEq/L. Which of the following instructions should the nurse include? A) Bananas B) Carrots C) Cheddar cheese D) Baked chicken

A) Bananas

A client visits his provider's office, stating that he does not feel like himself. Laboratory testing indicates a low potassium level. Which of the following physiological responses should the nurse expect related to the client's hypokalemia? A) Cardiac dysrhythmias B) Hypoglycemia C) Hyperreflexia D) Increased appetite

A) Cardiac dysrhythmias

A nurse is caring for a client who was admitted to the hospital with congestive heart failure (CHF) and is taking digoxin (Lanoxin) 0.25 mg daily. The client refused breakfast and is complaining of nausea and generalized weakness. Which of the following actions should the nurse perform first? A) Check the client's vital signs. B) Request a dietitian consult. C) Suggest that the client rests before eating the meal. D) Request an order for an antiemetic.

A) Check the client's vital signs.

A nurse is preparing to administer IV therapy to a client who is compromised. Which of the following are clinical manifestations of left-sided heart failure. (Select all that apply.) A) Dyspnea B) Gastrointestinal bloating C) Jugular vein distention D) Orthopnea E) Paroxysmal nocturnal dyspnea

A) Dyspnea D) Orthopnea E) Paroxysmal nocturnal dyspnea

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A) Frothy sputum B) Dependent edema C) Nocturnal polyuria D) Jugular distention

A) Frothy sputum

A nurse is caring for a client who has heart failure and has a potassium level of 2.4 mg/dL. An adverse effect of which of the following medications is a possible cause of this potassium level? A) Furosemide (Lasix) B) Nitroglycerin (Nitro-Bid) C) Metoprolol (Lopressor) D) Spironolactone (Aldactone)

A) Furosemide (Lasix)

A nurse is caring for a client who receives furosemide (Lasix) to treat heart failure. Which of the following laboratory values should the nurse be sure to monitor specifically for this client? A) Potassium B) Albumin C) Chloride D) Bicarbonate

A) Potassium

A nurse is monitoring a cardiac output on a client who has left-sided heart failure. The nurse should expect which of the following findings to compromise the readings? A) The client who has premature atrial contractions. B) The client who has decreased oxygen saturations. C) The client who has bilateral wheezes. D) The client who has lower leg edema.

A) The client who has premature atrial contractions.

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A) Vital signs B) Self-report of pain C) Severity of the condition D) Nonverbal behavior

B)

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A) Expect ringing in the ears. B) Take the medication with food. C) Store the medication in the refrigerator. D) Monitor for weight loss.

B)

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A) "I will walk briskly for 30 minutes before bedtime." B) "I will no longer have a glass of wine before bedtime." C) "I will have a cup of hot cocoa immediately before bedtime." D) "I will do my muscle relaxation techniques each afternoon."

B)

A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect? A) Decreased brain natriuretic peptide (BNP). B) Elevated central venous pressure (CVP). C) Decreased pulmonary pressure. D) Increased urinary output.

B) Elevated central venous pressure (CVP).

A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia? A) Pitting edema B) Fatigue C) Dyspnea D) Oliguria

B) Fatigue

A nurse is caring for an infant who has congestive heart failure (CHF) secondary to a ventricular septal defect (VSD) and was brought to the clinic by the parent with a report of poor feeding. After instructing the parent about nasogastric (NG) tube feedings, the nurse evaluates that teaching has been effective when the parent states, "I will A) give every other feeding by the NG tube." B) nurse my baby for 20 minutes then give the rest by NG tube." C) administer all of my baby's feedings through the NG tube." D) let my baby suck until tired."

B) nurse my baby for 20 minutes then give the rest by NG tube."

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene? A) Closes the door to the client's room B) Measures the client's vital signs routinely C) Asks a group of nurses in the hall to speak quietly D) Flushes the client's toilet after emptying the urinary catheter's drainage bag

D

A nurse is providing teaching to a client who has history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid? A) Noodles B) Vegetable soup C) Baked fish D) Cheddar cheese

D

A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching? A) "I should only use the device when it's absolutely necessary." B) "I will ask my family to push the dose button when I am asleep." C) "I'll be careful about pushing the button so I don't overdose." D) "I should tell the nurse if I can't control my pain with this device."

D)

A nurse is caring for a client who has congestive heart failure (CHF) and was started on digoxin (Lanoxin). Which of the following client statements should alert the client may be experiencing a side effect of digoxin? A) "I can walk a mile a day." B) "I've had a backache ever since I got home." C) "I've lost half a pound in the last 2 days." D) "I feel nauseated and have no appetite."

D) "I feel nauseated and have no appetite."

A nurse in the emergency department is assessing a client. The client's laboratory values are obtained, and she is now requesting an alcoholic beverage. After reviewing the client's admission laboratory results, which of the following medication prescriptions should the nurse question? Sodium 144 mEq/L Potassium 3.5 mEq/L Chloride 106 mEq/L Carbon dioxide 32 mEq/L BUN 55 mg/dL Glucose 468 mg/dL Creatinine 5 mg/dL A) Oxazepam (Serax) B) Glipizide (Glucotrol) C) Regular insulin (Humulin R) D) Amphotericin B (Fungizone)

D) Amphotericin B (Fungizone)

A nurse is preparing to administer digoxin (Lanoxin) to a client who has heart failure. Which of the following actions is appropriate? A) Withholding the medication if the heart rate is above 100/min B) Instructing the client to eat foods that are low in potassium C) Measuring apical pulse rate for 30 seconds before administration D) Evaluating the client for nausea, vomiting, and anorexia

D) Evaluating the client for nausea, vomiting, and anorexia

A nurse is caring for a client who has heart failure and is prescribed furosemide (Lasix). For which of the following findings should the nurse withhold the medication? A) Weight gain B) Increased blood pressure C) Hematocrit of 33.4% D) Potassium 2.8

D) Potassium 2.8

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A) Jugular venous distention B) Right upper quadrant pain C) Pitting edema of the lower legs D) Shortness of breath while lying down

D) Shortness of breath while lying down

A nurse is giving a presentation about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? A) Furosemide (Lasix) B) Hydrochlorothiazide (HCTZ) C) Mannitol (Osmitrol) D) Spironolactone (Aldactone)

D) Spironolactone (Aldactone)

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize is at risk for hypokalemia? A) The client who has a tracheostomy tube attached to humidified oxygen. B) The client who has a Foley catheter to gravity. C) The client who has a chest tube to water seal. D) The client who has an NG tube to suction.

D) The client who has an NG tube to suction.

A nurse is assessing a client who receives chlorothiazide sodium (Diuril). Which of the following is a sign of hypokalemia? A) Shallow respirations B) Hypertensive crisis C) Diarrhea D) Hyperflexion

A) Shallow respirations