ATI Final Practice Exam

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

position the child laterally

A home health nurse is caring for a client who is quadriplegic following a SCI and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

"I am using the modified feeding utensils at every meal. I still spill, but I'm getting better."

A nurse is teaching a client who has acute AKI about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding the teaching?

"I will make a list of my favorite beverages"

A nurse is providing teaching to a client who has a pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching?

"The pacemaker can be checked from home by using the telephone"

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

"large incisions in the eschar will be made to improve circulation"

A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

35 normal BUN 6-24

A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect?

increased urine output

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following should the nurse notify the provider?

movement of the trachea toward the unaffected side

A nurse admits a client to the ED who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

increased serum amylase

A nurse is caring for a client who is 12 hrs post op and has a chest tube to a disposable water seal drainage system with suction. The nurse should intervene for which of the following observations?

continuous bubbling in the water-seal chamber

A nurse is reinforcing teaching with a client regarding reduction of risk factors for CAD. Which of the following statements by the client indicated an understanding of the teaching? SATA

I must stop smoking, I need to monitor my weight, I am limiting my intake of fast foods

An ED nurse is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following lab tests are used to diagnose MI? SATA

Troponin I, troponin T, CPK, myoglobin

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?

a client who has multiple tattoos

A nurse is planning care for a client who has cirrhosis. Which of the following actions should the nurse include in the plan? SATA

administer furosemide, implement a low sodium diet, measure client's abdominal girth

A nurse is preparing to administer phenytoin 50mg by intermittent IV bolus to a client who has a seizure disorder. Which of the following actions should the nurse take?

administer the medication over one minute

A nurse is caring for a client who has an ICP reading of 40. Which of the following findings should the nurse identify as a late stage sign of increased ICP? SATA

bradycardia and nonreactive dilated pupils

A nurse is providing teaching to a client who has a history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid?

cheddar cheese avoid high fat foods

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

cheddar cheese no tyramine foods!

A nurse is providing teaching to a client who has renal failure and an elevated phosphorus level. The provider instructed the client to take aluminum hydroxide 300mg PO three times daily. For which of the following adverse effects should the nurse inform the client?

constipation constipation is a common side effect of aluminum-based antacids

A nurse is observing the closed chest drainage system of a client who is 24hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

continue to monitor the patient's respiratory status slow, steady bubbling in the suction chamber is normal. Bubbling in the water seal chamber is bad and suggests an air leak

A nurse is caring for a client with Parkinsons and is taking diphenhydramine. Which of the therapeutic outcomes should the nurse expect to see?

decreased tremors

A rehab nurse is caring for a client who has had a spinal cord injury the resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehab efforts by the staff. Which of the following actions should the nurse take?

establish a plan of care with the client that sets attainable goals

A rehab nurse is planning care of a client who had a left CVA 3 weeks ago. Which of the following goals should the nurse include in the client's rehab program?

establish the ability to communicate effectively

A nurse is caring for a child who is postop following a VP shunt placement. In which of the following positions should the nurse place the client?

flat, on the unoperated side

A nurse is caring for a client immediately following HD. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

headache and restlessness

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

heart rate

An ED nurse is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vitals are as follows: BP 198/110, HR 82, RR 24, temp 100.8F. Which of the following neurologic disorders should the nurse expect?

hemorrhagic stroke

An ER nurse is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

inspect the mouth for inhalation injuries

A nurse is providing teaching to a client who has a new diagnosis of Parkinsons. On which of the following medications should the nurse prepare to instruct the client?

levadopa/carbidopa

A nurse is assessing the depth and the extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

location of the burn

An ED nurse is assessing a client who is having a suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? SATA

nausea, tachycardia, diaphoresis

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

no fluctuations in the water seal chamber fluctuation stops when the lung has re-expanded

A nurse is reviewing the ABG values of a client who has CKD. Which of the following sets of values should the nurse expect?

pH 7.25, HCO3 19, PaCO2 30

A nurse is caring for a client who has an AKI. Which of the following abg values would the nurse expect this client to have?

pH 7.26, HCO3 14, PaCO2 30 AKI causes metabolic acidosis bc the kidneys can't excrete acidic substances.

A nurse is reviewing the abg results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

pH 7.35

A nurse is caring for a client who has a T2-3 SCI. When planning care, the nurse should anticipate which of the following types of disability?

paraplegia

A nurse is assessing a client with ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

perform a Romberg's test

A nurse is planning care for a client who has ARDS. Which of the following interventions should the nurse include in the plan?

place in a prone position

A nurse in a CICU is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?

prevents dysrhythmias

A nurse is providing teaching to the family of a client who has Parkinsons. Which of the following info should the nurse include in the teaching?

provide client supervision

A nurse is planning care for a client who had a TBI and is emerging restless from a coma. Which of the following interventions should the nurse include in the plan?

reduce stimuli

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

reduce the client's intake of protein

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

supplements via nasogastric tube

hyperkalemia

tall, peaked t wave

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

test the drainage for glucose

A nurse is caring for a client who has a T4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

the client's bladder becomes distended

A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?

rest frequently throughout the day

An ICU nurse is caring for a client who is postop following a right pneumonectomy. After extubation from the vent, in which of the following positions should the client be placed?

semi-fowlers

An ED nurse is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

airway obstruction

A nurse is discussing kidney transplant with a client who has end-stage renal disease. Which of the following should the nurse identify as a contraindication for this treatment?

alcohol use disorder

A nurse is caring for a client who has a new AV graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

auscultate the site for a bruit

A nurse is caring for a client whose abg results show a pH of 7.30 and PaCO2 of 50. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

respiratory acidosis

A nurse is reviewing the ABG value for a client. The pH is 7.32, PaCO2 48, HCO3 23. The nurse should recognize that these findings indicate which of the following acid base imbalances?

respiratory acidosis

A nurse is caring for a client who has ESRD and reports having SOB and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated BP. The nurse should suspect which of the following based on the client's manifestations?

hypervolemia

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication.

hypotension

A nurse in the ED is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? SATA

hypotension, absence of bowel sounds, weakened gag reflex

A nurse is assessing a 3yr old who has aortic stenosis. Which of the following findings should the nurse expect? SATA

hypotension, weak pulses, murmur

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

inability to recognize family members

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? SATA

loosen restrictive clothing, place a pillow underneath the client's head

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

maintain the integrity of the sac

A nurse is teaching a client who has hepatitis A. Which of the following info should the nurse include?

manifestations are similar to flu-like symptoms

A nurse is admitting a client who reports flu like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following conditions?

metabolic acidosis

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

monitor the pulmonary artery pressure

A nurse in an ED is planning care for a client who is having an MI. The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

morphine

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

respiratory status

A nurse is caring for a client with CKD and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I take the antacid magaldrate I have at home? The nurse explains aluminum hydroxide is better because it lowers what?

serum phosphorus levels

A nurse is caring for a 2 yr old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

shake the container vigorously

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

spider angiomas

A nurse in the ED is caring for a client who reports chest pressure and SOB. Which of the following lab tests should the nurse anticipate the provider to prescribe?

troponin

A nurse in the Ed is caring for a client who is experiencing manifestations of an MI. Which of the following lab tests should the nurse expect the provider to prescribe?

troponin

A nurse is in a client's room when he begins to have a tonic-clonic seizure. Which of the following actions should the nurse take first?

turn the client's head to the side

A nurse is caring for a client who is 1-day postop following a left lower lobe lobectomy and has a chest tube. When assessing the client's 3-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

verify that the suction regulator is on and check the tubing for leaks

A nurse is reviewing the abg results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?

widened QRS complexes

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

withhold oral fluids and food