NURS 2061 ATI Practice A

11.) A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?

Administer the medication outside the 5-cm (2-in) radius of the umbilicus

8.) A nurse is providing teaching to a client who has peptic ulcer disease and is to start a new prescription for sucralfate. Which of the following actions of sucralfate should the nurse include in the teaching?

Forms a protective barrier over ulcers

36.) A nurse is planning care for a client who is receiving mannitol via continuous IV infusion. The nurse should monitor the client for which of the following AEs?

Bibasilar crackles

6.) A nurse is assessing a client's vital signs prior to the administration of PO digoxin. The client's BP is 144/86 mm Hg, HR is 55/min, and RR is 20/min. The nurse should withhold the medication and contact the provider for which of the following findings?

Heart rate (norm is 60-100/min)

19.) A nurse is planning care for a client who is prescribed metoclopramide following bowel surgery. For which of the following AEs should the nurse monitor?

Sedation

16.) A nurse at a clinic is providing follow-up care to a client who is taking fluoxetine for depression. Which of the following findings should the nurse identify as an AE of the medication?

Sexual dysfunction

23.) A nurse is teaching a client about warfarin. The client asks if they can take aspirin while taking the warfarin. Which of the following responses should the nurse make?

"Aspirin will increase the risk of bleeding."

12.) A nurse at an urgent care clinic is collecting a history from a female client who has a UTI. The nurse anticipates a prescription for ciprofloxacin. The nurse should identify that which of the following client statements indicates a contraindication for administering this medication?

"I have tendonitis, so I haven't been able to exercise."

35.) A nurse is providing discharge instructions to a client who has heart failure and a new prescription for captopril. Which of the following client statements indicates an understanding of the teaching?

"I should tell my provider if I develop a sore throat."

1.) A nurse is instructing a client on the application of nitroglycerin transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?

"I will take the patch off right after my evening meal."

25.) A nurse is teaching a client about cyclobenzaprine. Which of the following client statements should indicate to the nurse that the teaching is effective?

"I will taper off the medication before discontinuing it."

28.) A nurse is providing teaching to a client who has multiple sclerosis and a new prescription for methylprednisolone. Which of the following instructions should the nurse include? (SATA)

-> blood glucose levels will be monitored during therapy -> avoid contact w/ people who have known infections -> grapefruit juice can increase the effects of the medication

26.) A nurse is providing teaching to a client who is to begin taking oxybutynin for urinary incontinence. Which of the following AEs should the nurse include in the teaching? (SATA)

-> dry mouth -> blurred vision -> dry eyes

7.) A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribed. Which of the following information should the nurse enter as a complete documentation of the incident?

0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.

18.) A nurse is preparing to administer a scheduled antibiotic at 0800 to a client and discovers the antibiotic is not present in the client's medication drawer. The nurse should identify that administration of the medication can occur at which of the following time periods w/o requiring an incident report?

0830

24.) 400 mL IV infuse over 1 hr -> drop factor: 15 gtt/mL -> round nearest whole number, use leading zero if applies, do not use trailing zero

1000 gtt/min

30.) A nurse is teaching a group of unit nurses about medication reconciliation. Which of the following information should the nurse include in the teaching?

A transition in care requires the nurse to conduct medication reconciliation

32.) A nurse is caring for a client who is receiving heparin therapy via continuous IV infusion to treat a pulmonary embolism.

Blood in the urine

4.) A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramide. Which of the following actions should the nurse take first?

Check the client's blood glucose

5.) A nurse is caring for a client who has cancer and is taking oral morphine and docusate sodium. The nurse should instruct the client that taking the docusate sodium can minimize which of the following AEs of morphine?

Constipation

15.) A nurse is preparing to administer medications to a client who tells the nurse, "I don't want to take my fluid pill until I get home today." Which of the following actions should the nurse take?

Document the refusal and inform the client's provider

20.) A nurse is teaching a client who is to start taking hydrocodone w/ acetaminophen tablets for pain. Which of the following information should the nurse include in the teaching?

Decreased respirations might occur

33.) A nurse is planning care for a client who has hypertension and is to start taking metoprolol. Which of the following interventions should the nurse include in the plan of care?

Determine apical pulse prior to administering

22.) A nurse is administering donepezil to a client who has Alzheimer's disease. Which of the following findings should the nurse report to the provider immediately?

Dyspnea

21.) A nurse is providing teaching to a client who is taking buproprion as an aid to quit smoking. Which of the following findings should the nurse identify as an AE of the medication?

Insomnia

37.) A nurse is assessing a client who has myasthenia gravis and is taking neostigmine. Which of the following findings should indicate to the nurse that the client is experiencing an AE?

Miosis

17.) A nurse is preparing to administer PO sodium polystyrene sulfonate to a client who has hyperkalemia. Which of the following actions should the nurse plan to take?

Monitor the client for constipation

2.) A nurse receives a verbal order from the provider to administer morphine five milligrams every 4 hours subcutaneously for severe pain as needed. The nurse should identify which of the following entries as the correct format for the MAR?

Morphine 5 mg subcut every 4 hr PRN severe pain

27.) A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift and the client received atenolol instead of allopurinol. Which of the following actions should the nurse take first?

Obtain the client's BP

13.) A nurse is reviewing the laboratory results for a client who is receiving heparin via continuous IV infusion for DVT. The nurse should discontinue the medication infusion for which of the following client findings?

Platelets 96,000/mm3

31.) A nurse is caring for a 20-year-old female client who has a prescription for isotretinoin for severe nodulocystic acne vulgaris. Before the client can obtain a refill, the nurse should advise the client that which of the following tests is required?

Pregnancy test

9.) A nurse is reviewing the ECG of a client who is receiving IV furosemide for HF. The nurse should identify which of the following findings as an indication of hypokalemia?

Presence of U-waves

29.) A nurse is assessing a client who has schizophrenia and is taking haloperidol. The nurse should report which of the following findings to the provider as a manifestation of neuroleptic malignant syndrome (NMS)?

Temperature of 39.7 C (103.5 F)

34.) A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?

The client rates pain as 3 on a scale from 0 to 10

3.) A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma. For which of the following AEs should the nurse instruct the client to monitor and report?

Tingling of fingers

10.) A nurse on the acute care unit is caring for a client who is receiving gentamicin IV. The nurse should report which of the following findings to the provider as an AE of the medication?

Tinnitus

14.) A nurse is caring for a client who is in labor. The client is receiving oxytocin by continuous IV infusion with a maintenance IV solution. The external FHR monitor indicates late decelerations. Which of the following actions should the nurse take first?

Turn the client to a side-lying position.