ATI Assignments pt2
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
"I can't get rid of these hiccups."
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?
"I smoked a cigarette this morning to calm my nerves about having this procedure."
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
"I took my warfarin last night according to my usual schedule."
A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?
"I will add broccoli and kale to my diet."
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching?
"I will use the incentive spirometer every hour."
A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?
"When I sit down to watch television, I'll be sure to put my feet up."
A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching?
"You might no longer be able to feel chest pain."
A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?
0.45% sodium chloride
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer?
0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium?
1 cup plain yogurt
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium?
1 large hard-boiled eggs
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
A client who has diabetes mellitus
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
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care?
Administer IV fluids to the client evenly over 24 hr-Encourage the client to rise slowly when standing up-Weigh the client every 8 hr
A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?
Assisting with thrombolytic therapy
A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first?
Auscultate the client's lungs
A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft (CBAG). Which of the following client findings should the nurse expect?
Blood pressure 160/80 mm Hg
A nurse is caring for a client who had dehydration and is receiving IV fluids. Which assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload?
Bounding peripheral pulses
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess?
Cardiac rhythm
A nurse is reviewing the laboratory 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 laboratory values?
Cholesterol 190 mg/dL HDL 25 mg/dL LDL 160 mg/dL
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first?
Initiate high-flow oxygen therapy
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?
Weight gain of 0.9 kg (2 lb) in 24 hr
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?
Decreased muscle strength
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?
Dyspnea on exertion
A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. 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
A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect?
Hematocrit 34%
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?
Hyperactive deep-tendon reflexes
A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. The nurse should identify that which of the following findings indicates the medication is effective?
INR 2.0
While reviewing a client's laboratory results, a nurse notes a serum calcium level of 0.8 mg/dL. Which of the following actions should the nurse take?
Implement seizure precautions
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
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
A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (Select all that apply.)
Limited alcohol intake Regular exercise program Tobacco cessation
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
Mental status
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?
Orthostatic hypotension
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis?
PaCo2
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 this medication?
Persistent cough
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?
Place the patch on an area of skin away from skin folds and joints
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding?
Potassium 6.1 mEq/L
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
Previous allergic reaction to shellifsh
A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PoO2 89 mm hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take?
Provide calming interventions
A nurse is caring for a client who was admitted for treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?
Review serum electrolyte values.
A nurse is reviewing the medical record of a client who had diabetes mellitus and is recieving regular insulin by continous IV infustion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?
Serum potassium 3.0 mEq/L
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective?
Serum sodium 142 mEq/L
A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?
Slow peripheral pulses
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately?
Slurred speech
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider?
Sodium 128 mEq/L
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds?
Stop the heparin infusion
A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?
Urine output of 20 mL/hr
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
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
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
A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?
Withhold the medication
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. which of the following client findings should the nurse report to the provider?
blood pressure 160/80 mm Hg
A nurse in an emergency room is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for?
confusion
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except?
confusion
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse.
left fifth intercostal space in the midclavicular line.